Long-acting injectables an opportunity for pharmacists
APhA–ASP POLICY STANDING COMMITTEE
According to a 2009 British Journal of Psychiatry article, antipsychotic drugs were first discovered in 1952 and clinical utilization began soon after. However, like today, compliance was a major barrier in the effective treatment of schizophrenia and other mental health diseases, as noted in a 2012 American Journal of Health-System Pharmacy article. In 1966, the first long-acting injection (LAI), fluphenazine enanthate, was introduced. These injections were found to help adherence rates, but were quickly overshadowed by the approval and rapid adoption of second-generation (atypical) antipsychotics. In 2003, the first long-acting injectable second-generation antipsychotic, risperidone, became available, and since then three additional LAIs have been approved.
One challenge to uptake of antipsychotic LAIs is the stigma around mental health disorders. Research has even shown that there may be some historical connection to these long-term injectables being associated with punishment or trying to control the patient. Pharmacists and student pharmacists, as one of the most accessible health care providers, are in a strong position to fight this stigma and support patients’ needs.
A barrier that practitioners run into in the community pharmacy setting is the ability to bill for the administration of an LAI. For example, the October 2016 fee schedule shows that the HCPCS code for risperidone 0.5 mg LAI (J2794) is associated with a fee of $7.82. This would be the fee that the community pharmacist could bill on top of the actual dispensing fee (assuming that the patient chooses to fill their risperidone LAI at the same pharmacy that administers it). Being able to bill for the administration of the LAI allows for the practice to be more financially feasible.
As student pharmacists know through Operation Immunization programming and experiential rotations, pharmacists can have a dramatic impact on patients receiving immunizations. However, what you may not realize is that a recent systematic review and meta-analysis published in the November 2016 issue of Vaccine found that pharmacist involvement—whether it be as educator, facilitator, or administrator of the vaccine—resulted in an increase in immunization rates.
Will pharmacist administration of injectable medications result in increased adherence and patient outcomes?
The Academy takes action
As an Academy, APhA–ASP members rose in support of resolution 2016.2 with a united belief in the evidence-based power of vaccinations. The resolution reads as follows: 2016.2—Pharmacist Administration of Injectable Medications– APhA–ASP supports pharmacists and student pharmacists administering non-vaccine injectables, including but not limited to, antipsychotics, long-acting contraceptives, and other hormone therapy pursuant to prescription, protocol, or collaborative practice agreement. APhA–ASP supports the development of programs to properly train pharmacists and student pharmacists to administer non-vaccine injectables, such as continuing education and certificate training programs. APhA–ASP encourages all stakeholders, including but not limited to pharmacies, health systems, and third-party payers, to develop a sustainable and financially viable compensation model for pharmacist administration of non-vaccine injectables.
How you can make a difference
If you are interested in this issue, here is how you can get involved.
Familiarize yourself with your state’s pharmacy scope of practice act. Can pharmacists already administer LAIs in your state? Does it require any additional training or certification? Is it different than immunizations?
Contact your state association and ask if there are any plans to present a bill or to advocate for pharmacists’ authority to administer injectable medications. Inquire how student pharmacists can help!
Advocate for your patients’ access to pharmacist–provided patient care services. The ability to bill Medicare Part B would be vital to be paid for the administration of injectable medications.
Working as an integral part of the health care team, pharmacists and student pharmacists across the country can increase access and assist in improving medication adherence through administering non-vaccine injectables. Stay informed, take action, and advocate to advance this service in your state!
While this resolution specifically addresses antipsychotics or long-acting injectables, there are other opportunities for non-vaccine injectable medications. Other potential opportunities for pharmacist-administered injectables include: Bydureon (exenatide LAR; once weekly injection for type 2 diabetes) and Neulasta (pegfilgrastim; administered at least 24 hours after completion of chemotherapy to prevent neutropenia).
The valuable role of immunizations
By the APhA–ASP Policy Standing Committee
According to CDC and the World Health Organization (WHO), there are 24 vaccine-preventable diseases that have been eradicated in the United States and other countries with a high standard of living. Vaccination has had a tremendous impact on diseases like influenza, HPV, chickenpox, and pertussis, reducing their fatality risk over decades.
The “anti-vaxxer” movement is breathing new life into these previously dormant diseases by embellishing potential risks to vaccine recipients. Now many Americans are not correctly receiving CDC-recommended vaccines or vaccine series.
False assumptions and myths have created a pretense that certain diseases have been eliminated, and many people believe they can rely on herd immunity without accurately understanding the term. CDC defines herd immunity as the proportion of immunized individuals sufficient to protect the whole population from the spread of contagious disease. However, the percentage of the public that must be immunized for herd immunity to be effective is much higher than the national vaccination average.
For example, in order for herd immunity against measles to be maintained, 92% to 95% of children should receive the complete MMR vaccine series. But CDC found that MMR vaccination rates among kindergartners ranged from 99.7% in Mississippi to 81.7% in Colorado, with an additional seven states reporting an average of 90% or below.
Emergence of fatal diseases due to lack of vaccination could have serious economic and public health ramifications if vaccination does not fall back into favor. In 2016, Ozawa et al, estimated that the effects of 14 vaccine-preventable diseases caused a staggering $9 billion of economic burden in 2015—a single year—of which 80% is attributable to unvaccinated individuals.
The Academy takes action
As an Academy, APhA–ASP members rose in support of resolution 2016.3 with a united belief in the evidence-based power of vaccinations. The resolution reads as follows:
2016.3—Establishing Immunization Requirements
APhA–ASP affirms the valuable role immunizations play in protecting the public and strongly recommends that all persons receive immunizations currently recommended by the CDC, except when medically contraindicated. APhA–ASP recommends all private and public educational or childcare institutions require enrollees and employees to receive all CDC recommended immunizations, except when medically contraindicated. APhA–ASP strongly affirms that it is the professional responsibility of all health care personnel to receive CDC recommended immunizations and supports their employers mandating immunizations as a condition of employment, volunteering, or training, except when medically contraindicated.
How you can make a difference
There are plenty of ways to get involved and help inspire change in your community. Below we have provided a few examples of how to make a difference.
Familiarize yourself with common vaccination myths and professionally refute incorrect public statements. Popular myths include dangerous ingredients (aluminum, egg, etc.), vaccine-induced autism, or unsafe vaccination approvals. Share positive, proven evidence with your community to increase public knowledge on vaccinations.
Learn your state’s policies on vaccinations and advocate for best practices at the state and institutional level.
Explore CDC vaccination resources, such as its Vaccine Information Sheets and Vaccines Schedule app. Vaccine Information Sheets are written in a patient-friendly manner and address why patients should get a vaccine, who should not get a vaccine, and possible risks associated with vaccination.
Become comfortable with the appropriate language to make a strong vaccine recommendation to patients. Giving a strong recommendation in a respectful manner and overcoming patient barriers to vaccination can be difficult to balance with patient autonomy. Don’t be discouraged if some encounters do not lead to the outcome you anticipated. Practice makes perfect!
Get yourself vaccinated. With the busy schedule of a student pharmacist, it is often difficult to find time for yourself, but leading by example as a health care professional is the first step in increasing vaccination rates.
When it comes to your patients’ or your own health, take a shot at getting protected from disease. Encourage everyone to stay up-to-date on their vaccine recommendations!
Did you know the Advisory Committee on Immunization Practices, an advisory committee of medical experts for CDC, recently voted to recommend a two-dose series of the HPV vaccine for adolescents instead of three doses? Stay up to date on public health information and recommendations from CDC by reading their weekly publication, the Morbidity and Mortality Weekly Report Series.