A young patient with a history of opioid abuse, currently using amphetamines, requests extraction of painful teeth. When should the dental extractions be performed?

In a patient with active polysubstance abuse (opioids and amphetamines), elective dental extractions should be deferred until appropriate behavioral counseling and substance use assessment have been completed. Active amphetamine use poses anesthetic risks (increased epinephrine sensitivity, hypertensive crisis, dysrhythmias when combined with epinephrine-containing local anesthetics). Opioid abuse history complicates pain management. Before proceeding, collaboration with addiction medicine specialists and development of a safe anesthetic plan are essential. Emergency pain management may be provided with non-opioid analgesics while counseling is arranged. Full-mouth rehabilitation before counseling is unrealistic and premature.