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Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice

      To the Editor:
      Hamza and Bryson
      • Hamza H.
      • Bryson E.O.
      Buprenorphine maintenance therapy in opioid-addicted health care professionals returning to clinical practice: a hidden controversy.
      argue against health care professionals returning to clinical practice while taking buprenorphine, based on purported neurocognitive effects. Their argument is based on weak science and flawed assumptions. Studies examining neurocognitive effects associated with buprenorphine are mostly based on small, selected samples and frequently fail to account for preexisting neurocognitive function or to distinguish between short- and long-term effects (after development of full tolerance) of the drug. Most studies use weak, ie, nonrandomized study designs. None of the studies was based on health care professionals. These limitations preclude firm conclusions regarding the presence or absence of neurocognitive effects associated with buprenorphine.
      More important, the impact of purported neurocognitive effects on job performance is not clear. Laboratory tests that show subtle effects cannot be extrapolated to real work performance. This would require direct measures of job task performance after long-term use of the drug—ideally using randomized study designs.
      Furthermore, many factors affect neurocognitive performance. Examples include baseline ability, age, previous head injury, impaired sleep, chronic illness, viral infection, and many commonly prescribed medications (including those that are not controlled). Thus, even if buprenorphine is shown through scientifically valid studies to have meaningful effects on neurocognitive performance after long-term use, it would be wrong to single out health care professionals taking this medication. Rather, the same standards for evaluation of neurocognitive performance would have to be uniformly applied to all health care professionals regardless of the cause for any decrement in performance. It is doubtful that most health care organizations are prepared to undertake such mass neurocognitive screening given its high costs and uncertain benefit.

      Reference

        • Hamza H.
        • Bryson E.O.
        Buprenorphine maintenance therapy in opioid-addicted health care professionals returning to clinical practice: a hidden controversy.
        Mayo Clin Proc. 2012; 87: 260-267

      Linked Article

      • Opioid Substitution Therapy for Dependent Health Care Practitioners: Approach With Caution
        Mayo Clinic ProceedingsVol. 87Issue 8
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          In a recent article in Mayo Clinic Proceedings, Hamza and Bryson visit the difficult decisions involved in returning addicted health care practitioners (HCPs) back to work; their article focuses on maintenance therapy of addiction disorders with opioid maintenance therapy. Specifically, they propose that “abstinence-based recovery should be recommended until studies demonstrate that it is safe to allow this population to practice while undergoing opioid substitution therapy.”1 They review the current (and limited) research on the cognitive effects of opioid medications, including buprenorphine.
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      • Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals
        Mayo Clinic ProceedingsVol. 87Issue 8
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          In their article entitled “Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals,”1 Hamza and Bryson draw a distinction between a “harm reduction and damage control model” of opioid-addiction management and treatment for which abstinence (including, very specifically, abstinence from prescribed agonists) defines both the treatment process and its therapeutic objective. The authors' notion that there is an inherent contradiction between continued prescribing of medication and a patient's “recovery” and the suggestion that reducing harm and controlling damage are not part and parcel of any practice of medicine are extraordinary.
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      • Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy
        Mayo Clinic ProceedingsVol. 87Issue 8
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          The article by Hamza and Bryson1 cites several studies to support their opinion that health care professionals should not be returned to practice if their treatment includes opioid agonist therapy. The quality of the evidence cited is poor. Three of the studies2-4 evaluate the effects of buprenorphine in “healthy volunteers” rather than in patients after careful dose titration. Other studies are small and poorly controlled for the duration of therapy and other drug use. The most relevant study5 compares patients taking buprenorphine with those taking naltrexone.
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      • In reply
        Mayo Clinic ProceedingsVol. 87Issue 8
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          We read with great interest the Letters to the Editor written in response to our article discussing the use of buprenorphine maintenance therapy in opioid-addicted health care professionals, and we are encouraged by the discussion that continues to evolve around this important issue. We are pleased that our review has generated so much conversation from those on the front lines of addiction medicine and welcome the opportunity to reply to the letters from Drs Earley, Newman, Selzer and Stancliff, and Fiscella.
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