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Opioid-Abusing Health Care Professionals: Options for Treatment and Returning to Work After Treatment

      We congratulate Mayo Clinic Proceedings and the authors Hamza and Bryson
      • Hamza H.
      • Bryson E.O.
      Buprenorphine maintenance therapy in opioid-addicted health care professionals returning to clinical practice: a hidden controversy.
      on their decision to publish an important and controversial article about the use of buprenorphine maintenance treatment in opioid-dependent health care professionals (HCPs). (Buprenorphine is a semisynthetic opioid agonist-antagonist drug with adverse effects shared with other opioids. It is sometimes used to treat opioid addiction, much as methadone is used.) The Hamza and Bryson article sheds light on some of the problems associated with this practice and with the state monitoring systems (eg, physician health programs [PHPs]) that are in place to secure recovery from addiction and protect the public. Our colleagues in addiction medicine have engaged in bipartisan clinical decision making related to the use of buprenorphine. There are zealots on both sides: some advocate for everyone with opioid dependence to have maintenance buprenorphine treatment, whereas others believe that no one should use it. Without scientific inquiry and data, we lack predictors to help determine the appropriate use of this treatment for our patients. Opioid-dependent HCPs are a distinct, singular group, but the literature reviewed by Hamza and Bryson and their documentation of state policies for the use of this treatment help us to understand buprenorphine's shortcomings in this population as well as limitations of the state monitoring systems, such as PHPs. This article exposes a buprenorphine practice that is relatively unsupported by literature and does not account for risks associated with cognitive deficits. The article also reveals how the lack of national standards for decision making on the timing of HCPs' return to work promotes variable decisions and potential risks.
      The success of methodone use in the maintenance treatment of heroin dependence is well documented.
      • Dole V.P.
      Narcotic addiction, physical dependence and relapse.
      The primary positive outcomes for this treatment include facilitating psychosocial stabilization, increasing treatment retention, reducing infections due to blood-borne pathogens, and reducing criminal behavior. Buprenorphine maintenance has also been studied extensively for the treatment of heroin dependence and has been shown to have outcomes comparable to those of methadone maintenance.
      • Lange W.R.
      • Fuldata P.J.
      • Dax E.M.
      • Johnson R.E.
      Safety and side-effects of buprenorphine in the clinical management of heroin addiction.
      Buprenorphine maintenance treatment of prescription opioid dependence is increasing in frequency and appears to be effective.
      • Weiss R.D.
      • Potter J.S.
      • Fiellin D.A.
      • et al.
      Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial.
      However, no data exist for buprenorphine maintenance treatment of addiction to fentanyl or sufentanil, the most common drugs of abuse among anesthesia personnel.
      • Kintz P.
      • Villain M.
      • Dumestre V.
      • Cirimele V.
      Evidence of addiction by anesthesiologists as documented by hair analysis.
      In addition, the role of buprenorphine maintenance treatment for such safety-sensitive specialties and professions has not been studied.
      Hamza and Bryson thoroughly document the literature on cognitive deficits associated with taking buprenorphine. Although not considered a major hindrance to buprenorphine's use for the general population, cognitive deficits are of great concern to practicing HCPs, whether the deficits result from ongoing buprenorphine use or the opioid on which the HCP was originally dependent. State medical boards and state PHPs need to consider these data when evaluating whether an opioid-dependent HCP can return to work while taking buprenorphine.
      Other problems with buprenorphine maintenance treatment exist. Nonopioid drug use (eg, benzodiazepines, cannabis) is common during maintenance treatment with buprenorphine and requires ongoing monitoring. The dropout rate is substantial for those on buprenorphine maintenance, often leading to opioid relapse.
      • Magura S.
      • Lee S.J.
      • Salsitz E.A.
      • et al.
      Outcomes of buprenorphine maintenance in office-based practice.
      Also, the abuse of buprenorphine appears to be increasing. It is commonly diverted to relieve opioid withdrawal symptoms and to reduce the use of other opioids.
      • Bazazi A.R.
      • Yokell M.
      • Fu J.J.
      • Rich J.D.
      • Zaller N.D.
      Illicit use of buprenorphine/naloxone among injecting and noninjecting opioid users.
      Patients report using it when they are out of money or opioids. Buprenorphine can be used in doses higher than the daily maintenance dose to provide intermittent euphoria and intoxication. All of these factors need to be accounted for among HCPs, especially if the HCP is being considered for return to work in a safety-sensitive position.
      Regarding opioid-abusing HCPs, considerable efforts have been made by numerous state PHPs to ensure abstinence, promote recovery from addiction, protect the public, and afford highly trained professionals the opportunity to return to their chosen fields. However, the survey on state policies regarding HCP work reentry while on buprenorphine treatment, provided by Hamza and Bryson, reveals significant concerns with such programs. The low response rate to their request for information and the lack of any standards among responders suggest a disorganized national system at best. Only under ideal monitoring should those with parenteral opioid dependence return to the health care workplace in settings that expose them to opioids. Without these ideal standards in place, abstinence rates will not be maximized, protection of the public cannot be ensured, and efficacy of such programs will continue to be questioned.
      • Berge K.
      • Seppala M.
      • Lanier W.
      Correspondence.
      State PHPs can be hesitant to ask HCPs to change their specialty or their practice, but such a change may be necessary for those with parenteral opioid dependence, even after appropriate medical treatment, because of the risk of relapse to using the dangerous and possibly lethal medications they encounter at work. The use of maintenance buprenorphine, with its potential to undermine cognitive functioning in a safety-sensitive clinical setting, may require HCP placement in a lower-risk occupational environment. For some, this may be a reasonable, even lifesaving, alternative. Time away from medical practice to prove abstinence and establish recovery behaviors is often recommended for parenteral opioid–dependent HCPs, but it is not standardized within the approach taken by individual states' PHPs. The American Association of Nurse Anesthetists (AANA) should be applauded for its clear, specific recommendations for nurse anesthetists with parenteral opioid dependence. The AANA recommends a minimum of 1 year away from the clinical anesthesia arena after a diagnosis of intravenous drug addiction or major opioid use. Unfortunately, such recommendations do not exist for other medical specialties or personnel. Furthermore, we would welcome evidence-based guidelines from the Federation of State Physician Health Programs similar to those from the AANA.
      Hamza and Bryson recommend against buprenorphine maintenance for HCPs with opioid dependence. Instead, they support abstinence-based recovery consistent with the current standard utilized by PHPs. With such standards, several PHPs have demonstrated the lowest relapse rate ever reported in the literature.
      • DuPont R.L.
      • McLellan A.T.
      • Carr G.
      • Gendel H.
      • Skipper G.E.
      How are addicted physicians treated? A national survey of Physician Health Programs.
      Such high success rates among HCPs are related to multiple factors, including the individual's motivation to maintain licensure and professional practice, the extensive treatment provided to this group, and the long-term monitoring established by state PHPs.
      • Berge K.H.
      • Seppala M.D.
      • Schipper A.M.
      Chemical dependency and the physician.
      In fact, one can clearly make the argument that reported success rates are so high that introducing opioid maintenance to this paradigm would not be appropriate. Individual and large collaborative studies of state PHPs have demonstrated that under ideal circumstances, 80% of physicians being monitored for the 5 years after abstinence-based, 12-step treatment do not have a single relapse.
      • McLellan A.T.
      • Skipper G.S.
      • Campbell M.
      • DuPont R.L.
      Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States.
      Will an institutional review board ever approve a study comparing buprenorphine maintenance with this form of treatment? Can buprenorphine maintenance be justified in the face of such data?
      Hamza and Bryson state that potentially addictive substances when appropriately prescribed can interfere with mandatory drug testing and that their use may be “psychotoxic.” We disagree on both counts. Because positive urine toxicological results in HCPs are routinely confirmed by gas chromatography or mass spectrometry techniques, prescribed drugs do not interfere with mandatory drug testing. We object to the use of the term psychotoxic because it is not defined. We are not aware of any published data that support the premise that buprenorphine maintenance therapy causes increased risk of relapse in HCPs.
      It has been our experience in working in the physician health field for several years that hospitals and clinics are extremely concerned that HCPs who take potentially impairing medications, even when appropriately prescribed, constitute increased risk and liability for these institutions. Also, it is unclear whether a malpractice insurance company would support and insure a physician returning to work on buprenorphine maintenance. Initial, as yet unpublished, studies from PHPs suggest that physicians who are being monitored by PHPs (without buprenorphine treatment) have fewer malpractice claims during the monitored period (typically 5 years) than in the 5 years preceding treatment and monitoring (D. Gunderson, MD, oral communication, December 2011). Further favorable reports are anticipated to mitigate this concern on the part of hospitals and clinics for those physicians in monitoring, but they are unlikely to alter concerns over the potential cognitive impairment associated with buprenorphine maintenance in the health care workplace.
      Finally, there may be an alternative to the use of opioid maintenance to reduce risk of relapse. A large treatment center (P. Earley, MD, and M. Oreskovich, MD, oral communication, December 2011) and a large PHP (P. Earley, MD, and M. Oreskovich, MD, oral communication, December 2011) have demonstrated a significant reduction in relapse when opioid-dependent HCPs receive monthly injections of depot naltrexone, an opioid antagonist drug that lacks the potentially intoxicating effects of buprenorphine. Routine use of this medication may negate the need or indication for buprenorphine maintenance among HCPs.
      We agree wholeheartedly with Hamza and Bryson that caution is needed in decisions associated with the use of buprenorphine maintenance among HCPs returning to the health care workplace. The foundation information required to make good decisions regarding this medication in this population working in safety-sensitive positions is lacking. The use of a medication that has the potential to undermine cognitive function in HCPs working in an emergency or critical patient care setting cannot be supported at this time, given the lack of evidence of efficacy in this population and the absence of adequate national standards for its use. We do support national guidelines regarding the use of buprenorphine among HCPs in the workplace, with limits regarding the type of work appropriate for this patient population.

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      Linked Article

      • Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy
        Mayo Clinic ProceedingsVol. 87Issue 3
        • Preview
          It remains controversial whether it is safe for recovering health care professionals to return to clinical practice after treatment for drug addiction. One specific component of reentry that remains particularly contentious is the use of pharmacotherapeutics, specifically buprenorphine, as opioid substitution therapy for health care professionals who wish to return to clinical work. Because health care professionals are typically engaged in safety-sensitive work with considerable consequences when errors occur, abstinence-based recovery should be recommended until studies demonstrate that it is safe to allow this population to practice while undergoing opioid substitution therapy.
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