OPIATE
WITHDRAWAL SCALE
For
each item, circle the number that best describes the
patient's signs or symptom. Rate only when directly
associated to opiate withdrawal. For example, if the
heart rate is increased because the patient was jogging
just prior to assessment, increased pulse rate would
not add to the score.
PATIENT NAME:
PATIENT NUMBER:
DATE & TIME:
REASON FOR ASSESSMENT:
1.)Resting pulse rate: ___________beats/minutes
*
Measured after the 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
2.)Sweating: over past 1/2 hour not accounted for by
room temperature or patient activity *
0 - no reports 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
3.)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
4.)Pupil size: *
0 - pupils pinned or normal size for room light
1 - pupils possibly larger than for normal room light
2 - pupils moderately dilated
5 - pupils so dilated that only the rim of the iris is visible
5.)Bone or joint aches: if patient was having pain previously,
only the additional component attributed to opiate withdrawal
score:
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 sit
still because of discomfort
6.)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
4 - nose constantly running or tears streaming down cheeks
7.)Gl Upset: over last 1/2
hour
0 - no Gl symptoms
1 - stomach cramps
2 - nausea or loose stool
3 - vomiting or diarrhea
5 - multiple episodes of diarrhea or vomiting
8.)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
9.)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/minutes
10.)Anxiety or Irritability:
0 - none
1 - patient reports increasing irritability or anxiousness
2 - patient obviously irritable/anxious
4 - patient so irritable or anxious that
assessment is difficult
11.)Gooseflesh*:
0 - skin is smooth
3 - piloerection of skin can be felt or hairs standing up
on arms
5 - prominent piloerection
TOTAL SCORE:_________________________
The total score is the sum of all 11 items
Signature of person completing
assessment:______________________
Score: 5-12 = mild; 13-24 = moderate; 25-36 = moderately
severe; more than 36 = severe withdrawal with at least
three *identifiers present to validate score
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