Early in my addiction medicine fellowship, I met a patient for the second time while shadowing another physician in their practice. The patient was a former nurse with opioid use disorder on maintenance therapy with buprenorphine (commonly called Suboxone, the original brand name of a formulation combined with naloxone), a partial opioid agonist that is FDA-approved for the treatment of opioid use disorder and can be conveniently prescribed in the outpatient setting. Buprenorphine can also be prescribed for those with chronic pain, being a much safer alternative to the use of full opioid agonists when an opioid prescription is beneficial (as long as not combined with other respiratory depressants).
The patient now wanted to return to work as a nurse but had heard that they could not renew their nursing license until they stopped taking buprenorphine. So they decided to taper off slowly under the supervision of a specialist, under coercion of not being able to return to meaningful work as a nurse otherwise.
During the first visit, the patient was relaxed. But this time, weeks later tapered to a lower dose of buprenorphine, they were sweaty, wide-eyed, and anxious. And I wondered: Why did the patient have to go through this process if the buprenorphine was helping them to remain healthy, functional, and alive? Why when we don’t limit licensure for health care providers taking other controlled and uncontrolled medications that also have the potential to affect cognitive function? Why when substance use is the main cause of physician license actions, reflecting a tremendous need for evidence-based treatment for health care workers who also have the right to maintain occupational stability? Even if the patient wanted to stop buprenorphine eventually, as is their right in bodily integrity/autonomy (although there may be an increased risk of return to use with possible overdose injury/death with discontinuation too early in treatment), why was it a coercive barrier and delay for the patient in returning to practice?
Why are we not practicing what we preach in medicine, especially during a deadly opioid epidemic triggered no less by the pharmaceutical, regulatory, and health care communities in the United States?’
The patient had been stable on buprenorphine ~16 mg daily for several years and then slowly tapered to 2 mg daily, then 1 to 2 mg daily, and were still tapering their last 0.5 mg daily at the time of this interview. This is a common recounting from patients and providers that the taper of the last buprenorphine 2 mg is most challenging. And the fear is so strong for some people with opioid use disorder that they fear potential future withdrawal from buprenorphine more than the increased risk of debilitating injury or death from continued non-prescription/illicit opioid use (which may have otherwise been stabilized/reduced by buprenorphine use). Therefore, tapering should occur only very slowly under monitored pharmacologic symptom management. But there is a significant lack of widespread expertise in the management of buprenorphine, so patients and providers often taper too quickly.
When the patient started to consider returning to work as a nurse, they spoke with someone from the New Jersey Recovery and Monitoring Program (RAMP) and received advice that frightened them. The patient asked if they could renew their nursing license while taking buprenorphine and reported receiving guidance from a staff member that nurses actively participating in the RAMP program after disciplinary action cannot return to work until they stop taking buprenorphine. The patient asked, “But what would happen if they had never had disciplinary action if they had voluntarily stepped back from their nursing duties? Could they continue to take buprenorphine then?” The employee at RAMP reportedly said “no.” And regardless of disciplinary action or not, why?
Afraid to reveal themselves, the patient stopped asking questions. They read the entire nursing handbook but didn’t find any information about buprenorphine. And the patient was embarrassed to say that after the call to RAMP, they never checked in with the New Jersey Board of Nursing directly because they now feared risking disclosure if they tried to gather more information.
The patient reports that they first experienced opioid use years ago when receiving oxycodone after wisdom teeth removal. They “felt amazing,” a common report of opioid users who begin after medical prescription, as there can often be either strong likeability or aversion. The patient then didn’t use opioids for five years until, while working as a nurse, they began a romantic relationship with someone who sniffed oxycodone (the formulation created and marketed by Purdue Pharma centered in the well-done Hulu series Dopesick) and started to use regularly. Within months, this progressed to uncontrolled IV use of heroin. The patient soon noticed impairment at work and decided to leave, allowing their licensure to expire.
Soon, they became homeless and continued to use opioids illicitly. In wanting to stabilize/reduce use, the patient then began methadone treatment for ten years as an effective harm reduction and treatment technique until they later transitioned to buprenorphine. When asked about their experience with methadone, another first-line treatment for opioid use disorder that can quickly stabilize high-risk patients but carries a high degree of stigma, the patient stated, “Back then … methadone saved my life. I had access to [buprenorphine], but I couldn’t use it properly. With methadone, I had to get up every morning and interact with social workers. And I felt like I didn’t ‘have to’ get high… It was a great thing, but [buprenorphine] is a better fit for me, now.”
As I was preparing to publish this article, I contacted the New Jersey Board of Nursing for a third time after two previously unsuccessful attempts to see if they would like to leave a comment. The response read, “The Board of Nursing decides to license nurses on a case-by-case basis. The student needs to notify the school and find out what their policy is concerning the issue.”
And therein lies the problem: The reply was not immediate, clear, universal support for nurses with a history of opioid use disorder or chronic pain to take prescribed buprenorphine at the centralized level of the Board of Nursing. However, this is not an issue unique to the New Jersey Board of Nursing. So systematic, universal implementation would benefit from policy change at the national/federal level to enhance efficiency and prevent state-by-state regulation delays.
This interview urges that all state health care licensing boards universally allow and support nurses, physicians, and any other license-eligible health care professional with a history of opioid use disorder or chronic pain being prescribed buprenorphine to continue taking their evidence-based, life-preserving medication without the requirement for additional monitoring/supervision as a result of prescription/adherence.
The Justice Department recently ruled that the Indiana State Nursing Board was discriminating against nurses with opioid use disorder by disallowing them to regain their licenses if they were taking prescribed buprenorphine. I hope that New Jersey — and all states, with a change at the federal level to secure universal national enforcement — will soon decide similarly.
If we are going to promote the provision of evidence-based treatment for our patients, we must avoid hypocrisy and support the equal rights of licensed health care professionals to do the same.
Arielle Gerard is an addiction medicine and preventive medicine/public health physician.
Image credit: Shutterstock.com
