Buprenorphine Maintenance and Health Care Professionals

Mayo Clinic
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Mayo Clinic Proceedings published a new article entitled, Buprenorphine Maintenance Therapy in Opioid-Addicted Health Care Professionals Returning to Clinical Practice: A Hidden Controversy.

From the article:

When considering all of the aforementioned issues with buprenorphine diversion, it does not seem reasonable to prescribe this medication to an HCP (Health Care Professional) with a history of opioid addiction. After carefully considering the evidence, we believe that opioid-substitution therapy with buprenorphine is not a reasonable choice for this particular patient population. HCPs are engaged in safetysensitive work that requires vigilance and full cognitive function. We therefore recommend abstinence-based recovery until studies with this specific HCP population performed in a simulated health care environment document that highly safety-sensitive tasks can be performed without deterioration in performance.

They also published an editorial that had a couple of complaints about the article but said:

Hamza and Bryson recommend against buprenorphine maintenance for HCPs with opioid dependence. Instead, they support abstinence-based recovery consistent with the current standard utilized by PHPs. With such standards, several PHPs have demonstrated the lowest relapse rate ever reported in the literature.10 Such high success rates among HCPs are related to multiple factors, including the individual’s motivation to maintain licensure and professional practice, the extensive treatment provided to this group, and the long-term monitoring established by state PHPs.11 In fact, one can clearly make the argument that reported success rates are so high that introducing opioid maintenance to this paradigm would not be appropriate. Individual and large collaborative studies of state PHPs have demonstrated that under ideal circumstances, 80% of physicians being monitored for the 5 years after abstinence-based, 12-step treatment do not have a single relapse.12 Will an institutional review board ever approve a study comparing buprenorphine maintenance with this form of treatment? Can buprenorphine maintenance be justified in the face of such data?

We agree wholeheartedly with Hamza and Bryson that caution is needed in decisions associated with the use of buprenorphine maintenance among HCPs returning to the health care workplace. The foundation information required to make good decisions regarding this medication in this population working in safety-sensitive positions is lacking. The use of a medication that has the potential to undermine cognitive function in HCPs working in an emergency or critical patient care setting cannot be supported at this time, given the lack of evidence of efficacy in this population and the absence of adequate national standards for its use.

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13 thoughts on “Buprenorphine Maintenance and Health Care Professionals

  1. I certainly appreciate the need for caution with meds like buprenorphine and methadone, but absistence can’t always work. What are you going to do when addicts suffer from heart palpitations and the like during withdrawal? As far as I know, the only two viable options are rapid detox (which is somewhat dangerous and astronomically expensive) and gradual dependency reduction. If anything, suboxone seems to be a safer alternative, and it works well for people with minor to moderate opiate dependencies.

    1. We have no concern about buprenorphine for detox, our concern is the explosion of buprenorphine maintenance. It’s become the first line treatment for people with insurance and there is no real informed consent with review of treatment options and their pros/cons.

      Thanks for reading and commenting!

      1. I’ve worked in the medication-assissted treatment field for over 10 years. I do tell my patients about all of their options. Many tell me they’ve already tried to access abstinence-based treatment. The average wait in my part of the country for indigent care is 6 weeks. Non-indigent treatment centers ask patients to show up with several thousand dollars to be admitted. I do believe the gold standard treatment of opioid addiction is inpatient detox followed by a month or more of residential treatment – but that’s out of reach financially for nearly all of the patients I see. Medication-assisted treatment isn’t perfect, but it saves lives and is the only practical option for many.

      2. I’ve got no objection to what you describe. I understand the need to be pragmatic, as long as the clients are given the whole picture. From our position paper on buprenorphine maintenance:

        We’re sadly persuaded that the driving force behind buprenorphine maintenance has little to do with any conviction that it constitutes an ideal approach. It appears, rather, to be driven by a resignation to suboptimal resources—practitioners can’t offer enough monitoring, they can’t offer more than short-term residential or inpatient treatment, they can’t offer community-based recovery support services, they can’t offer outpatient treatment of sufficient duration and intensity, they can’t address all of the client’s other problems that can interfere with recovery, etc.

        We understand that practical constraints challenge most practitioners, and we can respect the necessity of choosing a second best option when the best is not available. However, in such situations we expect informed consent:

        “The best treatment plan for you would include long term treatment, long term community-based recovery support and recovery monitoring for 5 years with rapid re-intervention in the event of a problem. However, this isn’t an option for you. So, ….”

        Patients and their families can’t advocated for better treatment if they don’t know it exists. Providers like you are critical to changing the sad state of affairs.

        Thanks for reading!

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