Pharmacology · single question

A patient with a history of alcohol abuse and illicit drug use requires a simple mandibular third molar extraction. For postoperative pain management, what is the MOST appropriate prescription?

Tramadol 50 mg every 6 hours
Hydrocodone 5 mg every 4 hours
Oxycodone 5 mg/acetaminophen 325 mg every 4-6 hours
Ibuprofen 400 mg every 6 hours + acetaminophen 325 mg alternating (multimodal non-opioid)

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Correct answer: D. Ibuprofen 400 mg every 6 hours + acetaminophen 325 mg alternating (multimodal non-opioid)

A. Tramadol has mu-opioid activity and significant addiction/abuse potential — contraindicated in patients with history of substance abuse.
B. Hydrocodone is a Schedule II opioid — contraindicated with drug abuse history.
C. Oxycodone/APAP is an opioid combination — absolutely contraindicated in a patient with substance abuse history.
D. CORRECT. In a patient with substance abuse history, opioids must be avoided. The current evidence-based approach is MULTIMODAL ANALGESIA: alternating ibuprofen (NSAID) 400 mg with acetaminophen 325–500 mg (staggering the doses) provides superior pain control without opioids. The combination targets different pain pathways (COX inhibition + central pain modulation) and is well-supported by dental literature.

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