Clean Enough?

Yesterday I received the following e-mail:
Hi Dr. Junig,
Please let me first say – Suboxone SAVED MY LIFE. I was down and out until 2 years ago, when I began using Suboxone. Now, having completed all the pre-req’s for medical school with nothing less than straight A’s, I find myself on track to apply to medical school.
But here’s the problem. I’m still taking Suboxone and have no desire to stop. I will quit if absolutely necessary, but I’m wondering if you’ve heard anything new regarding the legalities of health care providers taking buprenorphine.
I would love to enter a field like psychiatry or family medicine, as these are the doc’s I’ve grown fond of over the past two years. I haven’t told my doctors of my med school plans, as I fear that they will block my attempts to apply/matriculate. Do you have any insight on the subject? Do you know of any patients who have gone on to medical school?
Thank you,
MD to be
I have received a number of similar messages over the past few years.  Just today I received an e-mail from a person who wants to become a CNA.  I have been asked the same question by people wanting to work as truck drivers, nurses, and police officers, among other professions.
I generally reply that to date, I have not had any patient prevented from an occupation for taking prescribed buprenorphine.  But there have been times when people were almost prevented from working certain occupations, and it took significant advocacy to correct the situation.  I would hope that other physicians treating opioid dependence would do the same.  If our patients are doing everything right but face discrimination based on ignorance, by employers or potential employers, our roles include acting as advocates, and providing accurate information about buprenorphine.
Unfortunately, the easiest thing for any employer to do when an applicant or employee discusses buprenorphine is to say ‘no.’ Addiction carries a strong stigma, and while many people will publicly congratulate recovering addicts, in private the attitudes are less forgiving.  We must remember that those with histories of addiction are protected from discrimination by the Americans with Disabilities Act.  That does not mean, of course, that people should be allowed to work dangerous occupations while actively addicted to intoxicants.  The law is meant to protect those who are no longer actively addicted from being fired for having a history of addiction.
There is a great deal of confusion about the actions and subjective effects of buprenorphine.  The intellectually lazy approach is to see buprenorphine as a ‘replacement drug,’ and to disregard the profound differences in action between agonists and partial agonists.  As I explain to potential employers, a person on buprenorphine soon becomes completely tolerant to the actions of the medication.  And because of the ceiling effect of the medication, there is no sense of something ‘coming on’ or ‘wearing off.’
The package insert for buprenorphine says that the medication can cause drowsiness, but it is important to realize that there are huge differences between taking the medication acutely (short-term) vs. chronically.  In the former, buprenorphine has powerful opioid actions that are similar to the effects of potent pain medications. But after days to weeks, tolerance removes the subjective effects of buprenorphine.  People who take the medication chronically are not only unimpaired; they are completely normal from a cognitive standpoint.
To date, I am not aware of any consistent approach to buprenorphine by professional licensing authorities at the state level.  I have received several messages from healthcare workers taking buprenorphine, who fear that an employer or state regulator will take action against them.
I have even heard from nurses who were told by their regulatory board that they had two options; stop buprenorphine, or stop working with patients.  The writers express confusion over being told that in order to work with patients, they must stop the medication that is preventing cravings for opioids, and that would block any effects from opioids, were they to relapse!
One would think that the medical profession would lead the way on the issue of effective medical treatment for opioid dependence.  One would think that the medical profession would provide clarity for other professions, and demonstrate an attitude of support for those who became trapped by opioids, but who took effective action to treat their condition.  One may think such a thing—but then one would be wrong!