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Opioid Substitution Therapy for Dependent Health Care Practitioners: Approach With Caution

      To the Editor:
      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.”
      • Hamza H.
      • Bryson E.O.
      Buprenorphine maintenance therapy in opioid-addicted health care professionals returning to clinical practice: a hidden controversy.
      They review the current (and limited) research on the cognitive effects of opioid medications, including buprenorphine. Opioids are indeed potent drugs with primary targets in the central nervous system; it should come as no surprise that they alter brain functioning. Collateral information from a completely different angle comes from the magnetic resonance imaging research of Younger et al.
      • Younger J.W.
      • Chu L.F.
      • D'Arcy N.T.
      • Trott K.E.
      • Jastrzab L.E.
      • Mackey S.C.
      Prescription opioid analgesics rapidly change the human brain.
      They describe changes in neuronal structures when opioid-naive individuals are prescribed morphine for 1 month. These 2 widely divergent angles of study provide a compelling case for caution and further investigation.
      But what should addicted HCPs do while the research sorts itself out? Two different points of view emerge. One view is that proposed by Hamza and Bryson: to hold off on prescribing buprenorphine and other opioid agonists until we know more about the effects of these opioids on critical thinking. The other point of view comes from the vast clinical experience addicted HCPs have with partial or full μ-opioid agonists. Clinicians who have been using opioid replacement therapy for years may be tempted to see the Hamza and Bryson position as withholding humane care or even acting in a prejudicial or punitive fashion toward our colleagues who develop an addictive disease. I believe that careful consideration of that landscape of addiction care in this population upholds the cautious approach proposed in the article by Hamza and Bryson.
      My conclusion comes from 4 lines of reasoning. First, as prevalent as opioid replacement therapy is, we do not have a clear characterization of the recovery status and medication adherence with buprenorphine therapy. Buprenorphine alone or in combination with naloxone is reinforcing.
      • Comer S.D.
      • Collins E.D.
      Self-administration of intravenous buprenorphine and the buprenorphine/naloxone combination by recently detoxified heroin abusers.
      It is unclear whether replacement therapy eliminates the use of other drugs of abuse in naturalistic (nonresearch) settings. Patients taking buprenorphine are known to stockpile their medications, either out of concern for running short or at times to ensure an adequate supply for detoxification after a lapse.
      • Winstock A.R.
      • Lea T.
      • Jackson A.P.
      Methods and motivations for buprenorphine diversion from public opioid substitution treatment clinics.
      Buprenorphine abuse also occurs
      • Cicero T.J.
      • Surratt H.L.
      • Inciardi J.
      Use and misuse of buprenorphine in the management of opioid addiction.
      • Alho H.
      • Sinclair D.
      • Vuori E.
      • Holopainen A.
      Abuse liability of buprenorphine–naloxone tablets in untreated IV drug users.
      • O'Connor J.J.
      • Moloney E.
      • Travers R.
      • Campbell A.
      Buprenorphine abuse among opiate addicts.
      and is difficult to detect with simple screening of body fluids,
      • Martin J.
      Adherence, diversion and misuse of sublingual buprenorphine.
      and continued abuse in a safety-sensitive worker is especially problematic. Buprenorphine and methadone have a street value that alone sets them apart from other medications used in addiction care.
      Second, nearly every HCP who has developed opioid dependence is removed from the work setting while in the initial stages of treatment. Health care practitioners are commonly held out of work for a specified period by professional health programs and licensing bodies in the interest of public safety. This delay provides ample opportunity to complete the process of primary and secondary opioid withdrawal. Although maintenance therapy creates a smooth transition from short-acting, highly reinforcing opioid drugs to long-acting opioid drugs, maintenance therapy is often difficult and painful at the termination of the drug therapy, despite the best efforts of skilled practitioners. This occurrence suggests that the best counseling for the addicted patient (unless one plans lifelong treatment) would be to assist the patient in making a choice about when one will undergo the process of opioid withdrawal not if they will. In the case of HCP patients who are often away from work for a specified period, the best time to complete painful detoxification is the present.
      Third, substantive literature indicates that the long-term prognosis for opioid-addicted HCPs (especially physicians) is excellent with current abstinence-based protocols.
      • McLellan A.
      • Skipper G.
      • Campbell M.
      • DuPont R.
      Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States.
      • DuPont R.L.
      • McLellan A.T.
      • White W.L.
      • Merlo L.J.
      • Gold M.S.
      Setting the standard for recovery: Physicians' Health Programs.
      • Skipper G.E.
      • Campbell M.D.
      • Dupont R.L.
      Anesthesiologists with substance use disorders: a 5-year outcome study from 16 state physician health programs.
      In any medical field, before experts can academically espouse the helpfulness of a new protocol, it must be weighed against the current effective and well-studied paradigm. Therefore, clinicians who are promoting buprenorphine maintenance for HCPs can only assert scientific value of buprenorphine maintenance after they have compared it to the current standard in the same cohort. Today's standard for HCPs is abstinence-based treatment and documented support group meetings, combined with behavioral and drug screen monitoring. With the current effectiveness of treatment in this group, why would anyone want to throw an unevaluated protocol into the mix? One should be even more wary of untested protocols in safety-sensitive workers.
      Fourth, unjust or not, safety-sensitive workers are held to a different standard than other individuals. This has led the Federal Aviation Administration, for example, to restrict the use of any medication or substance that has the potential to impair reasoning or judgment (recently, a limited number of selective serotonin reuptake inhibitor medications have been approved for commercial pilots under the arduous “special issuance” procedure). Medical professionals likely have little concern about the cognitive effects of a pilot who has been stabilized with an antidepressant, such as bupropion or a selective serotonin reuptake inhibitor. However, one airline crash that involves a pilot who is taking such a medication could damage public opinion; the accuracy of this concern does little to alter its intensity. Similarly, one lawsuit against a physician who is taking a compound that has even a hint of potential to impair thinking or judgment could damage public faith in a hospital, health care system, or medicine in general. Whether we like it or not, politics have a say in our medical decisions. Living in the modern world, one cannot espouse any protocol without taking into account the impressions of the public and legal system, lest the effects of one unfortunate outcome prevent subsequent individuals from obtaining life-saving treatment.
      For these reasons, I applaud Hamza and Bryson for their strong note of caution. My guess is it may not be popular, but their call to await further well-designed studies before opioid substitution therapy is implemented is a sound call and good medical judgment.

      References

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        • Bryson E.O.
        Buprenorphine maintenance therapy in opioid-addicted health care professionals returning to clinical practice: a hidden controversy.
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        Prescription opioid analgesics rapidly change the human brain.
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        Self-administration of intravenous buprenorphine and the buprenorphine/naloxone combination by recently detoxified heroin abusers.
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        Drug Alcohol Depend. 2007; 88: 75-78
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        Br J Addict. 1988; 83: 1085-1087
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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 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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      • Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice
        Mayo Clinic ProceedingsVol. 87Issue 8
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          Hamza and Bryson1 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.
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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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      • Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals
        Mayo Clinic ProceedingsVol. 87Issue 8
        • Preview
          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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