A patient with a documented history of alcohol and drug abuse presents following third molar extractions and requires postoperative pain management. Which analgesic regimen is most appropriate?

In a patient with a history of alcohol and substance abuse, opioids are contraindicated due to the high risk of addiction, diversion, and overdose. Clinical evidence strongly supports the ibuprofen + acetaminophen combination as superior to opioids for post-extraction pain. A landmark trial in over 1,800 patients (JADA 2025) demonstrated that 400 mg ibuprofen + 500 mg acetaminophen outperformed hydrocodone/acetaminophen in pain control, sleep quality, and patient satisfaction. This combination works synergistically: ibuprofen (NSAID) targets peripheral inflammation, acetaminophen works centrally. For patients with substance abuse history, this non-opioid regimen is both clinically effective and ethically sound. Note: If the patient also has liver disease from alcohol use, acetaminophen should be limited to ≤2 g/day with monitoring.