Clinical Opiate Withdrawal Scale

Clinical Opiate Withdrawal Scale

  • Each item is scored for severity, and scores are totaled to reflect overall severity of the withdrawal syndrome:
    • Severe: higher than 36
    • Moderately severe: 25 to 36
    • Moderate: 13 to 24
    • Mild: 5 to 12
  • Piloerection
    • 5: prominent piloerection
    • 3: can feel piloerection on patient’s forearm
    • 0: smooth skin
  • Anxiety or irritability
    • 4: irritable or anxious to the point of difficulty participating in evaluation
    • 2: obviously anxious or irritable
    • 1: reports anxiety or irritability
    • 0: none
  • Yawning
    • 4: yawns several times per minute
    • 2: yawns 3 or more times during assessment
    • 1: yawns 1 or 2 times during assessment
    • 0: no yawns
  • Tremor (observation of outstretched hands)
    • 4: gross tremor present or muscle twitches
    • 2: mild tremor observed
    • 1: tremor felt but not observed
    • 0: no tremor
  • Gastrointestinal distress (over previous 30 minutes)
    • 5: multiple episodes of vomiting or diarrhea
    • 3: vomiting or diarrhea
    • 2: nausea or loose stools
    • 1: stomach cramps
    • 0: no gastrointestinal symptoms
  • Rhinorrhea or lacrimation (not counting cold or allergy symptoms)
    • 4: nose constantly running or tears streaming down face
    • 2: obvious rhinorrhea or lacrimation
    • 1: nasal congestion or unusually moist eyes
    • 0: not present
  • Arthralgia/myalgia (if pain was previously present, consider only additional component attributed to opiate withdrawal)
    • 4: observed rubbing muscles or joints and unable to remain still due to discomfort
    • 2: reports severe diffuse joint or muscle aches
    • 1: mild diffuse discomfort
    • 0: no pain or discomfort
  • Pupil size (observation)
    • 5: dilated to degree that only iris rim is visible
    • 2: moderately dilated
    • 1: possibly larger than normal for room light
    • 0: pinned pupils or normal size for room light
  • Restlessness (observation)
    • 5: cannot sit still for more than a few seconds
    • 3: frequent extraneous movements of legs and/or arms or shifting
    • 1: reports difficulty sitting still but is able to do so
    • 0: able to sit still
  • Sweating (over previous 30 minutes without being accounted for by room temperature or activity)
    • 4: sweat streaming off face
    • 3: beads of sweat on face
    • 2: flushed or has observable facial moisture
    • 1: subjective report of chills or flushing
    • 0: no chills or flushing reported by patient
  • Resting pulse rate (after patient has been lying or sitting down for 1 minute)
    • 4: more than 120 beats per minute
    • 2: 101 to 120 beats per minute
    • 1: 81 to 100 beats per minute
    • 0: fewer than 80 beats per minute
Resting pulse rate in beats per minute (after sitting or lying for 1 minute)
0Pulse rate 80 or below
1Pulse rate 81 to 100
2Pulse rate 101 to 120
4Pulse rate greater than 120
Sweating (over previous 30 minutes, not accounted for by room temperature or patient activity)
0No report of chills or flushing
1Subjective report of chills or flushing
2Flushed or observable moistness on face
3Beads of sweat on brow or face
4Sweat streaming off face
Restlessness (observation during assessment)
0Able to sit still
1Reports difficulty sitting still, but is able to do so
3Frequent shifting or extraneous movements of legs/arms
5Unable to sit still for more than a few seconds
Pupil size
0Pin size or normal size for room light
1Possibly larger than normal for room light
2Moderately dilated
5So dilated that only rim of iris is visible
Bone or joint aches (if patients was having pain previously, only the additional component attributed to opiates withdrawal is scored)
0Not present
1Mild diffuse discomfort
2Patient reports severe diffuse aching of joints and muscles
4Patient is rubbing joints or muscles and is unable to sit still because of discomfort
Runny nose or tearing (not accounted for by cold symptoms or allergies)
0Not present
1Nasal stuffiness or unusually moist eyes
2Nose running or tearing present
4Nose constantly running or tears streaming down cheeks
Gastrointestinal upset (over the past 30 minutes)
0No gastrointestinal symptoms
1Stomach cramps
2Nausea or loose stool
3Vomiting or diarrhea
5Multiple episodes of diarrhea or vomiting
Tremor (observation of outstretched hands)
0No tremor
1Tremor felt by examiner but not observed
2Slight observable tremor
4Gross tremor or muscle twitching
Yawning (observation during assessment)
0No yawning
1Yawning 1 or 2 times during assessment (approximately 2 minutes)
2Yawning 3 or more times during assessment
4Yawning several times per minute
Anxiety or irritability
1Reports increasing irritability or anxiousness
2Obviously irritable or anxious
4Participation in assessment is difficult due to irritability or anxiety
Gooseflesh skin (piloerection)
0Skin is smooth
3Piloerection of skin can be felt felt or hairs standing up on arms
5Prominent piloerection

Caption: Score: 5-12, mild; 13-24, moderate; 25-36, moderately severe; more than 36, severe withdrawal.


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