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Clinical Withdrawal Opiate Scale
Patient's Name:___________________________
cheeks ____________________________________________________ GI Upset: Over last 1/2 hour
0 no GI symptoms
1 stomach cramps
2 nausea or loose stool
3 vomiting or diarrhea
5 Multiple episodes of diarrhea or vomiting
____________________________________________________ Tremor: Observation of outstretched hands
0 No tremor
1 tremor can be felt, but not observed 2 slight tremor observable
4 gross tremor or muscle twitching
____________________________________________________
Yawning: Observation during assessment 0 no yawning
1 yawning once or twice during assessment
2 yawning three or more times during assessment 4 yawning several times/minute
____________________________________________________
Anxiety or Irritability:
0 none
1 patient reports increasing irritability or anxiousness 2 patient obviously irritable or anxious
4 patient so irritable or anxious that participation in the
assessment is difficult ____________________________________________________ Gooseflesh skin:
0 skin is smooth
3 piloerection of skin can be felt or hairs standing up on arms 5 prominent piloerection
The total score is the sum of all 11 items
(5-12 = mild 13-24 = moderate 25-36 = moderately severe >36=severe withdrawal)
Resting Pulse Rate: _____beats/minute
Measured after patient is sitting or lying for one minute
0 pulse rate 80 or below
1 pulse rate 81-100
2 pulse rate 101-120
4 pulse rate greater than 120
_____________________________________________________
Sweating: Over past 1/2 hour not accounted for by room temperature or patient activity
0 no report of chills or flushing
1 subjective report of chills or flushing
2 flushed or observable moistness on face 3 beads of sweat on brow or face
4 sweat streaming off face
_____________________________________________________
Restlessness: Observation during assessment 0 able to sit still
1 reports difficulty sitting still, but is able to do so
3 frequent shifting or extraneous movements of legs/arms 5 Unable to sit still for more than a few seconds
_____________________________________________________
Pupil size:
0 pupils pinned or normal size for room light
1 pupils possibly larger than normal for room light
2 pupils moderately dilated
5 pupils so dilated that only the rim of the iris is visible
_____________________________________________________
Bone or Joint aches: If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored
0 not present
1 mild diffuse discomfort
2 patient reports severe diffuse aching of joints/muscles 4 patient is rubbing joints or muscles and is unable to
Measured after patient is sitting or lying for one minute
0 pulse rate 80 or below
1 pulse rate 81-100
2 pulse rate 101-120
4 pulse rate greater than 120
_____________________________________________________
Sweating: Over past 1/2 hour not accounted for by room temperature or patient activity
0 no report of chills or flushing
1 subjective report of chills or flushing
2 flushed or observable moistness on face 3 beads of sweat on brow or face
4 sweat streaming off face
_____________________________________________________
Restlessness: Observation during assessment 0 able to sit still
1 reports difficulty sitting still, but is able to do so
3 frequent shifting or extraneous movements of legs/arms 5 Unable to sit still for more than a few seconds
_____________________________________________________
Pupil size:
0 pupils pinned or normal size for room light
1 pupils possibly larger than normal for room light
2 pupils moderately dilated
5 pupils so dilated that only the rim of the iris is visible
_____________________________________________________
Bone or Joint aches: If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored
0 not present
1 mild diffuse discomfort
2 patient reports severe diffuse aching of joints/muscles 4 patient is rubbing joints or muscles and is unable to
Date and Time: / / _______
0 not present
-
1 nasal stuffiness or unusually moist eyes
-
2 nose running or tearing
cheeks ____________________________________________________ GI Upset: Over last 1/2 hour
0 no GI symptoms
1 stomach cramps
2 nausea or loose stool
3 vomiting or diarrhea
5 Multiple episodes of diarrhea or vomiting
____________________________________________________ Tremor: Observation of outstretched hands
0 No tremor
1 tremor can be felt, but not observed 2 slight tremor observable
4 gross tremor or muscle twitching
____________________________________________________
Yawning: Observation during assessment 0 no yawning
1 yawning once or twice during assessment
2 yawning three or more times during assessment 4 yawning several times/minute
____________________________________________________
Anxiety or Irritability:
0 none
1 patient reports increasing irritability or anxiousness 2 patient obviously irritable or anxious
4 patient so irritable or anxious that participation in the
assessment is difficult ____________________________________________________ Gooseflesh skin:
0 skin is smooth
3 piloerection of skin can be felt or hairs standing up on arms 5 prominent piloerection
The total score is the sum of all 11 items
(5-12 = mild 13-24 = moderate 25-36 = moderately severe >36=severe withdrawal)
sit still because of discomfort
_____________________________________________________
Runny nose or tearing: Not accounted for by cold symptoms or ____________________________________________________ allergies
_____________________________________________________
Runny nose or tearing: Not accounted for by cold symptoms or ____________________________________________________ allergies
Total Score:__________________
Initials of person completing assessment:____________________
Reference: California Society of Addiction Medicine
Clinical Opiate Withdrawal Scale
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