The Critical Role of Naloxone in Sedation Dentistry

By Genni Burkhart, Incisor Editor

In the fight against opioid overdoses, few tools are as critical as naloxone, commonly known by its brand name, Narcan®. With a survival rate exceeding 99% when administered during opioid overdoses, naloxone's life-saving potential is remarkable.

A study conducted between March 2022 and August 2023 demonstrated that 99.2% of individuals who received a 4-mg intranasal dose and 99.0% of those who received an 8-mg dose survived¹. These numbers highlight naloxone’s unmatched effectiveness in a medical or community setting.

As opioid-related deaths in the U.S. exceeded 110,000 in 2023², the need for naloxone hasn't decreased. In fact, this medication isn’t merely an optional item in an emergency kit—it's a vital component. Having naloxone readily available can mean the difference between life and death in critical situations, reinforcing its indispensable role in emergency preparedness for sedation dental practices.

Why Naloxone Matters to Dental Providers

Sedation dentists take on significant responsibilities in managing opioid safety. This obligation also includes understanding the medications patients may or may not inform you they're taking. Because of this, naloxone serves as a safeguard, ensuring that emergencies can be managed effectively. Here are a few reasons why naloxone is considered indispensable:

• Emergency Reversal of Opioid Overdose: Opioids like fentanyl can cause life-threatening respiratory depression. Naloxone quickly reverses these effects, stabilizing the patient.
• Inclusion in Emergency Kits: Accidental overdoses, though rare, are possible even in controlled environments. Keeping naloxone in emergency kits ensures it's immediately available when needed.
• Short Duration of Action: Naloxone's half-life is only 1.2 to 2.7 hours, depending on the route of administration³. Counteracting long-acting opioids requires close monitoring and potentially repeated doses, so teams must be prepared for this scenario.
• Safety and Ease of Use: Naloxone’s intranasal and intramuscular administration methods make it accessible and easy for dental teams to use in high-stress situations.
• Risk Mitigation for Conscious Sedation: When opioids are combined with benzodiazepines for sedation, the risk of oversedation increases. Naloxone acts as a targeted solution to reverse opioid effects without impacting benzodiazepines.

A Brief History

Naloxone hydrochloride was first synthesized in 1960 by Mozes J. Lewenstein and Jack Fishman at Endo Laboratories to develop opioid antagonists. Initially intended to alleviate opioid-induced constipation, it was soon recognized for its effectiveness in reversing opioid overdoses.

Naloxone was patented in 1961 by Lewenstein, Fishman, and Sankyo, a Japanese company.

Approved by the FDA in 1971, naloxone initially saw limited use confined to clinical settings but gained prominence during the heroin resurgence in the 1990s and the prescription opioid crisis of the 2000s. The introduction of Narcan®, a nasal spray formulation approved by the FDA in 2015, made naloxone more accessible by allowing non-medical individuals to administer it effectively⁴.

Today, naloxone is recognized globally as an essential medication, featured on the World Health Organization’s List of Essential Medicines for its critical role in combating opioid overdoses.

Nasal Spray vs. Injectable Naloxone

Both nasal spray and injectable naloxone are effective but differ in practicality and application. The table below summarizes the main differences:

Use in Dental Sedation

While rare, adverse events requiring naloxone highlight the necessity of its inclusion in dental emergency kits. A study⁵ found that 90.8% of patients undergoing fentanyl-midazolam sedation experienced successful outcomes without naloxone intervention, but its presence provides a critical safety net.

Training and Preparedness

States like California⁶ now mandate continuing education on opioid prescribing and naloxone use. Training equips dental teams with the skills and confidence to administer naloxone effectively during emergencies. Through continued education, dental teams are prepared to respond quickly, manage dosing, and stabilize patients until additional help arrives.

Legal Protections for Dentists Administering Naloxone

1. Good Samaritan Laws⁷:
   • In most U.S. states, healthcare providers, including dentists, are protected under Good Samaritan Laws when administering naloxone in good faith during an emergency. These laws provide immunity from civil or criminal liability for actions taken to assist someone experiencing an opioid overdose as long as the provider acts reasonably and without gross negligence.
2. Prescriber Immunity:
   • State laws often include immunity for licensed prescribers, such as dentists, who prescribe or administer naloxone in good faith. For example, Alabama law explicitly grants immunity to licensed dentists and physicians acting in good faith when prescribing or administering naloxone.
3. Professional Liability Protections:
   • Dentists who administer naloxone appropriately in emergencies are also protected from professional sanctions (licensing boards' disciplinary actions), which ensures that dentists can prioritize patient safety without fear of jeopardizing their professional standing.
4. Requirements for Acting in Good Faith:
   • Acting in "good faith" typically means the dentist reasonably believes the patient is experiencing an opioid overdose and administers naloxone with reasonable care. For example, Arizona law⁸ specifies that healthcare providers are immune from liability as long as they act with reasonable care and do not engage in gross negligence or willful misconduct.

Practical Tips for Dentists

• Emergency Kits, Recording, & Storage: Ensure naloxone is included in emergency kits, regularly check expiration dates, and update your drug log and records.
• Provide Team Training: Conduct hands-on training for all staff to build confidence and competence in administering naloxone during high-stress situations.
• Stay Updated: Participate in continuing education courses by licensed professionals on opioid safety and naloxone use.
• Patient Education: Inform patients prescribed opioids about naloxone and its importance in overdose prevention. It's also vital to review with patients what illicit drugs or non-prescription drugs they might be taking as it can create a dangerous overdose or drug interaction situation.

In Conclusion

Naloxone’s role in sedation dentistry goes beyond emergency preparedness. It reflects a broader commitment to patient safety, harm reduction, and professional responsibility. By integrating naloxone into your emergency kit and providing continuing education for the entire dental team, practices can safeguard their patients during the rarest but most life-threatening situations.

Dr. Jerome Wellbrock's DOCS Education course, "Medical Emergencies: Avoiding a Disaster," offers invaluable expertise for those seeking deeper insights. This 1.5 CE credit course covers life-saving techniques, including Dr. Wellbrock’s experiences managing emergencies alongside EMS, and provides the tools and knowledge to handle critical situations confidently.

Author: With over 15 years as a published journalist, editor, and writer, Genni Burkhart's career has spanned politics, healthcare, law, business finance, technology, and news. She resides in Northern Colorado, where she works as the editor-in-chief of the Incisor at DOCS Education.

References:

1. Payne ER, Stancliff S, Rowe K, Christie JA, Dailey MW. Comparison of Administration of 8-Milligram and 4-Milligram Intranasal Naloxone by Law Enforcement During Response to Suspected Opioid Overdose — New York, March 2022–August 2023. MMWR Morb Mortal Wkly Rep 2024;73:110–113. DOI: http://dx.doi.org/10.15585/mmwr.mm7305a4.
2. National Center for Health Statistics. Provisional Drug Overdose Death Counts. Centers for Disease Control and Prevention. Updated January 15, 2025. Accessed January 27, 2025. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
3. DrugBank Online. Naloxone. DrugBank. Updated January 27, 2025. Accessed January 25, 2025. https://go.drugbank.com/drugs/DB01183?t
4. Remedy Alliance/For the People. History. Remedy Alliance/For the People. Accessed January 24, 2025. https://remedyallianceftp.org/pages/history?t
5. Yeo XH, Shehabi Z. Effectiveness and safety of dentist-led conscious sedation using fentanyl with midazolam in dentistry: a five-year retrospective service evaluation. Br Dent J. 2023 Jun 7:1–6. doi: 10.1038/s41415-023-5889-3. Epub ahead of print. PMID: 37286715; PMCID: PMC10246529.
6. California Dental Association. Dentists can help prevent fentanyl deaths. CDA. Published January 2, 2024. Accessed January 21, 2025. https://www.cda.org/newsroom/newsroom-archives/dentists-can-help-preven…
7. Government Accountability Office. Drug Misuse: Most States Have Good Samaritan Laws and Research Indicates They May Have Positive Effects. GAO-21-248. Published March 29, 2021. Accessed January 21, 2025. https://www.gao.gov/assets/gao-21-248.pdf
8. Arizona Department of Health Services. Naloxone FAQs. Arizona Department of Health Services. Accessed January 21, 2025. https://www.azdhs.gov/documents/prevention/womens-childrens-health/inju…