A patient with a long history of heavy alcohol and recreational drug use requires an analgesic after an extraction. There is no history of liver disease, gastric ulceration or renal impairment. Which is the BEST choice?

Correct answer: C. Ibuprofen

• A. ❌ Acetaminophen is the classic wrong answer here — the alcohol-acetaminophen interaction is precisely what the question is testing.
• B. ❌ Opioids are avoided in a patient with a substance use history because of dependence and diversion risk, and they carry additive CNS depression with alcohol.
• C. ✅ CORRECT — In a chronic heavy drinker, ACETAMINOPHEN is the drug to avoid: alcohol induces CYP2E1 and depletes glutathione, so the toxic NAPQI metabolite accumulates and hepatotoxicity can occur at ordinary doses. An NSAID is the safer choice provided there is no ulcer disease, renal impairment or bleeding risk.
• D. ❌ A combination product carries both the opioid risk and the acetaminophen hepatotoxicity risk.

Note: ⚑ Nuance worth discussing: NSAIDs also carry GI bleeding risk in drinkers, and if cirrhosis or varices are present neither drug is comfortable. The exam-level answer is ibuprofen; the clinical answer is 'consult the physician.'