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Withdrawal Scale

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0% found this document useful (0 votes)
118 views8 pages

Withdrawal Scale

Uploaded by

dr.nayeck
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

APPENDIX 7

CLINICAL INSTITUTE NARCOTIC ASSESSMENT (CINA) SCALE FOR WITHDRAWAL SYMPTOMS


The Clinical Institute Narcotic Assessment (CINA) Scale measures 11 signs and symptoms commonly seen in
patients during narcotic withdrawal. This can help to gauge the severity of the symptoms and to monitor changes
in the clinical status over time.

Minimum score = 0, Maximum score = 31. The higher the score, the more severe the withdrawal syndrome.
Percent of maximal withdrawal symptoms = total score/31 x 100%.
Source: Adapted from Peachey JE, Lei H. Assessment of opioid dependence with naloxone. Br J Addict. 1988 Feb;83(2):193-201.

PREGNANCY AND OPIOID EXPOSURE: GUIDANCE FOR NORTH CAROLINA


Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar)

Patient:__________________________ Date: ________________ Time: _______________ (24 hour clock, midnight = 00:00)

Pulse or heart rate, taken for one minute:_________________________ Blood pressure:______

NAUSEA AND VOMITING -- Ask "Do you feel sick to your TACTILE DISTURBANCES -- Ask "Have you any itching, pins and
stomach? Have you vomited?" Observation. needles sensations, any burning, any numbness, or do you feel bugs
0 no nausea and no vomiting crawling on or under your skin?" Observation.
1 mild nausea with no vomiting 0 none
2 1 very mild itching, pins and needles, burning or numbness
3 2 mild itching, pins and needles, burning or numbness
4 intermittent nausea with dry heaves 3 moderate itching, pins and needles, burning or numbness
5 4 moderately severe hallucinations
6 5 severe hallucinations
7 constant nausea, frequent dry heaves and vomiting 6 extremely severe hallucinations
7 continuous hallucinations

TREMOR -- Arms extended and fingers spread apart. AUDITORY DISTURBANCES -- Ask "Are you more aware of
Observation. sounds around you? Are they harsh? Do they frighten you? Are you
0 no tremor hearing anything that is disturbing to you? Are you hearing things you
1 not visible, but can be felt fingertip to fingertip know are not there?" Observation.
2 0 not present
3 1 very mild harshness or ability to frighten
4 moderate, with patient's arms extended 2 mild harshness or ability to frighten
5 3 moderate harshness or ability to frighten
6 4 moderately severe hallucinations
7 severe, even with arms not extended 5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations

PAROXYSMAL SWEATS -- Observation. VISUAL DISTURBANCES -- Ask "Does the light appear to be too
0 no sweat visible bright? Is its color different? Does it hurt your eyes? Are you seeing
1 barely perceptible sweating, palms moist anything that is disturbing to you? Are you seeing things you know are
2 not there?" Observation.
3 0 not present
4 beads of sweat obvious on forehead 1 very mild sensitivity
5 2 mild sensitivity
6 3 moderate sensitivity
7 drenching sweats 4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations

ANXIETY -- Ask "Do you feel nervous?" Observation. HEADACHE, FULLNESS IN HEAD -- Ask "Does your head feel
0 no anxiety, at ease different? Does it feel like there is a band around your head?" Do not
1 mild anxious rate for dizziness or lightheadedness. Otherwise, rate severity.
2 0 not present
3 1 very mild
4 moderately anxious, or guarded, so anxiety is inferred 2 mild
5 3 moderate
6 4 moderately severe
7 equivalent to acute panic states as seen in severe delirium or 5 severe
acute schizophrenic reactions 6 very severe
7 extremely severe
AGITATION -- Observation. ORIENTATION AND CLOUDING OF SENSORIUM -- Ask
0 normal activity "What day is this? Where are you? Who am I?"
1 somewhat more than normal activity 0 oriented and can do serial additions
2 1 cannot do serial additions or is uncertain about date
3 2 disoriented for date by no more than 2 calendar days
4 moderately fidgety and restless 3 disoriented for date by more than 2 calendar days
5 4 disoriented for place/or person
6
7 paces back and forth during most of the interview, or constantly
thrashes about
Total CIWA-Ar Score ______
Rater's Initials ______
Maximum Possible Score 67

The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires
approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need
additional medication for withdrawal.

Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A.; and Sellers, E.M. Assessment of alcohol withdrawal: The revised Clinical
Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction 84:1353-1357, 1989.
Clinical Institute Withdrawal
Assessment Scale - Benzodiazepines
Guide to the Use of the Clinical Withdrawal Assessment Scale for
Benzodiazepines

Person Report:

For each of the following items, circle the number that best describes how
you feel.

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Clinician Observations

Observe behaviour Observe tremor Observe feel palms


for sweating,
restlessness and
agitation

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Total Score Items 1 – 20


1–20 = mild withdrawal

41–60 = severe withdrawal


21–40 =moderate withdrawal

61–80 = very severe withdrawal

Source: Adapted from Busto, U.E., Sykora, K. & Sellers, E.M. (1989). A clinical scale
to assess benzodiazepine withdrawal. Journal of Clinical Psychopharmacology, 9 (6),
412–416.
Clinical Opiate
Withdrawal Scale

Introduction
The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale designed
to be administered by a clinician. This tool can be used in both inpatient
and outpatient settings to reproducibly rate common signs and symptoms
of opiate withdrawal and monitor these symptoms over time. The summed
score for the complete scale can be used to help clinicians determine the
stage or severity of opiate withdrawal and assess the level of physical
dependence on opioids. Practitioners sometimes express concern about
the objectivity of the items in the COWS; however, the symptoms of opioid
withdrawal have been likened to a severe influenza infection (e.g., nausea,
vomiting, sweating, joint aches, agitation, tremor), and patients should
not exceed the lowest score in most categories without exhibiting some
observable sign or symptom of withdrawal.

[Link]
Wesson & Ling Clinical Opiate Withdrawal Scale

APPENDIX 1
Clinical Opiate Withdrawal Scale

For each item, circle the number that best describes the patient' s signs or symptom. Rate on j ust the
apparent relationship to opiate withdrawal. For example, if heart rate is increased because the patient
was jogging just prior to assessment, the increase pulse rate would not add to the score.

Patient' s Name: Date and Time !


_ __ _ !

Reason for this assessment:


Downloaded by [HSRL - Health Science Research Library] at 14:04 02 September 2015

Resting Pulse Rate: beats/minute GI Upset: over last 1/2 hour


Measured after patient is sitting or lying for one minute 0 no GI symptoms
0 pulse rate 80 or below 1 stomach cramps
1 pulse rate 8 1 - 1 00 2 nausea or loose stool
2 pulse rate 1 0 1 - 1 20 3 vomiting or diarrhea
4 pulse rate greater than 1 20 5 multiple episodes of diarrhea or vomiting
Sweating: over past 1/2 hour not accounted for by Tremor observation ofoutstretched hands
room temperature or patient activity. 0 no tremor
0 no report of chills or flushing 1 tremor can be felt, but not observed
1 subjective report of chills or flushing 2 slight tremor observable
2 flushed or observable moistness on face 4 gross tremor or muscle twitching
3 beads of sweat on brow or face
4 sweat streaming off face
Restlessness Observation during assessment Yawning Observation during assessment
0 able to sit still 0 no yawning
1 reports difficulty sitting still, but is able to do so 1 yawning once or twice during assessment
3 frequent shifting or extraneous movements of legs/arms 2 yawning three or more times during assessment
5 unable to sit stil l for more than a few seconds 4 yawning several times/minute
Pupil size Anxiety or Irritability
0 pupils pinned or normal size for room light 0 none
1 pupils possibly larger than normal for room light 1 patient reports increasing irritability or anxiousness
2 pupils moderately dilated 2 patient obviously irritable or anxious
5 pupils so dilated that only the rim of the iris is visible 4 patient so irritable or anxious that participation in
the assessment is difficult
Bone or Joint aches if patient was having pain Gooseflesh skin
previously, only the additional component attributed 0 skin is smooth
to opiates withdrawal is scored 3 piloerrection of skin can be felt or hairs standing up
0 not present on arms
1 mild diffuse discomfort 5 prominent piloerrection
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
Runny nose or tearing Not accounted for by cold
-symptoms or allergies
Total Score
0 not present
1 nasal stuffiness or unusually moist eyes The total score is the sum of all 1 1 items
2 nose running or tearing Initials of person
4 nose constantly running or tears streaming down cheeks completing assessment:
Score: 5- 1 2 = mild; 1 3-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal
This version may be copied and used clinically.

Journal of Psychoactive Drugs Volume 35 (2), April - June 2003

Source: Wesson, D. R., & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive
Drugs, 35(2), 253–9.

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