Why Naloxone Should Never, Ever Be In Your Drug Kit

According to the Centers for Disease Control and Prevention, National Center for Health Statistics, there is an exponential increase in opioid-involved deaths in the US that started around 2013 - 2014. This is evidenced in the graph below, from the National Institute On Drug Abuse website (1). 

Several states, including New York, responded to this trend with a harm-reduction strategy, making opioid rescue kits available to the public at no cost.  In fact, the New York State Office of Addiction Services and Supports offers free naloxone online (2). In the past several years, I have noticed that many dental emergency kit suppliers seem to have capitalized on this trend by selling to dentists the same high-dose (4mg), single use intranasal devices that the State provides to the public at no cost.

While the research overwhelmingly supports naloxone distribution as an effective harm reduction strategy in communities (3,4), it is important to understand that the data is reflective of cases outside of any clinical setting.  The intent of this harm reduction strategy is to arm ordinary citizens who may or may not have learned CPR or rescue breathing with a tool to save a human life. The intent of these high-dose devices is NOT for use by a clinician (who has ventilatory training and protective equipment) to use within their practice.  

Including high-dose naloxone in a dental emergency drug kit is not only irresponsible, it may be dangerous to both you and the victim.  Here is why:

Understanding Opiates and Naloxone

Opiates bind to receptor sites located on the brain and spinal cord.  Their medicinal effects are to reduce pain signals, but their side effects include stupor, respiratory depression and dopamine release  (which leads to euphoria), the latter of which is sought out by abusers and addicts.  As with other mind-altering substances, such as alcohol, prolonged use and abuse can lead to an increase in tolerance.  As tolerance builds, more and more opiates are needed to produce the same analgesic effect and euphoric feeling.  Hence the foundation for addiction is established.  

When a person stops using the substance (perhaps during a period of incarceration or rehabilitation, for example) tolerance decreases.  When the substance is used again, the user may not be able to secure the same product from their previous sources. Since clandestine suppliers are uncontrolled, the exact amounts of active ingredients is unknown and various suppliers will likely supply various concentrations, or mix in other illicit substances to create their own “brand”.  All of this makes titration to effect an impossibility, increasing the risk of overdose.

Naloxone is an opioid antagonist that works by removing opiates from and preferentially binding to opiate receptors.  This increases the threshold blood concentration needed to cause the desired effects, reversing the obtundation, analgesia, respiratory depression and euphoria within a few minutes.  This, in turn, causes withdrawal symptoms such as anxiety, restlessness, nausea and vomiting, diarrhea, shaking, tachycardia, hallucinations, and seizures. As you might imagine, this causes the overdose victim to feel poorly and may manifest as rudeness, belligerence, or even violence.  

Recreational users of opiates may incorporate other illicit substances such as cocaine (commonly known as “speedballing”) or synthetic marijuana (also known as  “K2” or “Spice”). This is important to consider when making the clinical decision to administer naloxone, as this may exacerbate the effects of the other drugs.

Once the victim is awake, (s)he will be free to move about.  Any attempt to restrain the victim and keep them in your office until first responders / law enforcement arrives may not only be dangerous to you, but may actually constitute assault and battery of the overdosed victim.  This leaves him/her free to exit your office on foot, or perhaps to operate a vehicle.  Keep in mind that the half-life of naloxone is shorter than that of the opiate.  The subject who fled can experience overdose again, only now they are in a different location.  In a roadway?  Behind the wheel?  Alone, in a secluded area where they will not be found until it is too late?

If a victim has taken a stimulant (cocaine, for example) with the opioid, reversing the opioid effects will still allow the stimulant to act uncontrollably.  This can cause tachycardia, dysrhythmias, heart attack, stroke and cardiac arrest (which will require your AED and BLS skills).

It is probably also worth taking a moment to understand the difference between someone who is overdosed, and someone who is simply under the influence.  Using naloxone on a person who is not in respiratory failure and whom cannot be adequately ventilated in a clinical setting is punitive and cruel.  Remember that naloxone was designed to save a human’s life, not to punish him/her for overdosing.   

Assessing the Threat

Obviously, you know the community your office is in better than I do.  How frequently does someone without an appointment enter your office to “use the bathroom”, or sit in the waiting room for no apparent reason?  Is your office close to a more public restroom (a target that is more attractive for an addict to get high)?  Are you located in the city where there is much foot traffic, or in suburbia where automobiles (again, preferred locations for addicts) are essential to get anywhere?  If any person loiters in your office, would ask them to leave, or call law enforcement for assistance?  For these reasons, perhaps the most likely victim of accidental opiate overdose in your office is a member of your own team– a person who is already expected to be there.

Handling the Emergency  

Regardless of who the victim is, (s)he is not breathing adequately.  (S)he is becoming hypoxic and it is your priority to make sure effective ventilation is accomplished. This is best done by employing the basic life support measures that you (and hopefully your entire team) was trained to perform.  In a clinical setting, you will be expected to provide rescue breathing and chest compressions if necessary.  In the absence of any breathing, you will be expected to connect the AED (although a shockable rhythm is not likely to be present).  Most importantly, you will be expected to call 911 immediately.  

When paramedics arrive, they have the option to administer small doses of naloxone via IV, titrating to respiratory competency– the point where mechanical ventilation is no longer needed.  As long as ventilation is occurring, there is no need to wake the victim up and potentially cause more harm, as described above.  

Prepare For The Inevitable Medical Emergency

Call Have Dummy Will Travel today at (631)-849-4978 to set up training in basic life support for your team.  Better yet, engage your team in a dynamic, fun-filled event that requires them to work together through a series of realistic simulations of emergency scenarios likely to occur in your office.  Doctors will learn how to recognize and treat various medical emergencies in a quick, effective and professional manner. We will review the indications and contraindications of each drug in your kit, as well as facilitate administration practice (drawing up and injecting IM medications). Clinical assistants will discover their important role in supporting the doctors, and administrative team members will learn how their skills and natural talents can be used to make an emergency event run smoothly.   Each session is customized to meet individual needs and the overall culture of the office.

Go to nyemergencymeds.com for additional training opportunities, medication kits that were designed by a flight paramedic, and emergency expert, to help you manage the first 15 minutes of the most common medical emergencies, and AEDs and accessories that will keep you prepared and compliant.

Erik Zalewski is a Nationally Registered Paramedic and former New York State EMS Certified Instructor Coordinator with over 30 years experience responding to 9-1-1 calls for medical emergencies.  Erik has taught EMTs and paramedics at Stony Brook University, Borough of Manhattan Community College, and the Suffolk County, NY EMS academy.  Erik is also a certified flight paramedic.  He and his team at Have Dummy Will Travel, Inc. are dedicated to helping medical professionals respond to emergencies safely, efficiently and in the most cost-effective manner possible.  Call or text 631-849-4978 or email erik@havedummy.com for additional information.

References

1. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#Fig3

2. https://oasas.ny.gov/harm-reduction

3. Chimbar, L. & Moletta, Y. (2018). Naloxone Effectiveness A Systematic Review. Journal of Addictions Nursing (29)3: 167-171.

4. Fischer, L. et al. (2025). Effectiveness of naloxone distribution in community settings to reduce opioid overdose deaths among people who use drugs: a systematic review and meta-analysis. BMC Public Health 25(1135).