A patient with hepatitis B and a history of drug and alcohol dependence — abstinent for two years — needs analgesia. What do you recommend?

Correct answer: A. Ibuprofen plus acetaminophen

• A. Correct. A non-opioid combination gives analgesia equal or superior to a low-dose opioid for dental pain, and it avoids putting an opioid in front of a patient in recovery.
• B. Tramadol is also an opioid agonist with additional serotonergic effects, so it is not the safe alternative it is sometimes assumed to be.
• C. Hydrocodone is an opioid. Prescribing it to someone with a substance use history risks relapse and is avoided where an effective alternative exists.
• D. Oxycodone carries the same objection, with a higher abuse liability still.

Note: Because of the hepatitis B, cap the acetaminophen well below the usual maximum and confirm current liver function with the physician. Ibuprofen also needs care if there is any portal hypertension or coagulopathy.