How to use it
- Measure the resting pulse after the patient has sat or lain down for a minute.
- Observe the patient during the assessment and ask about the last half hour for sweating and stomach symptoms.
- Pick the matching description for each sign; symptoms clearly due to something else (a cold, an old injury) are not counted.
- Read the total and the severity group.
How the scale works
Eleven signs are scored with their own point steps; the total is the sum, up to 48.
| Total | Withdrawal |
|---|---|
| 0–4 | No active withdrawal |
| 5–12 | Mild |
| 13–24 | Moderate |
| 25–36 | Moderately severe |
| More than 36 | Severe |
Worked example
A patient last used heroin 14 hours ago. Pulse 108 (2), flushed face (2), frequent shifting (3), moderately dilated pupils (2), severe aching (2), runny nose (2), loose stool (2), tremor that can be felt (1), three yawns (2), obviously anxious (2) and hairs standing up on the arms (3). The total is 23, moderate withdrawal.
Tips
- Score what you observe at the time; do not carry over findings from an earlier assessment.
- A fast pulse from fever, pain or exercise inflates the score; note the context.
- Record the time of the last opioid dose with each score.
- This page is for information; opioid withdrawal treatment needs a clinician.