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!

Clean Enough, chapter 2.3 and 2.4, My story continued

My Story (cont.)
Local hero

Hero for a day in 1979

Interestingly, the heavy drug use came only months after a time in my life when I was riding as high as I ever had before or have since.  During the summer between my freshman and sophomore years of college I was working for the city of Beloit Wisconsin, planting flowers and shrubs in the center islands of the downtown roads and sidewalks.  I had taken a break underneath a large parking structure that spanned the Rock River, at an area where the very wide, calm river narrowed to fast and deeper waters. As I stood in the shade of the parking structure I thought about what I would do if I saw someone drowning in the river; it had always been a fantasy of mine to do something heroic!  To my astonishment, shortly after having that thought I heard moaning coming from the river, steadily growing louder as I listened. Shaken by the coincidence, for a moment I wondered if I was going crazy.  But then I realized that something was fast-approaching in the current.  I couldn’t see details through the darkness under the parking structure, so I ran along the bank trying to determine what I was hearing. When I reached the end of the parking structure I squeezed out through a narrow opening in the concrete into the bright sunlight.  I ran across the road and looked over the railing at the river below, just as a woman emerged from the darkness floundering in the current. She was half submerged, rolling from face-down to face-up, wailing alternating with gurgling.  I ran to the nearest side of the river and then through the brush along the bank, peeling off my shoes and pants, and eventually jumping into the water and swimming out to her.  After a brief struggle I towed her to the riverbank, and a group of boys fishing on shore ran to call the police. I lay at the edge of the river with the semi-conscious woman, grateful to hear sirens approaching. Eventually photographers from the newspaper appeared and took pictures of me standing in a T-shirt with red bikini briefs (didn’t I say I had no fashion sense?!).  To make matters more interesting, the back of the wet, clinging T-shirt read ‘Locally owned bank’, and the front of the T-shirt read ‘Beloit’s Largest!’ For the rest of the summer I enjoyed my nickname. What a fantasy it was, to walk into bars and have the people yell out: “Hey! It’s Beloit’s Largest!!”
I am grateful that I was given the opportunity to be a hero.  There have been times in my life since then when I questioned my worth as a human being, and I could look back on that moment and recognize that on that day I did a good thing. I continue to see that incident as a gift from God, for the times when I had little else to feel proud of..
Getting serious
Near the end of my sophomore year of college I tired of the drug scene and stopped using substances without any conscious effort. But drug use was replaced by something else: the need for academic success. I finished college with excellent grades, and enrolled in the Center for Brain Research at the University of Rochester in upstate New York.  After doing well there for two years I was accepted into the prestigious Medical Scientist Training Program.  I graduated with a PhD in Neuroscience, and two years later graduated from medical school with honors. I published my research in the scientific literature, something that results in requests for reprints from research centers around the world. My ego was flying high at that time, but I continued to struggle socially; for example I entered lecture halls from the back, believing that I stood out from my classmates in an obvious and negative way. I had only two or three close friends throughout all of those years of medical school.  My loneliness and longing to fit in was quite painful during those years, and is still painful to look back upon today.
Our son Jonathon was born during my last year of medical school. His birth and early years changed me in wonderful, unexpected ways.  His birth divided the lives and relationship of me and my wife, Nancy, into two parts: the meaningless part before and the meaningful part after.  After medical school I entered residency at the Hospital of the University of Pennsylvania, at the time one of the most prestigious anesthesia programs in the country.  Our young family moved to a suburb of Philadelphia, and each morning I drove alongside the Schuykill River, the Philly skyline in view, feeling at least initially that I had really ‘made it’.   But over the next few years my interests changed from wanting an academic position at an Ivy League institution to wanting to move back to Wisconsin, make some money, buy a house, and raise a family.
Our daughter Laura was born during the last year of anesthesia residency and again, the joy of gazing into her eyes made me resent my time away from home.  At the end of my residency I took a job in Fond du Lac Wisconsin, the small town where I continue to live today.