Should Addicted HCPs Return to Work While on Buprenorphine?

Megan Brooks

March 08, 2012

March 8, 2012 — Opioid-addicted healthcare professionals (HCPs) should not return to clinical practice while undergoing opioid substitution therapy with buprenorphine, a new report concludes.

A special article published in the March issue of the Mayo Clinic Proceedings notes that "most studies evaluating the effects of buprenorphine maintenance therapy found some degree of impairment when participants were subjected to a variety of tests designed to assess particular nuances of higher cerebral functioning."

Because HCPs are typically engaged in "safety-sensitive work" that requires "vigilance and full cognitive function" 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," Heather Hamza, CRNA, MS, from the University of Southern California in Los Angeles, and Ethan O. Bryson, MD, from Mount Sinai Medical Center in New York City, write.

Dr. Bryson recently finished a book on the topic of addicted healthcare professionals, scheduled for release in September, in which he calls for the creation of national standards for treatment and monitoring.

In a linked editorial, Marvin D. Seppala, MD, chief medical officer of the Hazelden Foundation, which operates addiction treatment centers, and Michael R. Oreskovich, MD, FACS, from the University of Washington School of Medicine in Seattle, note that although buprenorphine use is not considered a major hindrance in 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 [physician health programs] need to consider these data when evaluating whether an opioid-dependent HCP can return to work while taking buprenorphine," they write.

Report Called "Biased"

However, John A. Renner Jr, MD, chair of the American Psychiatric Association (APA) Council on Addiction Psychiatry, cautioned that "the article is biased, and its conclusions are not relevant for the majority of physicians in recovery."

"It is unlikely that these opinions are shared by the majority of physicians who specialize in the pharmacotherapy of addictions," Dr. Renner told Medscape Medical News.

Designed to rehabilitate opioid-addicted HCPs and return them to clinical practice, PHPs have been created by most state medical boards. Requirements for these programs vary but typically include monitoring for a period of at least 5 years as a way for the physician to keep his or her license.

Hamza and Dr. Bryson asked the 51 PHPs in the United States about their policy regarding HCPs returning to the workplace while on buprenorphine treatment.

"Fully 25 remained unavailable for comment despite our multiple attempts to contact them," they report. Spokespersons for 2 programs said they were unwilling to discuss this issue, and 1 program director reported feeling "uncomfortable" revealing the state's practice. The nursing programs were "a little more cooperative," the authors report, although 16 of 51 programs still remained unavailable for comment on this issue.

Controversial Issue

In an interview with Medscape Medical News, Dr. Bryson said he "fully expected that these programs would freely share this information. I guess I didn't realize that it is such a controversial issue," he said.

"Initially," said Dr. Bryson, "the goal of this project was to look at what evidence there is to support the use of buprenorphine in [HCPs] returning to work. The question originally arose from one of my colleagues asking whether or not this was allowed, and I didn't know the answer. I was surprised to find out that there is no US national policy, and the individual policies that are set by the states are not the same — there are a wide range of practices."

Most medical societies do not have a specific policy on this issue. An exception is the American Association of Nurse Anesthetists (AANA), which does have clear, specific recommendations for nurse anesthetists with parenteral opioid dependence, Drs. Seppala and Oreskovich point out.

"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."

Drs. Seppala and Oreskovich say they agree that "caution is needed" in decisions associated with the use of buprenorphine maintenance among HCPs returning to the healthcare workplace. "The foundation information required to make good decisions regarding this medication in this population working in safety-sensitive positions is lacking," they conclude.

Dr. Bryson said buprenorphine maintenance therapy "does have a role in certain circumstances, but in the population of healthcare professionals...it's not worth the risk until we actually determine that it is safe," he said.

He added that there is evidence in the literature that PHPs that use an abstinence-based model for physicians in recovery have "success rates in excess of other programs."

In 1 recent study, only 22% of physicians tested positive for drugs of abuse at any time during their 5-year monitoring period, and 71% remained licensed and employed 5 years after their initial treatment (DuPont et al, J Subst Abuse Treat, 2009;37:1-7).

Funding for the study was provided by institutional and departmental sources. The authors and editorialists have disclosed no relevant financial relationships.

Mayo Clin Proc. 2012:87:213-215,260-267. Full article, Editorial

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