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Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy

      To the Editor:
      The article by Hamza and Bryson
      • Hamza H.
      • Bryson E.
      Buprenorphine maintenance therapy in opioid-addicted health care professionals returning to clinical practice: a hidden controversy.
      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 studies
      • Pickworth W.B.
      • Johnson R.E.
      • Holicky B.A.
      • Cone E.J.
      Subjective and physiologic effects of intravenous buprenorphine in humans.
      • Zacny J.
      • Conley K.
      • Galinkin J.
      Comparing the subjective, psychomotor and physiologic effects of intravenous buprenorphine and morphine in healthy volunteers.
      • Jensen M.
      • Sjogren P.
      • Upton R.N.
      • et al.
      Pharmacokinetic-pharmacodynamic relationships of cognitive and psychomotor effects in intravenous buprenorphine infusion in human volunteers.
      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 study
      • Messinis L.
      • Lyros E.
      • Andrian V.
      • et al.
      Neuropsychological functioning in buprenorphine maintained patients versus abstinent heroin abusers on naltrexone hydrochloride therapy.
      compares patients taking buprenorphine with those taking naltrexone. The findings were not striking; although the buprenorphine patients differed significantly from the controls on several measures, they did not differ from the naltrexone group. In fact, the authors of this study state, “Furthermore, the non-differing percentage of abnormal cases between the two patient groups led us to infer that treatment with either BPM [buprenorphine] or FHAN [naltrexone] is not accompanied by qualitative differences in the cognitive profiles of these patients.”
      The poor response rate of the physician health programs they surveyed may have more to do with the skill of the authors in engaging their study participants than with secretive practices by these programs. The survey protocol is vague, and there is no statement of institutional review board approval for the study. Furthermore, the methods in the survey may have resulted in invalid findings. For example, we find the comment describing the New York program as “no policy, left to treating psychiatrist” extremely misleading. In fact, treatment decisions are made in collaboration with the physician health program and subject to its approval. Although it is not uncommon for a participant to require agonist therapy initially, continued use is carefully reevaluated, including the use of neuropsychiatric evaluation and clinical skills assessment before return to work if indicated. The same approach is used for participants prescribed other psychoactive medications with potential cognitive untoward effects.
      Much in this article is informed by bias rather than science. The authors characterize opioid-addicted health care professionals as “masters of drug diversion.” This view perpetuates stigma by stereotyping health care professionals with substance use disorders. Although the authors note that physicians in physician health programs tend to do better in treatment than other patients with substance use disorders, without good evidence they promote naltrexone because “it undeniably strengthens the safety net.” The pervasive bias is further reflected in value judgments about “the improved quality of life for the professional” with the use of the abstinence model and by citing an oral communication describing opioid agonist therapy as “psychotoxic” and “a potential predictor of increased risk for relapse.” Hamza and Bryson are correct in their conclusion that more study would contribute to a fuller understanding of the role of opioid agonist therapy in the treatment of health care professionals. It is unfortunate that their review and survey results are so unilluminating.

      References

        • Hamza H.
        • Bryson E.
        Buprenorphine maintenance therapy in opioid-addicted health care professionals returning to clinical practice: a hidden controversy.
        Mayo Clin Proc. 2012; 87: 260-267
        • Pickworth W.B.
        • Johnson R.E.
        • Holicky B.A.
        • Cone E.J.
        Subjective and physiologic effects of intravenous buprenorphine in humans.
        Clin Pharmacol Ther. 1993; 55: 570-576
        • Zacny J.
        • Conley K.
        • Galinkin J.
        Comparing the subjective, psychomotor and physiologic effects of intravenous buprenorphine and morphine in healthy volunteers.
        J Pharmacol Exp Ther. 1997; 282: 1187-1197
        • Jensen M.
        • Sjogren P.
        • Upton R.N.
        • et al.
        Pharmacokinetic-pharmacodynamic relationships of cognitive and psychomotor effects in intravenous buprenorphine infusion in human volunteers.
        Basic Clin Pharmacol Toxicol. 2008; 103: 94-101
        • Messinis L.
        • Lyros E.
        • Andrian V.
        • et al.
        Neuropsychological functioning in buprenorphine maintained patients versus abstinent heroin abusers on naltrexone hydrochloride therapy.
        Hum Psychopharmacol. 2009; 24: 524-531

      Linked Article

      • 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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      • 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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