Barring Healthcare Professionals from Working while on Buprenorphine

While buprenorphine has been prescribed for many patients over the last 10 years, there’s still controversy about whether healthcare professionals should be allowed to work while on buprenorphine.

In an article in March 2012 Mayo Clinic Proceedings, Hamza and Bryson  cite studies that support their conclusion that medical professionals should not be allowed to work while taking buprenorphine as maintenance for opioid addiction. The authors say studies show that people taking buprenorphine have some impairment when performing safety-sensitive tasks that are required in practice as a physician. (1)

I read this article with great interest, since I have been prescribing buprenorphine and telling my patients they won’t be impaired while taking a maintenance dose. Wanting to know if I am misleading patients, I scrutinized the studies cited in this paper.

I’m not sure the authors’ conclusions are backed up by the studies they cite.

The most worrisome misinterpretation was the Schindler et al study. The Mayo study by Hamza and Bryson interpreted the Schindler study thusly: “significant differences were found between them [methadone and buprenorphine groups] and the controls.” But when I read the original study, the authors’ conclusion was really the opposite: “The synthetic opioid-maintained subjects investigated in the current study did not differ significantly in comparison to healthy controls…” (2)

Hmmm…I’m confused.

When I looked at other articles cited by Hamza and Bryson, I discovered that what I read didn’t match Hamza and Bryson’s conclusions of what I read.

Three of the studies cited in the Mayo article (Pickworth et.al., Jensen et. al., and Zacny et.al.) all looked at healthy volunteers who were given buprenorphine, then tested to see if they were impaired. In other words, these test subjects weren’t opioid dependent. All three studies showed impairment, and I don’t doubt it, because opioid-naïve subjects would be expected to feel a great deal of opioid effect with their first dose of buprenorphine. But studies of opioids-naïve subjects given buprenorphine don’t seem applicable to opioid-addicted patients on buprenorphine for maintenance.

The Rapeli et al study looked at methadone and buprenorphine patients in early recovery, so these groups would be expected to be different than those on established maintenance therapy.

Soyka et al compared opioid addicts on buprenorphine and methadone at 2 weeks, then at 8-10 weeks. This study also had a control group. The patients on methadone and buprenorphine had impaired cognition on testing compared to the controls, but they improved with length in treatment. This study was randomized but not blinded. This means patients and researchers knew who was on methadone, buprenorphine, and who was a control subject. Interestingly, in a later letter to the editor defending their conclusions, Hamza and Bryson mistakenly claimed the study was double-blinded, but clearly it was not.  Also the study was relatively small, since only 46 patients completed the study. The purpose of the study was to see if methadone was more impairing than buprenorphine. The authors of the Soyka study didn’t conclude the buprenorphine group was impaired to the point they were unable to work, only that they performed better than methadone patients.

One study, by Messinis et al, did compare abstinent heroin addicts on naltrexone with opioid addicts on maintenance buprenorphine, and showed the buprenorphine group had more cognitive impairment than the naltrexone group in cognitive functions. To me, this is the main study that speaks to the actual issue of impairment. It gives a basis to require more studies be done. However, the small size of the study, 18 patients, limits the impact of this study. (3)

The ideal study to resolve this issue would be a double blinded prospective study of opioid-addicted healthcare professionals who are randomized either to abstinence-base treatment or buprenorphine maintenance treatment. Then cognitive abilities can be compared at various times during recovery, like 3 months, 6 months, 1 years, and 2 years. Such a test is unlikely to be done, since most addicted professionals enter abstinence-based recovery, and have a high rate of success.

I do think medication-free recovery is the ideal. I acknowledge that’s my bias, even though I strongly believe medication-assisted treatment is a life-saving option. But then, medication-free treatment is the ideal for all diseases. If a patient can achieve good blood pressure control by changing her diet and exercise, I think most of us would agree that’s a superior outcome to taking blood pressure medication to achieve the same result.

Most doctors and dentists have the resources to afford the prolonged inpatient treatment needed for medication-free recovery. The monitoring required for continued licensure is additional leverage and accountability that most opioid addicts don’t have after leaving inpatient treatment. These factors produce excellent recovery rates in these healthcare professionals, much better than that achieved by the average opioid addict.

But no recovery works for everyone. If a healthcare professional has failed traditional abstinence-based recovery, but is able to do well on medication-assisted recovery with buprenorphine, is the data strong enough to say such a recovering person on a stable dose of buprenorphine can’t work in healthcare?

We must be careful about this decision. If the decision is going to be based solely on patient safety, and not on a bias against medication-assisted recovery, then healthcare professionals on opioids for acute or chronic pain must also logically be removed from the workforce, unless we can prove they don’t have cognitive deficits from prescribed opioids. And what of other medications, like benzodiazepines, which are more likely than opioids to cause impairment?

If professional monitoring boards rely on the evidence cited by this study to refuse to allow healthcare professionals on buprenorphine to return to work, they leave themselves open to accusations inconsistent safety standards if they allow other healthcare professionals to work while being prescribed opioids or benzodiazepines.

It would be a mammoth task to monitor every healthcare professional who is prescribed a controlled substance. But if a professional on stable a dose of buprenorphine can’t work safely, how can we assume a surgeon who takes legitimately prescribed opioids for back pain is safe to work?

Frankly I suspect most of the posturing about the dangers of healthcare workers on buprenorphine is really an attempt to remove medication-assisted recovery as a treatment option for healthcare professionals. I don’t know if the mayo article authors, Hamza and Bryson, have any underlying bias against medication-assisted treatments, or perhaps biases favoring abstinence as the only worthy treatment goal. I don’t know these two people at all. But my impression is that they have taken a sweeping position supported by shaky evidence. The studies they cite are evidence enough to call for larger studies, but don’t seem adequate in themselves to deny a potentially life-saving treatment to a healthcare professional.

  1. Hamza H, and Bryson E, “Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy, Mayo Clinic Proceedings., 2012, 87(3);260-267
  2. Schindler SD, et al, “Maintenance therapy with synthetic opioids and driving aptitude, European Addiction Research, 2004; 10(2):80-87acol.
  3. Messinis et al, “Neuropsychological functioning in buprenorphine maintained patients versus abstinent heroin abusers on naltrexone hydrochloride therapy”. Hum. Psycholpharm. 2009;24(7):524-531
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7 responses to this post.

  1. Posted by dbc910281927681 on September 3, 2012 at 1:02 am

    This is like some bad joke … As you say, a person on full agonist opiods for back pain is ok, but not someone on buprenorphine. Argh. This country is so frustrating sometimes.

    Reply

  2. Posted by dbc910281927681 on September 3, 2012 at 1:04 am

    Oh, and BTW, *many* Buprenorphine doctors are themselves recovering addicts and on Buprenorphine themselves. I hope this wouldn’t extend to them … and instead only cover surgeons, but it sets a bad precedent regardless.

    Reply

    • Posted by dbc910281927681 on September 3, 2012 at 1:07 am

      Of course, as you say, I don’t mean to indicate it is a good policy for even surgeons. It is absurd. Absolutely insane in fact. Political motivations must be behind this, as you allude to in the inconsistencies.

      Reply

  3. Posted by Gary Mallit on January 20, 2013 at 12:08 am

    First I see no difference between substance abusers and opiate dependent practitioners taking buprenorphene for pain. It has been well established that pain patients do not receive the cognitive effects (euphoria) etc. that abusers do.

    Most reviewers on the board have limited education on this unique partial agonist. Not only does it not have the CNS effects that opiates have but they block (Prevent) the patient from receiving the CNS effects of a pure mu opiate if taken. Therefore it protects against the effects of relapses even if a person while on buprenorphene takes other full mu opiates. buprenorphene is a unique drug that can revolutionize treatment once physician’s believe that a 1939 “textbook” the Big Book of AA can be used in conjunction with these new medical sciences.

    As medical professionals we should use all tools available. There is no effidence that buprenorphene affects cognition. In fact so as increase competent practitioner do neuropsychiatric testing to see if these talented people are mentally intact. I’d like it see some of the elderly practitioners tested against those on Buprenorphene. I’m almost sure age would show more deficit than buprenorphene. Buprenorphene is a “partial mu agonist” and a kappa antagonist which gives it tis unique properties. As said there are many surgeons and doctors working on pure mu opiates for pain without question. If a person is in a monitoring program watched closesly by weekly peer meetings, random urinalysis, therapy with reports to the board, work site monitors and more why should they be discriminated against because they suffer from an illness such drug dependence in remission, chronic pain or any of a number of other conditions which can effect them more than those in monitored recovery.

    There are shortage of good primary care practitioners and addiction treatment professionals. Why waste these talented people who have subjected themselves to severe intuition into their personal life to prove to.the licensing boards they are safe. We are in the year 2013 and advances allow practioner to work helping people competently.

    Reply

  4. Posted by S Tison on February 27, 2013 at 1:19 pm

    Does anyone have access to a compiled list of monitoring boards for nursing that will allow the use of suboxone. I practiced under the radar of HIPPA and have been successful in recovery for eight years on medication assisted treatment. I would gladly move out of state to be in compliance and remain relapse free on my suboxone. South Carolina does not allow practice while on suboxone.

    Reply

    • You can find this information in an article by Hamza & Bryson at Mayo Clinic Proceedeings, I think March of 2012. It’s kind of a review article, though I think it’s a poorly done article which misrepresented the studies it described. Those authors called doctor and nurse monitoring boards for statements about whether they allow suboxone, but many of these programs didn’t reply.
      For more on this topic see my blog of September 3rd, 2012

      Reply

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