Special Populations in the ED: Drug Users

Drug users have a different reputation among health care providers, especially in the ED. According to World Health Organization (WHO), in 2018, an estimated 269 million people, or 5.4 percent of the global population aged 15–64, had used drugs in the previous year (1). Here we will focus on opioid users, which accounts for 57.8 million people globally in 2018, specifically the acute pain management in these patients.

What do I have to know about them:

Patients with opioid dependency can have three major obstacles to pain management

  1. Opioid-Induced Hyperalgesia (OIH): A sensitive disorder is caused by chronic use of opioids; It can affect patients under opioid use for chronic pain control, patients under substitution therapy (methadone and buprenorphine), and those abusing heroin. OIH typically produces diffuse and not well-defined pain.
  2. Opioid tolerance: These patients report higher pain scores, have slower pain resolution, and experience a longer hospital stay with an increased chance of readmission, compared with opioid-naive patients. Tolerance to CNS, respiratory, and analgesic effects develops quickly, while tolerance to constipating effects may not happen. (3). Cross-tolerance is a tolerance that patients taking chronic methadone need higher doses of morphine for pain relief than occasional IV heroin users (3), suggesting a cross-tolerance between methadone and other opioids.
  3. Opioid withdrawal: Symptoms are caused by sympathetic activation: tachycardia, sweating, insomnia, diarrhea, and anxiety. Opioid substitution therapy (OST), usually with methadone, is crucial in treating those in rehab from opioid abuse.
drug users 2

How could this be a problem?

  • Overtreatment: Higher dose equals more toxicity. Because of the OIH and opioid tolerance, higher doses may be necessary to relieve pain in these patients. Clinicians are generally afraid to give a higher amount of opioids due to the risk of toxicity, especially respiratory depression.
  • Relapse x undertreatment: Another common fear among clinicians is inducing a relapse in an abstinent patient or OST, leading to undertreatment of pain. This, instead of opioid use, has more power to cause a relapse. (2)

Acute pain management in the chronic opioid user

  • OIH (2): Multimodal analgesia, using acetaminophen, non-steroidal anti-inflammatories, and local anesthetics as “opioid-sparing drugs.” Adjuvant therapies also play an essential role, with ketamine, gabapentin, and pregabalin showing promising results in reducing OIH.
  • Withdrawal (2): Methadone in small doses (10 – 20 mg) can be used to prevent withdrawal symptoms in patients who are not in OST. Methadone can cause QT-interval prolongation
  • Toxicity (4): As commented above, chronic opioid users develop tolerance to respiratory and CNS effects as well, giving more space to higher doses of opioids for pain management. If toxic effects happen, provide ventilatory support and use antidotes (naloxone) if needed. Classic signs of opioid toxicity are as follows; decreased respiratory frequency (best predictor if < 12), depressed mental status, miotic pupils (however, normal pupils does not exclude opioid toxicity). 
  • Tolerance (3): Around the clock dosing is recommended rather than “as needed.” For patients on OST, their regular dose of methadone/buprenorphine should be continued alongside additional doses of short-acting opioids and other analgesics for adequate pain control.

Disposition to home (3)

The most crucial action here is to contact the assistant physician who is prescribing the opioids and make he/she knows what happened, how it was managed, what medications were prescribed, and in which dose. If opioids are needed for pain control at home, consider the services available in the outpatient setting: 

  • Immediate-release preparations are more effective for acute pain relief but carry a higher risk of abuse. If it is possible to arrange more frequent appointments, small doses of the medication can be prescribed, and the patient can be closely monitored.
  • If a closer follow-up is not possible, long-acting formulations are the safest way to provide good analgesia with a smaller risk of abuse.
Cite this article as: Arthur Martins, Brasil, "Special Populations in the ED: Drug Users," in International Emergency Medicine Education Project, March 10, 2021, https://iem-student.org/2021/03/10/drug-users/, date accessed: December 5, 2023

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References and Further Reading

  1. United Nations World Drug Report 2020 (available at https://wdr.unodc.org/wdr2019/
  2. Quinlan J, Cox F. Acute pain management in patients with drug dependence syndrome. Pain Rep. 2017;2(4):e611. Published 2017 Jul 27. doi:10.1097/PR9.0000000000000611
  3. Vadivelu N, Lumermann L, Zhu R, Kodumudi G, Elhassan AO, Kaye AD. Pain Control in the Presence of Drug Addiction. Curr Pain Headache Rep. 2016;20(5):35. doi:10.1007/s11916-016-0561-0
  4. UpToDate: https://www.uptodate.com/contents/acute-opioid-intoxication-in-adults?search=opioid&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=4
  • UN World Drug Report 2020 – https://wdr.unodc.org/wdr2020/index.html
  • Haber PS, Demirkol A, Lange K, Murnion B. Management of injecting drug users admitted to hospital. Lancet. 2009;374(9697):1284-1293. doi:10.1016/S0140-6736(09)61036-9
  • Sahota PK, Shastry S, Mukamel DB, et al. Screening emergency department patients for opioid drug use: A qualitative systematic review. Addict Behav. 2018;85:139-146. doi:10.1016/j.addbeh.2018.05.022

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: December 5, 2023

Pain Relief

Healthcare providers should have a sound understanding of the anatomy, physiology, and psychology of addictive behaviors. A focused history and examination should concentrate on items that can indicate inconsistencies or falsifications associated with inappropriate drug-seeking behavior. It was always difficult as a decision has to be made between “losing” to drug seekers and denying analgesia to patients who are genuinely in need. It is best to give patients the benefit of the doubt with due diligence.

"Drugs for pain relief' chapter written by Nik Ahmad Shaiffudin Nik Him and Azizul Fadzi was added into the content list.

From experts to our students: Opioid Overdose

A 22-year-old male


Acute Appendicitis

by Ozlem Dikme, Turkey

A previously healthy 22-year-old male was brought to the emergency department (ED) with recently-started abdominal pain. He had not eaten anything since that morning due to loss of appetite. He was nauseated and vomited three times. His abdominal pain started around the umbilicus and epigastric area. His pain increased as it moved towards his right lower quadrant (RLQ). The maximum pain was felt on the right iliac fossa. He had not taken any medication. His social history revealed that he was non-drinker, non-smoker and did not use any illicit drugs. His diet mostly consisted of carbohydrates. The past and family histories were unremarkable. His blood pressure was 120/70 mmHg, pulse rate was 100/min, the temperature was 37.8°C (100°F), and respiration rate was 22/min. 

What is the cut-off number in Alvarado score to suspect appendicitis?

Touch Me

Alvarado Score

1-4 appendicitis unlikely, 5-6 appendicitis possible, 7-8 appendicitis probable, 9-10 appendicitis very probable
51.1 - abdominal - pain - appendicitis ultrasound

Physical examination showed normal bowel sounds, tenderness and voluntary guarding, particularly over the right iliac fossa. The costa-vertebral angles were not tender. Oral intake was stopped, intravenous (IV) catheter was inserted, blood and urine tests were planned, and fluid therapy was started. The urinalysis was normal. White blood cell (WBC) count was 14,500 with 89% polymorphous and 11% lymphocytes. The ultrasonography (USG) showed a non-compressible tubular structure of 9 mm in diameter at RLQ. He admitted to the surgical ward with the diagnosis of acute appendicitis.