Substance Abuse
ISSN: 0889-7077 (Print) 1547-0164 (Online) Journal homepage: http://www.tandfonline.com/loi/wsub20
Buprenorphine-Naloxone Treatment in Physicians and Nurses With Opioid Dependence María Dolores Braquehais MD, PhD, Christian Fadeuilhe MD, Anders Håkansson MD, Miquel Jordi Bel MD, María Cecilia Navarro MD, Carlos Roncero MD, PhD, Eugeni Bruguera MD & Miquel Casas To cite this article: María Dolores Braquehais MD, PhD, Christian Fadeuilhe MD, Anders Håkansson MD, Miquel Jordi Bel MD, María Cecilia Navarro MD, Carlos Roncero MD, PhD, Eugeni Bruguera MD & Miquel Casas (2015) Buprenorphine-Naloxone Treatment in Physicians and Nurses With Opioid Dependence, Substance Abuse, 36:2, 138-140, DOI: 10.1080/08897077.2014.996698 To link to this article: http://dx.doi.org/10.1080/08897077.2014.996698
Accepted author version posted online: 04 Mar 2015.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wsub20 Download by: [University of Lethbridge]
Date: 06 November 2015, At: 09:24
SUBSTANCE ABUSE, 36: 138–140, 2015 Copyright Ó Taylor and Francis Group, LLC ISSN: 0889-7077 print / 1547-0164 online DOI: 10.1080/08897077.2014.996698
Buprenorphine-Naloxone Treatment in Physicians and Nurses With Opioid Dependence
Downloaded by [University of Lethbridge] at 09:24 06 November 2015
Marıa Dolores Braquehais, MD, PhD,1,2 Christian Fadeuilhe, MD,2 Anders Hakansson, MD,3 Miquel Jordi Bel, MD,1,2 Marıa Cecilia Navarro, MD,1 Carlos Roncero, MD, PhD,1,2,4 Eugeni Bruguera, MD,1,2 and Miquel Casas1,2
To the Editor: Substance use disorders (SUDs) in physicians and nurses have major professional, legal, and health consequences,1–3 and over and above the overall risk of developing SUDs, health care professionals may be at a particular risk of developing SUDs related to substances to which they have higher access, including opioids. Delay in help seeking when SUDs develop also complicates the prognosis of this type of problem in this professional group.3 Opioid dependence in health care professionals is likely to challenge their ability to return to work, and opioids represent a significant percentage of SUDs reported from samples of health care professionals suffering from SUDs.4,5 The first-line treatment of opioid dependence is maintenance treatment with either methadone or buprenorphine, supported by a large number of controlled studies,6 including the combination product of buprenorphine with added naloxone. Buprenorphine has been suggested to have a lower risk of cognitive impairment than methadone,7 although systematic and controlled data are few and have failed to prove this consistently.8 The importance of maintained cognitive ability is obvious for health care professionals aiming to return to work. Importantly, recent years have seen some research strongly indicating the usefulness of maintenance treatment in patients who are dependent on prescription opioids rather than on illicit opioids such as heroin.9,10 On the other hand, however, the use of 1 Integral Care Program for Sick Health Professionals, Galatea Clinic, Galatea Foundation, Col¢legi Oficial de Metges de Barcelona, Barcelona, Spain 2 Department of Psychiatry and Legal Medicine, Vall d’Hebron UniverR sity Hospital, CIBERSAM, Universitat Aut noma de Barcelona, Barcelona, Spain 3 Malm€ o Addiction Center (Beroendecentrum Malm€ o), Malm€ o University Hospital, Department of Clinical Sciences Lund, Division of Psychiatry, Lund University, Sweden 4 Outpatient Drug Clinic (CAS) Vall Hebron, Psychiatry Services, Vall d’Hebron University Hospital, ASPB, Barcelona, Spain Correspondence should be addressed to Marıa Dolores Braquehais, MD, PhD, Clinical Director Psychiatric Inpatient Unit for Health Professionals, Galatea Clinic, Integral Care Program for Sick Health Professionals, Galatea Foundation, Col¢legi Oficial de Metges de Barcelona, Passeig Bonanova, 47, 08017, Barcelona, Spain. E-mail: mdbraquehais. [email protected]
methadone or buprenorphine maintenance in health care professionals has been sparsely—if ever—documented in the scientific literature. McLellan and colleagues reported that although opioids were the primary drug in more than a third of the examined population of 904 physicians with SUDs, only one single individual received opioid maintenance treatment, indicating that this treatment modality is likely to be underutilized in this group. Instead, health care professionals appear more likely to receive only psychosocial interventions or antagonist treatment with naltrexone for opioid dependence.5,11 Opioid maintenance treatment in physicians returning to work has been debated,12,13 and data on this type of treatment for opioid dependence in health professionals are lacking. Here, we report a series of clinical cases where physicians and nurses with opioid dependence have been treated with buprenorphine-naloxone maintenance treatment. The Physicians’ Health Program (PHP) of Barcelona was created jointly by the Department of Health of the Regional Government of Catalonia and the Catalan “Colegio de Medicos” in 1998. In Spain, “Colegio de Medicos” act both as medical associations and regulatory bodies. In 2000, the program for sick doctors was extended to nurses. Both programs belong to the Barcelona Integral Care Program for Sick Health Care Professionals, with the objective to treat medical professionals with SUDs and/or other mental disorders, including an aim to facilitate a safe return to professional practice. Patients’ last names are changed upon admission to the program for improved confidentiality. Once health professionals are admitted to the program, they are offered outpatient or inpatient treatment depending on the severity of each case. Mandatory treatment is reserved for patients with evidence or risk of an actual practice problem due to their mental disorders. When SUDs are identified, abstinence is necessary for the patients in order to keep their license to practice. In cases with previous or potential practice problems, a specific therapeutic contract is signed that stipulates work site monitoring as well as regular monitoring and follow-up in the program. Patients with SUDs are followed weekly at the outpatient facilities during 2 years after their hospitalization. They receive both group psychotherapy, psychiatric assessment, and, in some cases, individual psychotherapy. They also have regular drug screening (at least once a week). After this 2-year period, if necessary, they continue with random drug testing and individual psychiatric follow-up. In cases where there is evidence of lack of treatment
Downloaded by [University of Lethbridge] at 09:24 06 November 2015
LETTERS TO THE EDITOR
compliance or relapses, the frequency of drug testing is increased during the treatment period. We retrospectively analyzed 9 clinical records of 7 physicians and 2 nurses who received buprenorphine-naloxone maintenance treatment. These patients all met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria for opioid dependence14 and were consecutively admitted from February 2011 to December 2013 to the Psychiatric Inpatient Unit of the Integral Care Program for Sick Health Professionals located in Barcelona (Spain). After discharge, patients were followed at the psychiatric outpatient facilities of the program where they had regular supervised drug urine screenings as well as weekly group psychotherapy and frequent individual psychiatric and psychotherapeutic interventions. Confirmation blood testing was applied in cases with positive urine drug screening. Patients who went back to their professional practice proved to remain abstinent, and no incidences were reported from their work monitors. In this study, the definition of “relapse” included any confirmed positive drug screening during their follow-up as well as the failure to attend treatment sessions and evaluations. Patients included in this case series report gave written informed consent to publish the information from their clinical records. The median age was 45 (22–59) years, 40.5 (25–59) years for men and 45 (43–53) years for women. Most patients (n D 5; 56%) were working before their admission, 3 (33%) were on sick leave, and 1 (11%) was unemployed. Four (44%) were married, 3 (33%) were divorced, and 2 (22%) were single. Patients were followed during a median of 5.0 (1.2–29.9) months. In the end, 7 patients (78%) proved to remain abstinent; 6 patients (67%%) were able to go back to work safely and 1 (11%) remained unemployed, whereas 2 (22%) relapsed not long after their discharge. Six patients (78%) were dependent on heroin and the rest on legal opioids. The median dose of buprenorphine-naloxone for the sample was 8/2 mg (2/0.5– 20/5) mg per day (10/2.5 mg [2/0.5–20/5] for patients who remained abstinent). Only 1 patient (11%) reported previous pharmacologic treatment for his opioid dependence (methadone), but it was ineffective. The present series of cases is—to the best of the authors’ knowledge—the first description of cases where physicians or nurses with opioid dependence are treated with buprenorphinenaloxone maintenance. Thus, although buprenorphine-naloxone treatment is well documented in other groups of patients, the present description is likely to be unique in the group of medical professionals assessed here. It should be noted that in our sample, most patients were dependent on heroin rather than on legal opioids that could be accessed through self-prescription. Nevertheless, despite severe patterns of substance use, most patients described here remained abstinent and were able to return to work, and their treatment had no impact in their work performance according to their work monitors surveillance. Our findings suggest that maintenance treatment with buprenorphine-naloxone may be a feasible and an effective option in the treatment of health care professionals with opioid dependence who aim to get back to work. As cognitive functions should be preserved when returning to work, the benefits of buprenorphine compared with methadone as maintenance treatment for opioid dependence should be considered as a better option to
139
warrant an efficient professional practice. Clinicians in this study chose buprenorphine-naloxone as the first treatment option due to its lower impact on cognitive functioning compared with methadone and due to its effectiveness as a maintenance treatment in other populations. Our preliminary experience suggests further systematic and controlled trials to prove the benefits of this treatment in this specific patient group.
ACKNOWLEDGMENTS We want to thank the Galatea Foundation, the Col¢legi Oficial de Metges de Barcelona, the Organizaci on Medica Colegial, and the Col¢legi Oficial d’Infermeria de Barcelona for their constant support and their effort to improve the physician well-being.
FUNDING Carlos Roncero, who contributed to the discussion of the paper, carried out the PROTEUS project, which was funded by a grant from Reckitt-Benckisert. However, neither the correspondent author nor the rest of authors have any other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. This study has not received any internal or external funding.
REFERENCES [1] Strang J, Wilks M, Wells B, Marshall J. Missed problems and missed opportunities for addicted doctors. BMJ. 1998;316:405–406. [2] Marshall EJ. Doctors’ health and fitness to practise: treating addicted doctors. Occup Med. 2008;58:334–340. [3] Braquehais MD, Lusilla P, Bel MJ, et al. Dual diagnosis among physicians: a clinical perspective. J Dual Diagn. 2014;10:148–155. [4] Beaujouan L, Czernichow S, Pourriat JL, Bonnet F. Prevalence and risk factors for substance abuse and dependence among anaesthetists: a national survey. Ann Fr Anesth R eanim. 2005;24:471–479. [5] McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ. 2008;33:a2038. [6] Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance therapy versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207. [7] Soyka M. Opioids and traffic safety—focus on buprenorphine. Pharmacopsychiatry. 2014;47:7–17. [8] Rapeli P, Fabritius C, Kalska H, Alho H. Cognitive functioning in opioid-dependent patients treated with buprenorphine, methadone, and other psychoactive medications: stability and correlates. BMC Clin Pharmcol. 2012;11:13. [9] Soeffing JM, Martin LD, Fingerhood MI, Jasinski DR, Rastegar DA. Buprenorphine maintenance treatment in a primary care setting: outcomes at 1 year. J Subst Abuse Treat. 2009;37:426–430. [10] Weiss RD, Potter JS, Fiellin DA, et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychol. 2011;68:1238–1246.
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SUBSTANCE ABUSE
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[11] DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. Setting the standard for recovery: physicians’ health programs. J Subst Abuse Treat. 2009;36:159–171. [12] Hamsa H, Bryson EO. Buprenorphine maintenance therapy in opioid-addicted health care professionals returning to clinical practice: a hidden controversy. Mayo Clin Proc. 2012;87:260–267.
[13] Newman RG. Buprenorphine maintenance therapy in opioidaddicted health care professionals. Mayo Clin Proc. 2012;87:804– 805. [14] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders. 4th ed. Washington DC: American Psychiatric Association; 1994.
ISSN: 0889-7077 (Print) 1547-0164 (Online) Journal homepage: http://www.tandfonline.com/loi/wsub20
Buprenorphine-Naloxone Treatment in Physicians and Nurses With Opioid Dependence María Dolores Braquehais MD, PhD, Christian Fadeuilhe MD, Anders Håkansson MD, Miquel Jordi Bel MD, María Cecilia Navarro MD, Carlos Roncero MD, PhD, Eugeni Bruguera MD & Miquel Casas To cite this article: María Dolores Braquehais MD, PhD, Christian Fadeuilhe MD, Anders Håkansson MD, Miquel Jordi Bel MD, María Cecilia Navarro MD, Carlos Roncero MD, PhD, Eugeni Bruguera MD & Miquel Casas (2015) Buprenorphine-Naloxone Treatment in Physicians and Nurses With Opioid Dependence, Substance Abuse, 36:2, 138-140, DOI: 10.1080/08897077.2014.996698 To link to this article: http://dx.doi.org/10.1080/08897077.2014.996698
Accepted author version posted online: 04 Mar 2015.
Submit your article to this journal
Article views: 83
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wsub20 Download by: [University of Lethbridge]
Date: 06 November 2015, At: 09:24
SUBSTANCE ABUSE, 36: 138–140, 2015 Copyright Ó Taylor and Francis Group, LLC ISSN: 0889-7077 print / 1547-0164 online DOI: 10.1080/08897077.2014.996698
Buprenorphine-Naloxone Treatment in Physicians and Nurses With Opioid Dependence
Downloaded by [University of Lethbridge] at 09:24 06 November 2015
Marıa Dolores Braquehais, MD, PhD,1,2 Christian Fadeuilhe, MD,2 Anders Hakansson, MD,3 Miquel Jordi Bel, MD,1,2 Marıa Cecilia Navarro, MD,1 Carlos Roncero, MD, PhD,1,2,4 Eugeni Bruguera, MD,1,2 and Miquel Casas1,2
To the Editor: Substance use disorders (SUDs) in physicians and nurses have major professional, legal, and health consequences,1–3 and over and above the overall risk of developing SUDs, health care professionals may be at a particular risk of developing SUDs related to substances to which they have higher access, including opioids. Delay in help seeking when SUDs develop also complicates the prognosis of this type of problem in this professional group.3 Opioid dependence in health care professionals is likely to challenge their ability to return to work, and opioids represent a significant percentage of SUDs reported from samples of health care professionals suffering from SUDs.4,5 The first-line treatment of opioid dependence is maintenance treatment with either methadone or buprenorphine, supported by a large number of controlled studies,6 including the combination product of buprenorphine with added naloxone. Buprenorphine has been suggested to have a lower risk of cognitive impairment than methadone,7 although systematic and controlled data are few and have failed to prove this consistently.8 The importance of maintained cognitive ability is obvious for health care professionals aiming to return to work. Importantly, recent years have seen some research strongly indicating the usefulness of maintenance treatment in patients who are dependent on prescription opioids rather than on illicit opioids such as heroin.9,10 On the other hand, however, the use of 1 Integral Care Program for Sick Health Professionals, Galatea Clinic, Galatea Foundation, Col¢legi Oficial de Metges de Barcelona, Barcelona, Spain 2 Department of Psychiatry and Legal Medicine, Vall d’Hebron UniverR sity Hospital, CIBERSAM, Universitat Aut noma de Barcelona, Barcelona, Spain 3 Malm€ o Addiction Center (Beroendecentrum Malm€ o), Malm€ o University Hospital, Department of Clinical Sciences Lund, Division of Psychiatry, Lund University, Sweden 4 Outpatient Drug Clinic (CAS) Vall Hebron, Psychiatry Services, Vall d’Hebron University Hospital, ASPB, Barcelona, Spain Correspondence should be addressed to Marıa Dolores Braquehais, MD, PhD, Clinical Director Psychiatric Inpatient Unit for Health Professionals, Galatea Clinic, Integral Care Program for Sick Health Professionals, Galatea Foundation, Col¢legi Oficial de Metges de Barcelona, Passeig Bonanova, 47, 08017, Barcelona, Spain. E-mail: mdbraquehais. [email protected]
methadone or buprenorphine maintenance in health care professionals has been sparsely—if ever—documented in the scientific literature. McLellan and colleagues reported that although opioids were the primary drug in more than a third of the examined population of 904 physicians with SUDs, only one single individual received opioid maintenance treatment, indicating that this treatment modality is likely to be underutilized in this group. Instead, health care professionals appear more likely to receive only psychosocial interventions or antagonist treatment with naltrexone for opioid dependence.5,11 Opioid maintenance treatment in physicians returning to work has been debated,12,13 and data on this type of treatment for opioid dependence in health professionals are lacking. Here, we report a series of clinical cases where physicians and nurses with opioid dependence have been treated with buprenorphine-naloxone maintenance treatment. The Physicians’ Health Program (PHP) of Barcelona was created jointly by the Department of Health of the Regional Government of Catalonia and the Catalan “Colegio de Medicos” in 1998. In Spain, “Colegio de Medicos” act both as medical associations and regulatory bodies. In 2000, the program for sick doctors was extended to nurses. Both programs belong to the Barcelona Integral Care Program for Sick Health Care Professionals, with the objective to treat medical professionals with SUDs and/or other mental disorders, including an aim to facilitate a safe return to professional practice. Patients’ last names are changed upon admission to the program for improved confidentiality. Once health professionals are admitted to the program, they are offered outpatient or inpatient treatment depending on the severity of each case. Mandatory treatment is reserved for patients with evidence or risk of an actual practice problem due to their mental disorders. When SUDs are identified, abstinence is necessary for the patients in order to keep their license to practice. In cases with previous or potential practice problems, a specific therapeutic contract is signed that stipulates work site monitoring as well as regular monitoring and follow-up in the program. Patients with SUDs are followed weekly at the outpatient facilities during 2 years after their hospitalization. They receive both group psychotherapy, psychiatric assessment, and, in some cases, individual psychotherapy. They also have regular drug screening (at least once a week). After this 2-year period, if necessary, they continue with random drug testing and individual psychiatric follow-up. In cases where there is evidence of lack of treatment
Downloaded by [University of Lethbridge] at 09:24 06 November 2015
LETTERS TO THE EDITOR
compliance or relapses, the frequency of drug testing is increased during the treatment period. We retrospectively analyzed 9 clinical records of 7 physicians and 2 nurses who received buprenorphine-naloxone maintenance treatment. These patients all met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria for opioid dependence14 and were consecutively admitted from February 2011 to December 2013 to the Psychiatric Inpatient Unit of the Integral Care Program for Sick Health Professionals located in Barcelona (Spain). After discharge, patients were followed at the psychiatric outpatient facilities of the program where they had regular supervised drug urine screenings as well as weekly group psychotherapy and frequent individual psychiatric and psychotherapeutic interventions. Confirmation blood testing was applied in cases with positive urine drug screening. Patients who went back to their professional practice proved to remain abstinent, and no incidences were reported from their work monitors. In this study, the definition of “relapse” included any confirmed positive drug screening during their follow-up as well as the failure to attend treatment sessions and evaluations. Patients included in this case series report gave written informed consent to publish the information from their clinical records. The median age was 45 (22–59) years, 40.5 (25–59) years for men and 45 (43–53) years for women. Most patients (n D 5; 56%) were working before their admission, 3 (33%) were on sick leave, and 1 (11%) was unemployed. Four (44%) were married, 3 (33%) were divorced, and 2 (22%) were single. Patients were followed during a median of 5.0 (1.2–29.9) months. In the end, 7 patients (78%) proved to remain abstinent; 6 patients (67%%) were able to go back to work safely and 1 (11%) remained unemployed, whereas 2 (22%) relapsed not long after their discharge. Six patients (78%) were dependent on heroin and the rest on legal opioids. The median dose of buprenorphine-naloxone for the sample was 8/2 mg (2/0.5– 20/5) mg per day (10/2.5 mg [2/0.5–20/5] for patients who remained abstinent). Only 1 patient (11%) reported previous pharmacologic treatment for his opioid dependence (methadone), but it was ineffective. The present series of cases is—to the best of the authors’ knowledge—the first description of cases where physicians or nurses with opioid dependence are treated with buprenorphinenaloxone maintenance. Thus, although buprenorphine-naloxone treatment is well documented in other groups of patients, the present description is likely to be unique in the group of medical professionals assessed here. It should be noted that in our sample, most patients were dependent on heroin rather than on legal opioids that could be accessed through self-prescription. Nevertheless, despite severe patterns of substance use, most patients described here remained abstinent and were able to return to work, and their treatment had no impact in their work performance according to their work monitors surveillance. Our findings suggest that maintenance treatment with buprenorphine-naloxone may be a feasible and an effective option in the treatment of health care professionals with opioid dependence who aim to get back to work. As cognitive functions should be preserved when returning to work, the benefits of buprenorphine compared with methadone as maintenance treatment for opioid dependence should be considered as a better option to
139
warrant an efficient professional practice. Clinicians in this study chose buprenorphine-naloxone as the first treatment option due to its lower impact on cognitive functioning compared with methadone and due to its effectiveness as a maintenance treatment in other populations. Our preliminary experience suggests further systematic and controlled trials to prove the benefits of this treatment in this specific patient group.
ACKNOWLEDGMENTS We want to thank the Galatea Foundation, the Col¢legi Oficial de Metges de Barcelona, the Organizaci on Medica Colegial, and the Col¢legi Oficial d’Infermeria de Barcelona for their constant support and their effort to improve the physician well-being.
FUNDING Carlos Roncero, who contributed to the discussion of the paper, carried out the PROTEUS project, which was funded by a grant from Reckitt-Benckisert. However, neither the correspondent author nor the rest of authors have any other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. This study has not received any internal or external funding.
REFERENCES [1] Strang J, Wilks M, Wells B, Marshall J. Missed problems and missed opportunities for addicted doctors. BMJ. 1998;316:405–406. [2] Marshall EJ. Doctors’ health and fitness to practise: treating addicted doctors. Occup Med. 2008;58:334–340. [3] Braquehais MD, Lusilla P, Bel MJ, et al. Dual diagnosis among physicians: a clinical perspective. J Dual Diagn. 2014;10:148–155. [4] Beaujouan L, Czernichow S, Pourriat JL, Bonnet F. Prevalence and risk factors for substance abuse and dependence among anaesthetists: a national survey. Ann Fr Anesth R eanim. 2005;24:471–479. [5] McLellan AT, Skipper GS, Campbell M, DuPont RL. Five year outcomes in a cohort study of physicians treated for substance use disorders in the United States. BMJ. 2008;33:a2038. [6] Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance therapy versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207. [7] Soyka M. Opioids and traffic safety—focus on buprenorphine. Pharmacopsychiatry. 2014;47:7–17. [8] Rapeli P, Fabritius C, Kalska H, Alho H. Cognitive functioning in opioid-dependent patients treated with buprenorphine, methadone, and other psychoactive medications: stability and correlates. BMC Clin Pharmcol. 2012;11:13. [9] Soeffing JM, Martin LD, Fingerhood MI, Jasinski DR, Rastegar DA. Buprenorphine maintenance treatment in a primary care setting: outcomes at 1 year. J Subst Abuse Treat. 2009;37:426–430. [10] Weiss RD, Potter JS, Fiellin DA, et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychol. 2011;68:1238–1246.
140
SUBSTANCE ABUSE
Downloaded by [University of Lethbridge] at 09:24 06 November 2015
[11] DuPont RL, McLellan AT, White WL, Merlo LJ, Gold MS. Setting the standard for recovery: physicians’ health programs. J Subst Abuse Treat. 2009;36:159–171. [12] Hamsa H, Bryson EO. Buprenorphine maintenance therapy in opioid-addicted health care professionals returning to clinical practice: a hidden controversy. Mayo Clin Proc. 2012;87:260–267.
[13] Newman RG. Buprenorphine maintenance therapy in opioidaddicted health care professionals. Mayo Clin Proc. 2012;87:804– 805. [14] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Health Disorders. 4th ed. Washington DC: American Psychiatric Association; 1994.
