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. Many studies compared performance with buprenorphine vs methadone, clearly showing that although buprenorphine causes less impairment, it still causes impairment. Unfortunately, evidence is lacking in the specific population of HCPs treated with this medication. Studies need to be conducted that evaluate participants' ability to perform tasks specific to those required of HCPs while undergoing buprenorphine therapy. These studies should involve standardized patients or operating room simulation, using realistic scenarios that require rapid analysis and action, complex decision making, eye-hand coordination, and fine motor skills.
Considerations of damage control and harm reduction are appropriately influential when prescribing pharmacotherapeutic adjuncts in a comprehensive program of recovery. For example, if the only way for a heroin addict to maintain abstinence is to become dependent on methadone or buprenorphine, the risk-benefit ratio may be justified. From an epidemiologic standpoint, dependence on these other medications can reduce the risk of human immunodeficiency virus infection, hepatitis, and other complications related to intravenous drug use. These harm-reducing measures multiply in heroin-abusing populations that are known to share needles, but they hardly apply to the population of addicted HCPs because these people typically have access to sterile needles and syringes, thus reducing that risk exponentially.
The effect of abstinence-based recovery has implications apart from the public health and safety considerations. The improved quality of life for the professional under this model of treatment further justifies the use of the abstinence model specifically in HCPs, and the literature suggests that the success rate of PHPs is much higher than in other populations.22
This offers another argument against use of buprenorphine in HCPs and one that may be more persuasive to addicted professionals and others who are considering how to get them needed help.
Abstinence from all potentially addictive drugs remains the criterion standard for HCPs in recovery. Most PHPs that use an abstinence-based model for physicians in recovery report success rates far in excess of other programs.23
There is a long history of success using this model, and the most recent data reported only 22% of physicians testing positive for drugs of abuse at any time during their 5-year monitoring contract and fully 71% remaining licensed and employed 5 years after their initial treatment.24
In certain situations, potentially addictive drugs can and should be used when the benefit outweighs the risk, but in most of these cases, the situation is extreme and generally time limited. In the case of HCPs in early recovery who are not working clinically, patient safety is not compromised, but the longer-term use of these potentially addictive medications is problematic. These medications can interfere with mandated drug testing and increase the liability carried by the HCP and employer should there be a bad patient outcome. The inability to remain abstinent is often associated with multiple relapses. Although these medications can be widely used to help retain people in the detoxification phase of treatment, maintenance is another matter and indicates severe difficulty with maintaining recovery. More important, these drugs may actually be “psychotoxic” to those in recovery, and inability to remain abstinent without opioid maintenance therapy may be a potential predictor of increased risk for relapse (Mark Broadhead, MD, medical director of the Idaho Physician Health Program, oral communication, February 24, 2011).
The real possibility of relapse once recovering HCPs have returned to clinical practice has a number of implications for the health and safety of the HCPs and their patients. Because the risk of relapse and death is highest during the first year of sobriety and decreases over time, it seems reasonable that the HCP in recovery should spend some time away from clinical practice before returning to work. The appropriate length away from clinical practice after discharge from the initial inpatient treatment facility has not been determined. Most nursing programs require a period away from clinical practice, ranging from a few months to a year or more, but this practice is not standardized and varies from state to state. Physician programs are equally varied, and although recommendations suggesting a minimum of 1 year have been made,25
there is still no consensus.26
When a formerly opioid-dependent HCP who is maintained with a full μ-opioid antagonist (naltrexone) returns to clinical practice, it undeniably strengthens the safety net. Conversely, if a reentrant is taking a partial μ-agonist and relapses on a very potent full μ-agonist, such as fentanyl, it is reasonable to assume that this would precipitate an overdose.