To the Editor:
The article by Hamza and Bryson1 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 studies2-4 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 study5 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.