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
| Score | Criteria |
|---|---|
| Resting pulse rate in beats per minute (after sitting or lying for 1 minute) | |
| 0 | Pulse rate 80 or below |
| 1 | Pulse rate 81 to 100 |
| 2 | Pulse rate 101 to 120 |
| 4 | Pulse rate greater than 120 |
| Sweating (over previous 30 minutes, 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 | Pin size or normal size for room light |
| 1 | Possibly larger than normal for room light |
| 2 | Moderately dilated |
| 5 | So 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) | |
| 0 | Not present |
| 1 | Mild diffuse discomfort |
| 2 | Patient reports severe diffuse aching of joints and muscles |
| 4 | Patient 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) | |
| 0 | Not present |
| 1 | Nasal stuffiness or unusually moist eyes |
| 2 | Nose running or tearing present |
| 4 | Nose constantly running or tears streaming down cheeks |
| Gastrointestinal upset (over the past 30 minutes) | |
| 0 | No gastrointestinal 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 felt by examiner but not observed |
| 2 | Slight observable tremor |
| 4 | Gross tremor or muscle twitching |
| Yawning (observation during assessment) | |
| 0 | No yawning |
| 1 | Yawning 1 or 2 times during assessment (approximately 2 minutes) |
| 2 | Yawning 3 or more times during assessment |
| 4 | Yawning several times per minute |
| Anxiety or irritability | |
| 0 | None |
| 1 | Reports increasing irritability or anxiousness |
| 2 | Obviously irritable or anxious |
| 4 | Participation in assessment is difficult due to irritability or anxiety |
| Gooseflesh skin (piloerection) | |
| 0 | Skin is smooth |
| 3 | Piloerection of skin can be felt felt or hairs standing up on arms |
| 5 | Prominent piloerection |
Caption: Score: 5-12, mild; 13-24, moderate; 25-36, moderately severe; more than 36, severe withdrawal.
