To the Editor:
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. Most studies use weak, ie, nonrandomized study designs. None of the studies was based on health care professionals. These limitations preclude firm conclusions regarding the presence or absence of neurocognitive effects associated with buprenorphine.
More important, the impact of purported neurocognitive effects on job performance is not clear. Laboratory tests that show subtle effects cannot be extrapolated to real work performance. This would require direct measures of job task performance after long-term use of the drug—ideally using randomized study designs.
Furthermore, many factors affect neurocognitive performance. Examples include baseline ability, age, previous head injury, impaired sleep, chronic illness, viral infection, and many commonly prescribed medications (including those that are not controlled). Thus, even if buprenorphine is shown through scientifically valid studies to have meaningful effects on neurocognitive performance after long-term use, it would be wrong to single out health care professionals taking this medication. Rather, the same standards for evaluation of neurocognitive performance would have to be uniformly applied to all health care professionals regardless of the cause for any decrement in performance. It is doubtful that most health care organizations are prepared to undertake such mass neurocognitive screening given its high costs and uncertain benefit.