There is no question that something needs to be done about the opiod epidemic, as it is costing too many lives in the US ( as well as Canada).  I am a firm believer that much of this epidemic is driven by the unintended consequences of making pain the 5th vital sign, emphasis on patient satisfaction scored (HCAHPS) and their effect on reimbursements.  I bring this up only because I wish to point out some unintended consequences of the current proposed regulatory changes.

1)  Milligram Morphine Equivalencies -  this is a topic that comes from pain medicine and equianalgesic doses.  It has been increasingly emphasized due to the CDC recommendations.  However, the CDC recommendations were meant to be guidelines for consideration by practitioners and not laws.  The CDC was clear on this, and made such recommendations because of the public health crisis posed by the Opioid Epidemic.  Dentists are not trained on this.  I would say few understand that hydrocodone has a 1:1 equivalency with ORAL morphine ( IV morphine is 3 times that of oral morphine due to bioavailability) or Oxycodone is 1:5 : 1.  Codeine shows a major flaw in this equianalgesic / equavalency paradigm, as it is completely dependent on metabolism of a prodrug into active metabolites.  Each individual does so differently.  However, the MME helps to study effects across the plethora of different opioid drugs.

This becomes problematic when a dentist prescribes medications for a 3-5 day period that is typical after dental surgical procedures.  It was long taught that dentists should prescribe Hydrocodone / Acetaminophen 5/325 as 1-2 tabs every 4-6 hrs as needed for pain, perhaps with 16-20 pills.  This allows the patient to adjust their dosing within a safe range depending on pain levels.  A pharmacist will review this Rx as 60 MME daily.  This is regarded as equivalent to an MD prescribing Hydrocodone / Acetaminophen 5/325 2 every 4 hours for 30 days, or 360 pills. Dentists should be encourages to prescribe for less than 7 days (as noted in these changes) for acute pain, not necessary on the basis of MMEs. Most of our crisis is due to misuse, especially of extra supply of medications.

2)  Naloxone requires some training to use.  Dentists being encouraged to prescribe these items to patients and their families will require thorough understanding of respiratory depression secondary to excess narcotics and how to use naloxone.  Intranasal naloxone requires expensive Mucosal atomization devices, and requires high volumes of drug (although there are now more expensive conentrated versions of naloxone), approximately 4 ml.  Intramuscular devices are like epi pens and cost upwards of 600 dollars.  Even the original naloxone formulation has had a price increase of nearly 300% since these rules, going from appoximately 9 dollars to 30 dollars on my most recent order - and it is getting worse.

3) Naloxone with any concomitant use of benzodiazapene - we use benzodiazepenes frequently in dentistry for sedation and anesthesia.  Should we give every patient that gets an opioid prescription Naloxone then?  This would basically mean every patient receiving sedation or anesthesia would need a prescription for Naloxone.  It is true that there can be a synergistic effect of narcotics and benzodiazapenes on respiratory depression, but such a blanket "must" is, in my opinion, a waste of medical resources.

In summary, I would ask you to reconsider the wording of the Naloxone requirements for the reasons above.  I also believe that it is more efficacious for dentists to be encouraged to maximize non-narcotic analgesic techniques first and to limit narcotics to breakthrough pain during the acute phase of recovery (5-7 days maximum) either in addition to or in leui of focussing solely on MMEs.