Abstinence therapy safer, preferable for opioid-addicted HCPs

Many health care professionals (HCPs) have easy access to controlled medications and the diversion and abuse of drugs among this group may be as high as 10%. Controversy surrounds the safety of allowing addicted HCPs to return to clinical practice while undergoing medical treatment with opioid substitution therapy such as buprenorphine. In the March issue of Mayo Clinic Proceedings, Heather Hamza, CRNA, MS, of the Department of Anesthesiology, Los Angeles County Medical Center at the University of Southern California, and Ethan O. Bryson, MD, of the Departments of Anesthesiology and Psychiatry, Mt. Sinai Medical Center, New York, review the evidence and call for abstinence-based recovery instead.

"Because health care professionals are typically engaged in safety-sensitive work with considerable consequences when errors occur, abstinence-based recovery should be recommended until studies demonstrate that it is safe to allow this population to practice while undergoing opioid replacement therapy," says Dr. Bryson.

Buprenorphine is not completely free of abuse potential. Ms. Hamza and Dr. Bryson comprehensively reviewed a number of studies that examine the risk. "Opioid-addicted HCPs are masters of drug diversion. In this population, intelligence can be used to cleverly circumvent narcotic accountability and drug substitution. It does not seem reasonable to prescribe this medication to an HCP with a history of drug addiction," Ms. Hamza says.

Many trials have assessed psychomotor performance, decision-making ability, and neurocognitive functioning under the influence of buprenorphine. "Most found some degree of impairment when participants were subjected to a variety of tests designed to assess particular nuances of higher cerebral function," Dr. Bryson reports. "Studies using standardized patients or operating room simulation, presenting realistic scenarios that require rapid analysis and action, complex decision making, and fine motor skills are needed."

Most state medical and nursing societies provide professional health programs (PHPs) which allow for the eventual return of addicted practitioners to clinical practice. Many were unavailable or declined to comment on their policies regarding the re-entry of HCPs while undergoing buprenorphine therapy, an indicator of the controversy surrounding this issue. However, published literature suggests that the success rates of PHPs is higher than in other populations, and most PHPs that use an abstinence-based model for physicians in recovery report success rates in excess of other programs.

"Abstinence from all potentially addictive drugs remains the criterion standard for HCPs in recovery," Hamza and Bryson conclude. "HCPs are engaged in safety-sensitive work that requires vigilance and full cognitive function. We therefore recommend abstinence-based recovery until studies with this specific population document that highly safety-sensitive tasks can be performed without deterioration in performance."