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Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals

      To the Editor:
      In their article entitled “Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals,”
      • Hamza H.
      • Bryson E.O.
      Buprenorphine maintenance therapy in opioid-addicted health care professionals returning to clinical practice: a hidden controversy.
      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. The authors accept a role for medications such as buprenorphine and methadone when “used to help retain people in the detoxification phase of treatment” but postulate that “maintenance is another matter and indicates severe difficulty with maintaining recovery.” In fact, the primary challenge faced by health care professionals and recipients of addiction treatment of all kinds is precisely this “difficulty.” In other words, the problem is not the achievement of abstinence but how to maintain it.
      • Newman R.G.
      The need to redefine addiction.
      No empirical evidence is presented to support the recommended exclusion from practice, across the board, of health care professionals who are being prescribed buprenorphine. None of the studies cited relied on employment data, malpractice experience, or other measures or proxies of practice competence, and several reported results of buprenorphine administration (some by intravenous injection) among nontolerant individuals. Furthermore, to the extent that there is a basis for concern over individuals receiving maintenance treatment with opioid agonists, it would presumably be vastly greater for those receiving opioids for pain management (acute or chronic) and probably extend to those taking benzodiazepines for insomnia, antidepressants, and a wide variety of other medications.
      The efficacy of maintenance treatment of addiction has been confirmed consistently in reports from throughout the world for almost half a century. This treatment has been strongly endorsed by the highest governmental, academic, and clinical authorities in the United States and internationally. It is ironic that health care professionals, of all people, should argue that it should be rejected when it comes to colleagues who want and need the help that it can provide.

      References

        • 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
        • Newman R.G.
        The need to redefine addiction.
        N Engl J Med. 1983; 308: 1096-1098

      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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      • 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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      • 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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