Recovery Use of Medications: What Non-Prescribers Need to Know About Medication

Hello, everyone. Good afternoon. Welcome to
Recovery to Practice. We are so happy that you are joining us this afternoon.
This is the final webinar of – or almost-final webinar – of SAMHSA’s Recovery to Practice.
It’s our final series. And we are pleased to let you know that this webinar and all
48 of the Recovery to Practice webinars on recovery-oriented practices are recorded and
available on the SAMHSA RTP website on SAMHSA’s YouTube channel.
Today we are delighted to offer you a webinar on what non-prescribers need to know about
psychiatric-recovery-oriented pharmacology with Dr. Kim Mueser and Melody Riefer as our
presenters, and we’ll introduce them in just a moment.
Before that, this – you should know – that this and all the RTP webinars are funded by
Substance Abuse and Mental Health Services Administration, or SAMHSA. We’re grateful
for this support and the opportunity that it creates to help behavioral and primary
care practitioners improve the delivery of recovery-oriented services, supports, and
treatment. The views and opinions and content of this
presentation are those of the authors and presenters and do not necessarily reflect
the views, opinions, or policies of SAMHSA or the Department of Health and Human Services.
A couple of housekeeping details before we get started.
Please use the Chat boxes on your screen to request technical assistance, to pose questions
to the presenters, or to share ideas with one another. We will include a time at the
end of the presentation for answering these questions.
At the end of the presentation I will also tell you how you can get Continuing Education
hours or a Certificate of Attendance for this webinar.
And lastly, on the left side of your screen, below the pictures of our presenters, you’ll
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To introduce our top-flight set of presenters for today. Dr. Kim Mueser, PhD, is a Clinical
Psychologist and Professor at the Center for Psychiatric Rehabilitation at Boston University.
And Melody Riefer, MSW, my colleague and a Senior Program Manager at Advocates for Human
Potential. They will address what non-prescribing team members need to know about person-centered
pharmacology, psychotropic medication as a tool for recovery, and engaging individuals
in decisions about medications and ways practitioners can help ensure medications help individuals
meet personal goals. Kim is the Executive Director for the Center
for Psychiatric Rehabilitation at Boston University. His clinical research and interests include
family psycho education, treatment of co-occurring psychiatric and substance use disorders, psychiatric
rehab for people with serious mental illnesses and PTSD. He’s the author of a number of
books and treatment manuals and has published extensively.
Melody has over 30 years’ experience in behavioral health services, having worked
as an advocate in systems transformation, in inpatient, residential, and psychosocial
rehab programs before joining AHP. She was the Director of Training for Pat Deegan, PhD
and Associates and served as the inaugural Director for the Oklahoma Office of Consumer
Affairs and established Georgia First Run Peer Center.
Let me check in. Dr. Larson, are you with us now?
Yes, I am. Can you hear me now? We can hear you now!
Oh, great. And I’m going to mute my computer so that we don’t have an echo.
Thank you. Hi. I’m sorry to be late calling in. I had
a little bit of some challenges which I’m sure are completely my fault with calling
in. But I am Justine Larson. I am the Senior Medical
Advisor for the Center for Mental Health Services. I’m a child psychiatrist and a psychiatrist.
And just – I do think that non-prescribing team members have a very important role when
it comes to medication as a tool for recovery. And so I think this is a really important
topic. And I’m happy to be helpful as the conversation goes on.
Well, thank you. We’re so delighted that you are here with us.
And at this point I believe I turn it over to you, Melody.
Thank you, Laurie. We’re really excited to bring you this information,
and I’m actually going to hand it off to my colleague, Kim, and he’s going to introduce
the topic and take us through our first couple of sections. So Kim, it’s all yours.
Great. It’s great to be here. I just wanted to make a very slight correction which is
that I am no longer the Executive Director for the Center for Psychiatric Rehabilitation
but I continue to be here and to be involved in rehabilitation research.
So, to begin with, let’s talk about the role of medication in the recovery of people
with a serious mental illness. You know what, I realized that we did not
go through the review, and so backtracking a couple of slides. And we’ll talk a little
bit about what it is that we’re going to cover in today’s webinar.
We’ll talk a little bit about what is person-centered psycho pharmacology. And then get into discussing
how individuals can be engaged in decision making about medication.
And then what we’ll do is talk about ways that practitioners can ensure that medications
can help individuals meet their personal goals. And then we’ll talk about the role that
teams can play in coordinating with prescribers to ensure that individuals’ goals and healthcare
needs are being met. And now we’ll get into a little bit of discussion
about the role of medication or medicine in the recovery of people with serious mental
illness. So we think it’s helpful to talk about a
few basic facts about medications for psychiatric disorders. And there are both upsides and
downsides, or challenges. If we talk about some of the upsides of medications,
we now have broad-range medications that can be used to treat a variety of different disorders.
There are medications that can be helpful for people with a psychosis. Medications that
are useful in the treatment of mood disorders. And anxiety disorders. And medications that
are also useful in the treatment of alcohol and drug use disorders.
We know that medications can be effective sometimes at reducing distressing symptoms,
whether it’s hallucinations, anxiety, depression, or cravings to use substances. And that in
some instances medications can even eliminate symptoms altogether.
We also know that medications can be helpful in preventing relapses when medications are
taken on an ongoing basis. Even when a person doesn’t have symptoms or has minimal symptoms,
medication can prevent the chances of symptoms coming back and sometimes having a full-blown
relapse such as requiring a hospitalization. But it’s also important to recognize that
there are challenges, or downsides, associated with medications. Medicines don’t fix everything,
and for most people they work best when they are used with the support of other interventions
including psychiatric rehabilitation or psychosocial treatment approaches.
And most medications have side effects. And these can be difficult or challenging to live
with. And not everybody benefits from medication.
We certainly know that some people improve, get better, without medication.
And it can also be difficult to find what the right medication is. Or what the right
combination of medications are for an individual. This can be complicated by the fact that sometimes
medications can take an extended period of time to become effective at a particular dosage
level. So it requires a combination of patience and experimentation with the prescriber, and
with the consumer, and with other supportive persons.
So the decision to use medication is a complex and a personal one.
Let’s talk a little bit about the processes, or the approaches, to engaging and supporting
people in making decisions about medication. Let’s talk a little bit about the considerations
for the whole treatment team, because this webinar is really focused on the role that
non-prescribers can play in the use of medication to facilitate the recovery of – recovery
from a serious mental illness. First of all, the engagement in making decisions
about medications pertains both to people who are currently taking medications, because
they need to be involved in decisions about (inaudible) to take medications, about potentially
making changes in medications, or addressing side effects, or getting more of a benefit
out of medications. But it also pertains to people who are currently
not using medications so they can make informed decisions about whether they want to take
medications or not. And the procedures, the processes, involved
in helping people make decisions about medication, and then following through on those decisions,
also pertain to people to make a decision not to use medication. And what’s critical
is maintaining a therapeutic relationship with individuals. Keeping the focus on what
their recovery goals are, as Melody will be talking about shortly in a few minutes. Being
mindful and potentially developing a relapse prevention plan in case symptoms should come
back and there is a plan in place for dealing with a relapse.
And all those processes really pertain to both people who are taking medication as well
as people who are not taking medication because people sometimes make changes in their decisions
about taking medication. So, at this point I want to turn it over to
Melody who is going to delve a little bit more into some ways that treatment team members
and non-prescribers can support people in making decisions about taking medications
and in getting the most out of medications if they choose to take them.
Thanks, Kim. I’m really glad to be able to speak to this topic a little bit today,
and I want to share with you all some little bit why that’s important to me.
So, I’m a person in recovery from a serious mental illness. And I do use medication to
help me manage my – my symptoms. I have yet to find any medication that is just, you
know, the end-all, be-all, that takes care of every symptom and makes my life perfect.
And I’m pretty sure that there is no medication that makes one’s life perfect. That – that
medication is a tool found, and one of many tools that I rely on personally.
And then another hat that I wear is when I have worked as a clinician. And have worked
with people as they make these decisions about the role of medication in their lives.
And then another hat that I’ve worn is that of a consultant and training and working with
physicians and other team members about how they approach the relevance of medications
in a person’s life and recovery. And one of the things that I think is so important
is to remember that nobody’s goal is to take medicine. Or even to be adherent to medicine.
The goal is what’s beyond that. You know, the same way a carpenter’s goal is not a
hammer. The goal is to build something. And that the hammer is a tool to be in that building
process. So – so it’s important to know that what
motivates someone really influences the role that medicine will have, the importance of
aligning the choices around medicine and other tools with meeting that goal. And to ensure
that discussions that are held with any team member are really aimed at ensuring that the
person’s priorities and values are really important to the discussion. But if there’s
a mismatch, if those two can’t be aligned, then that tension is where a lot of the difficulties
with how one uses medicine, if it’s working for them or not, the priority that it’s
given, the – the honesty that one can have with their team members or their team members
can have with the person. So – so, in brief, aligning the use of medicine with the values
and priorities of the individual help ensure that the best decisions are made by the folks
who are experts in those components. So the person being expert in their life, the team
bringing various expertise on considerations, and certainly the physician having the – the
expertise around what medicines can do and what’s outside the scope of a medicine.
Another piece that’s really important, and this is not necessary – historically this
hasn’t always happened – but that is ensuring that people have access to information about
the medicines that they are taking. And what they are. Why they are using it. What they
can expect from it. How soon they can expect something from it. Ways that key people in
their life can support them. And since the advent of the internet, it’s even more important
that the team helps people develop the skills they need to access reliable information.
So it used to be that we couldn’t get any information. And now we’re just flooded
with information. And there’s so much information that it’s really challenging to figure out
what’s dependable, what’s accurate, what’s been influenced by some third party or other
group of people. And to find something that one can count on and understand. And so if
you’re able to see the slide right now, you’ll notice that we’ve actually given
a link to MedlinePlus. And MedlinePlus is an online resource that talks about all medications
in a very accessible way. It’s part of the National Institute of Health and the U.S.
National Library of Medicine. So it’s not paid for by for-profit entities that are connected
to medications, but it’s more influenced by what – what the science says about a
specific medicine, and the translation of that information into a more-accessible language
that’s not full of unnecessary jargon. I mean, it’s hard when you’re talking about
medicine to not bump into some medical jargon, of course. But it really tries to simplify
the – the information that’s shared. So, whether you are working as a case manager,
or a peer specialist, or a therapist. Maybe you’re a nurse educator. Really kind of
figuring out what resources are available that are – that are easily accessible, that
are free, which is really good, and that people can understand. These are some directions
that I would – that I would look at. It’s also important not to just give people
information. That conversations about the information are much more meaningful than
just a four-page stapled piece of paper. That it’s – that it’s that relationship with
the information that’s important. And then, with that, there are other strategies
that the team can make, and so I’m going to hand this back to Kim. Oh, let’s see.
I think I may have – let’s see. I’m sorry. Yeah, I’m going to hand this back
to Kim so that he can talk about some other things that the team can do.
Thank you, Kim. Great. Thanks, Melody.
So, the next part really addresses people who have made a decision to take medications.
And it addresses issues related to adherence or the taking of medications as prescribed
because medications are only effective to the extent that they are taken.
And there are a number of different strategies that can be used to help people increase or
maintain a good adherence to medications that they have been prescribed.
The research has focused on a variety of different strategies. But one of the simplest strategies
actually has the strongest research behind it. And that is called behavioral tailoring.
So behavioral tailoring refers to when you help a person fit the taking of their medication
into their personal routine. And, of course, all of these are strategies that can be used
to help people remember to take any medications, and many of these may be strategies that participants
in this webinar are familiar with. I certainly use them myself.
So with behavioral tailoring, what you do is to try to combine the taking a medication
with a habit, such as brushing one’s teeth in the morning. So if you put the toothbrush
right next to the medication dispenser, then when you go to brush your teeth you are reminded
to take your medications. You can even attach your toothbrush to the medication dispenser
so that you can’t help but be reminded of it. And so you take it every morning, or every
morning and evening, whenever you brush your teeth.
So integrated it into a routine is useful because what it does is it solves the problem
of remembering to take medication. You don’t really have to remember it because it’s
incorporated into your routine by pairing it with another behavior that’s already
in that routine. Pill boxes. The use of alarms and reminders
is another set of strategies that can be very useful.
There’s also research that shows that the complexity of an individual’s medication
regimen influences their ability to adhere to it. So that the more different medications
a person is taking, and the more times throughout the day a person has to take medication, the
more complex the medication regimen is, and the more difficult it is for people to adhere
to it properly. So, there are ways of simplifying medication
regimens, and clearly this is something in which the prescriber needs to take a lead
role or at least a role in explaining how it can be done potentially with some discussion
with treatment team members. But there is a variety of different strategies that can
be used to help simplify people’s medication regimens. So, for example, with many medications
they can be taken once a day rather than being taken multiple times throughout the day. So
if a person has a complex medication regimen, and many people do, talking this over with
the prescriber with the goal of trying to reduce that complexity in and of itself could
increase the person’s adherence. Another consideration, which has sometimes
been thought of as a last resort but really shouldn’t be, is the use of Depo or long-acting
medications. These are medications which are usually given by a shot, and they can last
anywhere from several weeks to several months. And what they do is they distribute the medication
throughout the body at an even rate during that period of time so that the person doesn’t
have to remember to take any medications at all.
The advantages, of course, of these Depo medications are that people don’t have to be reminded
about taking medications. They don’t have to be reminded about having a mental health
condition which some people don’t like to think about. And they can result in very,
very stable levels of medication in the body for these extended periods of time.
So, decisions about taking long-acting medications should really be part of the discussion of
medications, different ways of taking them, from the outset with consumers. Rather than
being held as a last resort for people who have difficulty adhering to oral medications.
There are lots of reasons why a person might choose to take these kind of medications for
reasons other than difficulty adhering to oral medications.
Sorry about that. Another really critical thing for all team
members to be involved in doing is trying to help the person get the answers they need
about medications. It’s very common that many questions come up in terms of why a person
is on a particular medication or is on a particular combination of medications. What are medications
being prescribed for. Whether the medication is helpful. What the side effects of those
medications are. And these are all important types of information
that need to be, of course, coordinated from the prescribe, but which these medication
fact sheets can provide very, very useful information about.
So, to have staff members reach out to the prescriber on a team, and help field questions
about medications, identify important resources such as those fact sheets that can provide
information about medications, and help consumers answer questions that they have about medications
that they are either taking or considering taking, can facilitate the decision-making
process. So, clearly the prescriber is a part of the
team and needs to be involved in all of this. But the important message here, really, is
that all members of the team need to understand about medications, both broadly as well as
specific medications that somebody that they are working with is taking, in order to be
able to help the person access accurate information about those medications. And, as we’ll be
discussing in a few minutes, in order to help them get the most out of medications.
Often when you’re helping consumers learn about medications and make decisions about
medications, what you need to do is to help them prepare for having discussions about
medications with their doctor or other prescriber. And having discussions with doctors can be
scary for many people out there. So, it’s important to try to have some ways
of reducing the very normal anxiety that people have about asking doctors questions about
either medical conditions or about medication. So there are a number of different strategies
that can be used to try to reduce the anxiety that people have about these conversations.
First of all, sometimes it’s helpful to actually have role plays with the person in
which they practice talking to their doctor about their medications and questions they
have, such as the side effects of a medication. Why a particular medication is being prescribed.
How to know, or how should they know, whether a particular medication is helping them.
And in doing role plays, or kind of pretend interaction, it can be very useful for the
treatment team member to first play the role of the client to give an example of how to
ask questions and have a conversation with the doctor about it. And then just switch
roles and have the client practice it. Have the consumer be in the driver’s seat.
And to provide additional feedback and additional practice experiences if that would be helpful.
Often people feel even more comfortable practicing something after they have practiced it a few
times rather than just doing it once. Another strategy is to help people develop
a list of questions that they want to ask the doctor. I mean, this is something that
many of us do before we’re going to see a doctor. Especially if we have a lot of questions,
in order to be organized, not to feel flustered during the meeting with the doctor, we take
out our little list of questions, and we go over that. And so helping a person be prepared
for a visit with the doctor, and this can be done in addition to role plays, of course,
can reduce some of the anxiety about having to perform on the spot. And having to remember
everything that they want to remember to ask. Another important thing is to consider, in
certain circumstances, accompanying the person during a meeting with a prescriber. And this,
of course, is done with the consumer’s consent. It’s important to provide people with whatever
the supports are that they need in order to get information they need in order to make
decisions about taking medications as well as making sure that they are getting the most
out of their medication. And so, having a hands-on role, and facilitating actual interaction
with the prescriber. And this could be in addition to behind-the-scenes role in which
a team member lets a prescriber know that a consumer has a number of questions and that
he or she is going to bring up those questions during their next visit so the prescriber
is aware of it and is receptive to it. Part of helping people make decisions about
the use of medication involves getting everybody on the treatment team on board with the importance
of people having information about medications and their right to make basic decisions about
the taking of medications. And so it’s critical that the prescriber be a member of the team
and be onboard with this. And team members can keep the prescriber abreast with how the
consumer is doing in terms of progress towards other goals and things like that. As well
as let the prescriber know when there are questions that the consumer is going to be
bringing up and discussing in a forthcoming meeting that they have – will be having.
So this goes a little bit more into the goal of treatment team members. This slide is how
do you know that the person is taking the right medications? How does the person know?
And are they working towards the right goal? Well, the right goal for people to be working
towards really is their recovery goal or their personal goals. And it becomes critical for
everybody on the treatment team, including the prescriber, to know what the person’s
individual recovery goals are. So always make them the primary focus of what the collaborative
work is. And in exploring decisions about taking medications,
and trying to optimize medications, these are being done really for the purposes of
helping people achieve personal recovery goals. So it’s always important that everybody
is one the same page in terms of understanding and supporting the person in making progress
toward those goals. Treatment team members also need to know about
the side effects of different medications that people are taking. And that’s because
often treatment team members, the non-prescribing members of a treatment team, often know better
about how somebody is doing in their day-to-day life than do the prescribers who tend to see
consumers less frequently and for shorter periods of time.
So if somebody is working at a job, or returning to school, or has a full-time job as a mother,
treatment team members who have regular contact with that person in the community may be aware
of side effects such as lethargy or sleepiness early in the day when it’s important to
be alert. Or fine motor, perhaps, which could interfere with working certain kinds of jobs.
So the familiarity of treatment team members with the side effects of the medication can
increase the ability of prescribers to identify what the proper dosage and medications are
for individuals in order to reduce the chances of side effects. And the reason this is so
important is that people aren’t always fully aware of whether something that they are experiencing
is a side effect or not. And so for treatment team members, and family members, and other
significant persons to be familiar with medications and their side effects increases the chances
that possible side effects will be detected and minimized as soon as possible. And that’s
important to do because we do know that medication side effects are one of the most important
reasons why people sometimes choose to stop taking medication.
And that goes to the next slide, which essentially repeats that point.
It’s important to help the consumer address any conflicts that might be appearing between
medication side effects and the person’s ability to make progress towards their personal
goals, their recovery goals. And here’s the – an example of a situation
where somebody who experiences fine motor tremors related to a medication, when this
could be a problem, they were pursuing or involved in work such as an artist, a pianist,
or a mechanic. Or, alternatively, a brain fog, or the kind
of fuzzy, cognitive state of very mild confusion, could be problematic for people who are parents
of young children and really need to be as alert as possible to how their children are
doing. So the familiarity of treatment team members
with the specific side effects of the medications that people are taking really can be critical
to optimizing the effects of medications. What this really gets back to is the importance
of the collective wisdom of the team. And this, of course, includes the consumer as
a member of his or her own treatment team. Ensuring that workable solutions are found
for people who are making decisions about taking a medication to aid them in their recovery.
To review some of the things that we’ve been talking about, critical for everybody,
including the prescriber on the team, to know what goals the person is working towards.
Because decisions about taking medications and strategies for optimizing medications
need to keep what the person’s goals are in sight and so the person can weigh specific
decisions regarding medications with respect to how much they will help them achieve their
goals. It’s critical for the person’s goals to
be monitored for progress towards those goals, to be monitored over time. Not just so we
know what the person’s goals are, but we are paying regular attention to the progress
that they are making towards those goals, what the obstacles are towards the goals,
and what additional treatment or other kinds of strategies or supports might be marshalled
to help the person make better progress towards goals.
And identifying challenges towards achieving goals. And sharing those challenges around
with everybody and including prescribers. Challenges may be medication related, but
they may be related to many other things such as a person’s symptoms. Or there may be
environmental challenges completely unrelated to the mental illness.
So all of these are important ways in which the collective knowledge of a team can help
the person get the most out of taking medications. I’d like to talk for a minute or two about
relapse and recovery. Relapse refers to when a person who has not been experiencing symptoms
begins to experience those symptoms again. Or has a major reoccurrence of those symptoms.
Or also relapse refers to – for people who have persistent symptoms – it refers to
a worsening of the symptoms which can often result in problems functioning. Problems taking
care of one’s self. Going to work. Being a parent. Things like that.
All of those are considered – or both of those situations are considered – relapses.
And we know that medications taken on a regular basis have the effect of reducing the chances
of people having a relapse. Now it should be recognized that relapses
can be a normal part of the recovery process. So a relapse isn’t necessarily a terrible
thing, although it can be certainly a setback. And it can be a demoralizing experience sometimes
especially if the person has to go back into the hospital.
And so trying to minimize the chances of relapses are very important.
Medication can be effective in preventing relapses. But changes in medication also,
such as a temporary increase in medication, can be effective at preventing a full-blown
relapse early in the process of symptoms coming back.
And so, for example, if you have a person who is taking medication. And one of their
symptoms is auditory hallucinations when they are more symptomatic, but they’re not having
any auditory hallucinations. Sometimes the beginning of a relapse, and this is sometimes
called the early warning signs of a relapse, is the person beginning to hear voices again?
Or you could have somebody where before they’ve had a relapse they’ve begun to feel more
depressed. And they haven’t connected with other people. They’ve begun to avoid other
people. And these changes have occurred before a full-blown relapse, say of depression.
And so being aware of what a person’s early warning signs of relapse are, and being able
to pick up on them, can enable the person to have a special meeting with their prescriber,
and say a potential of an increase in their medication dosage, which can actually completely
prevent a relapse. So being able to know what the early signs
and symptoms of a relapse are, and being able to recognize them and take quick action in
working with prescribers, family members, and the consumers themselves, of course, can
be a very effective way of using medications to prevent relapses.
In fact, this is – is such a well-established technology, the technology of relapse prevention,
that multiple programs in which standardized approaches to preventing relapses have been
developed. So, for example, the Wellness Recovery in Action, developed by Mary Ellen Copeland,
the WRAP program, has dimensions of relapse prevention built into it. Or in the Illness
Management and Recovery Program, an evidence-based practice that can be downloaded for free from
SAMHSA, that has a module that is focused on relapse prevention and developing a relapse
prevention plan or worksheet. And so, having a relapse prevention plan in
place can be a critical component of helping people get the most out of their medication.
And, this also pertains to people who are choosing not to take medication. When a person
makes a decision not to take medication, it can be especially important to develop a relapse
prevention plan that not only has the early warning signs of a relapse identified on it
and situations that have precipitated relapses in the past, but it has specific actions about
what is going to be done if the person begins to have a relapse. That the person agrees
on and has shared with everybody. Having one of these relapse prevention plans can be critical
in terms of preventing a full-blown relapse and may lead the person down the road to reconsider
decisions about not taking medication if it turns out that they are prone to having frequent
relapses. So medication can be one of the most important
tools that people who are in recovery have to work with. And work with in close collaboration
with their – their treatment teams. Medication is – collaborative medication
prescription is person centered, as we’ve made quite clear. It focuses on the person’s
goals. And the purposes of taking medication are really understood or explored in terms
of their ability to help the person achieve goals.
People need to be engaged in an active decision-making process, which is an ongoing decision-making
process. It’s not just a one-time thing. That decision-making process is, of course,
informed by the person’s goals. And it’s coordinated with everybody on the
treatment team, including the prescriber, in order to ensure that everybody is working
towards the same goals and the potential role of medication in helping the person achieve
those goals is – is consistent and unified. I think I might have done your last slide
there, Melody, but let me turn it over to you and Laurie.
Sure. I just want to say quickly that I think it’s important to know that medication by
itself is almost never the fix. And that’s whether we’re talking about a very specific
physical health complaint or condition. Or whether we’re talking about serious mental
illness. That we know in modern medicine that social supports are as important as medication.
That having meaning and purpose and activity and community are all contributing to our
– our wellness, and that we want to take advantage of every tool possible and particularly
when we identify those that work for ourselves that – that we keep those around and use
them so that we can achieve the – the best life possible. It’s everyone’s goal.
And so, with that I will turn this over to Laurie to kind of guide us through questions
and discussions. Wonderful! Kim and Melody, that was such a
rich and important discussion. Thank you so much for putting that together and sharing
it with us today. We have had a number of questions come in.
And I’d like to – to start with one. When you were talking about long-acting injectables
of long-acting medication, that triggered a very large response in the Chat and a number
of questions came in related to that. I would like to ask Dr. Larson, are you – are you
still with us, Dr. Larson? Yeah, I am. Can you hear me?
I can. Let me throw you these medication questions to take advantage of your expertise this afternoon
if you – if you don’t mind. Of course.
A couple of the questions that came in, I’m going to cluster them together, and that is
why – long-acting medications seem to be – have a lot of pros and cons. And some
people are asking why they aren’t used more often, and other people are saying, you know,
isn’t there a lot of stigma related to that. So there’s – can you talk to the pros
and cons of those? And also, are there generics available?
Yes! Yes. So, first about the pros and cons. So I think to think – the way to think about
it is really it’s about choice. So you want to help people think about what will – what
will make sense for them in their lives and what’s, you know, there’s various – there
are various reasons why a person might decide to do a long-acting injectable as opposed
to an oral medication. There are – there’s debate about whether
taking an injectable versus the oral will result in, you know, it’s more efficacious
if you take the oral kind of regularly and as prescribed. Some people say that it’s
the same thing as taking a long-acting injectable, and some people actually feel like the long-acting
injectable may keep people out of relapse more effectively.
But – so there’s debate about that part. But in general, I would say that some people
choose to do a long-acting injectable for the convenience. Like you don’t have to
take an oral medication every day, You just have to take the injections. For some medications
it’s every two weeks. Sometimes it’s every three weeks or four weeks.
And I had one patient who actually wanted to take a long-acting injectable so that she
didn’t have her family kind of too much in her business, looking at her pill bottles,
that kind of thing. And that was just her preference.
So I think the key thing is to help people figure out what their choices – what choice
would feel the most empowering for them, and the most helpful for them.
So sometimes what I – what I do when I’m talking about long-acting injectables with
people is, you know, kind of acknowledge that it sounds scary or – or sometimes people
have an association with needles and sort of coercion and being forced to do things.
And to kind of acknowledge that – that – but also to say that, you know, now, you know,
it’s more just another choice and another option that people should be aware of. So
kind of putting it in as a way of empowering people to just inform them about their options
and choices. So shared decision making is, as a rule of
thumb, all the way through including what’s – what’s the best vehicle for delivering
these medications, and people – Yeah.
Have different responses to that. Exactly. And I think that, you know, you could
– you – in talking to someone, you can acknowledge that for some people in many places
it’s so, you know, it can be associated with sort of coercion. But that, you know,
it doesn’t – it doesn’t necessarily have to be associated with coercion. Really
it’s about their choice and what makes the most sense for them in their lives.
Wonderful. Thank you for that. Another question has to do with how do we
– Kim, I think maybe you might want to take the firs stab at this – how do we as non-prescribing
clinicians work with a physician who really doesn’t want to be focused around recovery
or shared decision making? Who wants to be the decider. And there may be many reasons
for that including the physician is rushed, or they’re seeing so many people. How do
we as clinicians and peer-support specialists, help people kind of deal with that situation?
That’s a great question. I think that even – even when prescribers are feeling rushed,
even when they really have a particular decision they very much want the consumer to – to
follow, that in the vast majority of situations, that what they really want is what is best
for the consumer. And they’re afraid of the person making their own decisions and
not necessarily making the best ones. And so I think that the most important thing is
to engage prescribers in their concern for helping people use medication and to make
medication decisions, that are the best and most effective medication decisions that they
can make. And that helping people link the taking of
medication to personal goals is one way of getting people more invested in learning about
their medication and taking it regularly if that’s the decision that they have made.
And one doesn’t have to make reference to recovery goals proper but rather to the importance
of personal goals and motivating people to be involved in their own medical care for
any health-related condition. The second thing is to address the fact that
many people benefit from learning information about medication and that helping people learn
about medication can actually increase their investment in it and lead to better adherence
and outcomes. Because frequently the psychiatrists really do, in fact, care about outcomes, the
notion that engagement linking medication to goals, psycho education about medications
can increase the person’s ability to adhere to medication, is often a welcome message
to prescribers. And so I think engaging them around their interest and motivation in helping
the person with a serious mental illness do as well as possible and move towards recovery
in the community. And then going from there to strategies that the prescriber can do and
how the team can help the prescriber in doing that, such as bringing in goals as a focus
of the conversation, and providing additional information, and talking over medication decisions.
I think that those are the best strategies for working with prescribers who perhaps have
not seen the light but may nevertheless be open to these approaches to engaging consumers
around medication decision making. Thanks, Kim.
I was going to say something else. Is that okay if I chime in about what I’m seeing?
Yeah. This is just being Larson. I just also wanted
to say that sometimes, and maybe, you know, folks always do this, but sometimes it’s
useful to try to have a conversation with the prescriber about the reasons for their
decision making around it. Sometimes what I’ve seen is that the clinician or the therapist
can – will talk with a patient, and the patient will have a certain, you know, feeling
or perspective after their visit which isn’t, you know, isn’t always, you know, which
may not be positive. And so sometimes the therapist can play a useful role in helping
to mediate if the psychiatrist has some kind of reasoning behind their decision and so
then the therapist can – can understand better and support the medication regimen.
I had a situation when I was a medical director in Arlington County where some of the therapists
were coming to me very upset about decisions that a medical provider had been making and
complaining about them on behalf of their patients. After kind of looking into it a
little bit, the provider had made a decision to try to taper people off of their opiates.
They were a medical provider that was providing integrated care, and – but, you know, which
in lot of ways sounds like a good thing, to help people get off of opiates. But I think
that it would have been, you know, more effective if the provider had worked collaboratively
with the therapists to – to support the person in basically trying to come off opiates.
And so the fact that they didn’t communicate caused a lot of, you know, confusion and problems.
So I think when there is a doubt about what the provider is thinking or what the prescriber
is doing, I think just reaching out to them and having a conversation can be really helpful.
Thanks, Dr. Larson. Melody, I’m going to give you a chance to
have a last word here. It’s on the short side, but I think it’s an important issue.
And that is, as non-prescribers, as clinicians, as peer specialists, what’s our role and
responsibility when we become aware that someone is messing with their meds? Whether they’re
going off medication, they’re changing the dosage, they’re changing the time, they’re
fiddling around with this and that. What is it that we need to do?
I think that’s really important, and for me, having worked in peer support for a number
of years, I think – I always look at how do we address this as a team. And then one
of the first things that I do when I am working with someone is I – I just kind of say up
front that I’m one of a bunch of people who are going to be involved with your care,
and for us to be a team and to be the most effective, we can’t keep secrets. And then
just by saying that at the beginning of the relationship, it then frees me up to remind
the person like, you know, making these decisions is kind of like trying to do your own surgery,
or to cut your own hair, or to do your own tattoo. It’s just better to have somebody
else giving you some input. And we need to take this to the team.
I don’t think people should be forced to take medicine. I don’t think that people
should be on medicine that’s painful for them. But I think that starting and stopping
are equally important, that how you do it really influences your health. So I would
invite folks to, even if it’s a hard discussion, to have the discussion and be safe.
Thanks, Melody. Want to know more about these topics and the
conversation that we started today, there are a number of resources on this slide, and
it looks like it lost its format when we put it onto this webinar platform. However, you
can download this set of citations that you might find of interest if you look in the
Download Material box. If you look to your lower right you’ll see 5N5 Resources. That
is a paper copy, or a pdf copy, of what you see here on the screen. We encourage you to
download that and take a – take a look at it.
We also have available for you a recent newsletter that just came out from Recovery to Practice
that is a companion to some of the material and the topic that we’ve been talking about
today and we will talk about again on July 11th with Dr. Lisa Dixon. We encourage you
to take a look at that. You can also download that from the Materials box if you have not
already received it from the RTP mailing list. We want to remind you that this webinar and
all RTP products and resources are based on these ten principles and four major dimensions
of recovery from SAMHSA. Together these elements form a solid foundation for developing recovery-oriented
lives, for building recovery-oriented services, and the systems needed to support them.
We are sad to inform you that SAMHSA’s Recovery to Practice initiative will be ending this
September in this year, and we are deeply grateful to SAMHSA for their support over
the past four years and have felt honored to work with people around the country and
offer the field’s superior content and subject-matter experts. A lot of the RTP content is on our
website at SAMHSA, and that will continue to live on including those 48 webinars.
Our last webinar in the series will be July 11th with Dr. Lisa Dixon. And we will be taking
a look at a psychiatrist’s view on the role of medication in recovery to practice or a
recovery-oriented framework. We also have two brand new e-learning courses.
If you have not checked those out, please do. They are both on the website.