Opinion: Dentists Who Do Not Provide Sedation Should Not Be Required to Carry Naloxone

No, it was not a copy editor who wrote the title of this opinion piece. It was I, Derek, a practising dentist anesthesiologist, who wrote this after having contemplated writing a piece on something rather the opposite. I thought it might be interesting to discuss Evzio, a naloxone auto-injector that is beginning to encounter more widespread use in North America and abroad. Perhaps, thought I, it would be interesting to discuss the indications and routes of administration of naloxone for a suspected opioid overdose occurring in a dental office.

In advance of my research on the pharmacokinetics/pharmacodynamics of opioid reversal agents, I thought it appropriate to promote the merits of naloxone in a dental practice. I sought evidence of the value of stocking naloxone in a dental practice, even in practices that don’t perform sedations with opioids. I scoured the literature for case reports, or even news reports, of dentists administering an opioid-reversal agent to resolve a suspected overdose; they’re considerably more difficult to find than I expected. Most articles described chance encounters on the street where a passer-by used an intranasal naloxone kit after recent training. Almost non-existent were the cases of in-office dental patients experiencing episodes of opioid overdose who were in-crisis or unresponsive.

That begs the question: should dentists that do not provide sedation be required to carry naloxone as an emergency medication in their resuscitation kit? I assert the answer is no. Before you stop reading this article over belief that I am some sort of opioid-crisis-denying, naloxone-withholding monster, please know that I appreciate the following:

There is an ongoing and increasingly severe opioid crisis occurring in Canada that causes thousands of deaths per year¹ and taxes an already over-burdened healthcare system;²
Naloxone quickly reverses the clinical effects of opioids (including airway obstruction and hypoventilation);³ and
Dentists continue to be among the highest prescribers of opioids in North America.⁴

Having noted the above, some dental jurisdictions are considering the enforcement of mandatory stocking of naloxone as an emergency medication. I believe this would be a heavy-handed and costly approach. Further, I do not believe it would yield a reduction in the morbidity and mortality rates that would be targeted. My thought process (based on my clinical training, my experience, and logical thinking) is as follows:

If a patient takes a dentist-prescribed opioid and they experience a significant adverse event, I feel it is unlikely that they would return to a dental office but instead seek help from our medical system by calling 911 or going to a hospital;
If a patient becomes unresponsive in a dental practice, it is unlikely, albeit not impossible, that the decreased level of consciousness is due to opioid use; and
More than almost any other profession, dentists are airway experts. We know how to perform airway manoeuvres and rescue breathing with a bag-valve-mask. These are basic healthcare skills that should be taught and regularly practiced to respond to any unresponsive patient. Oxygen and ventilation save lives of patients who are not breathing, not just naloxone.

I believe there are much stronger means of enacting and advocating for safer opioid use and overdose rescue in Canada. For example, dentists should be at the forefront of evidence-based opioid prescription to patients. Discussions must be had with patients about the safe use of opioids, the potential risk of over-sedation, and the proper disposal of any remaining narcotic. While some may argue that dentists are healthcare providers and should therefore be ready to administer naloxone, it is now an unregulated drug in nasal or intra-muscular injection form. The general population can carry and administer naloxone in these formulations, so why not stock it in proximity to locations where adverse reactions are more likely to occur (i.e., near residential complexes⁵) and that are open 24 hours a day? Perhaps more accessible public locations like convenience stores or gas stations are worthy of both our consideration and maybe even our subsidization as a profession.

If my provincial dental college mandated that all dentists must possess and be able to administer naloxone, would you find me picketing with sign in hand? No. But it merits noting that dentistry’s history of self-governance has had instances where our regulatory bodies formulated policy not based on data, cost-benefit analysis, and careful thought, but on the basis of best intentions and public opinion.

We must begin to have discussions like the one outlined in this article to determine the role best suited for dentists to help the public that we have committed to serve. Above all else, whether we stock naloxone or not, it is imperative that dentists make a strong and concerted effort to help resolve the opioid crisis.

Oral Health welcomes this original article.

References

Belzak L, Halverson J. The opioid crisis in Canada: a national perspective. Health Promot Chronic Dis Prev Can. 2018 Jun;38(6):224-233.
Clarke H, Bao J, Weinrib A, Dubin RE, Kahan M. Canada’s hidden opioid crisis: the health care system’s inability to manage high-dose opioid patients: Fallout from the 2017 Canadian opioid guidelines. Can Fam Physician. 2019;65(9):612-614.
Kim D, Irwin KS, Khoshnood K. Expanded access to naloxone: options for critical response to the epidemic of opioid overdose mortality. Am J Public Health. 2009;99(3):402-407.
Pasricha SV, Tadrous M, Khuu W, et al. Clinical indications associated with opioid initiation for pain management in Ontario, Canada: a population-based cohort study. Pain. 2018;159(8):1562-1568.
Public Health Ontario, 2019. Opioid Mortality Surveillance Report. [online] Toronto: Queen’s Printer for Ontario. Available at: <https://www.publichealthontario.ca/-/media/documents/o/2019/opioid-mortality-surveillance-report.pdf?la=en> [Accessed 10 December 2020].

About the Author

Dr. Derek Decloux completed his DMD at the University of British Columbia, his MSc in Dental Anesthesia at the University of Toronto, and he is completing a MSc in Pharmacology and Toxicology at Michigan State University. He served as a Canadian Armed Forces dental officer and continues to serve as a reservist dental officer. He practices dental anaesthesia in offices in Southern Ontario, is a staff dentist anesthesiologist at Toronto’s Mount Sinai Hospital’s Department of Dentistry, and is a clinical dental anesthesia instructor at the University of Toronto’s Faculty of Dentistry.