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To the Editor: I am writing in response to the article in the September 2004 issue by Dr. Keith and his colleagues (1) on "practical" aspects of long-acting risperidone. I believe that a balanced discussion of long-acting risperidone should have included some acknowledgement of its "impractical" features.
Obtaining long-acting risperidone is complicated and time-consuming. There is a paperwork burden associated with procurement of the drug. Storage and administration of long-acting risperidone is cumbersome and time-consuming. The drug must be refrigerated. Our agency receives the drug at multiple sites, and it is handled by multiple persons. The chain of custody must be ensured. Assembling the components of the injection system takes time and dexterity. The actual cost of the drug includes the drug itself—about $500 a month—plus increased cost to insurers because of the necessity of more clinic visits by patients who are receiving the drug plus nonreimbursable clerical costs to the clinic.
Unless the mental health agency has deep pockets and an experienced billing department and has prepurchased the drug, no long-acting risperidone is available for immediate use. The moment a patient says, "Yes, I'll take the shot," the physician must reply, "Great! Come back next week." This is no way to initiate treatment. In addition, because gluteal injection is required, I cannot be alone with my female patients or my homophobic male patients.
There are significant disincentives to the use of long-acting risperidone that should have been anticipated and considered by the manufacturer. I believe that the underutilization of fluphenazine and haloperidol decanoate had more to do with physician reluctance than patient reluctance. The cost and the problems with storage and use of long-acting risperidone are daunting obstacles for a community practitioner who is not surrounded by a bevy of nurses and clerks.
A journal that once contained the word "community" in its title should be taking a lead in demanding pharmacologic treatments that are not simply effective but also accessible.
Dr. Amdur is medical director of Thresholds in Chicago.
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