Pharmacology · patient case question
Which analgesic should NOT be prescribed to this patient?
Patient case: Viral hepatitis and a history of opioid misuse
Patient: Male, 41 years old
Chief complaint: “I need this tooth out, it's been aching for a week.”
History: HIV on antiretroviral therapy. Chronic hepatitis B and hepatitis C co-infection with documented hepatic impairment. History of opioid use disorder, currently in recovery for 18 months.
Findings: Non-restorable tooth #31 with a chronic apical abscess. Moderate pain. INR mildly prolonged at 1.4.
Show answer and explanation
Correct answer: C. Hydrocodone
- A. Ibuprofen requires caution in advanced liver disease because of gastrointestinal bleeding risk and effects on renal perfusion, but it is not the prohibited drug here and short-course NSAID use is often the appropriate choice.
- B. A long-acting local anaesthetic block, bupivacaine for instance, is an excellent opioid-sparing strategy for exactly this patient.
- C. CORRECT. HYDROCODONE is an opioid, and this patient has a documented history of OPIOID USE DISORDER in sustained recovery. Prescribing an opioid risks precipitating relapse and undermining 18 months of recovery. Non-opioid analgesia plus definitive treatment of the source is the standard of care, and where an opioid is genuinely unavoidable it should be prescribed in consultation with the patient's addiction physician, in the smallest quantity, with the patient's knowledge and consent.
- D. Acetaminophen is hepatically metabolised and its ceiling dose must be reduced in liver disease — commonly to 2 g per day or less — but at a reduced dose it remains usable and is often preferred over NSAIDs.
Note: The definitive treatment is extraction. Analgesic choice is a bridge, and the best opioid-sparing plan is prompt removal of the source of pain.