Reason for this assessment:
1. Resting pulse rate: ______ beats/minute 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 7. GI upset: over last half hour 0 No GI symptoms 1 Stomach cramps 2 Nausea or loose stool 3 Vomiting or diarrhea 5 Multiple episodes of diarrhea or vomiting
2. Sweating: over past half hour not accounted for by room temperature of patient activity 0 No reports of chills or flushing 1 Subjective reports of chills or flushing 2 Flushed or observable moisture on face 3 Beads of sweat on brow or face 4 Sweat streaming off face 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
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 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/minute
4. Pupil size 0 Pupils pinned or normal size for room light 1 Pupils possibly larger than normal for room light 2 Pupils moderately dilated 5 Pupils so dilated that only the rim of the iris is visible 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 participation in the assessment is difficult
5. Bone or joint aches: if patient was having pain previously, only the additional component attributed to opiate withdrawal is scored. 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 11. Gooseflesh skin 0 Skin is smooth 3 Piloerection of skin can be felt or hairs standing up on arms 5 Prominent piloerection
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 cheeksTotal Score: _______________ [The total score is the sum of all 11 items.] Initials of person completing assessment: _____

Score: 5–12=Mild; 13–24=Moderate; 25–36=Moderately severe; >36=Severe withdrawal

Source: Adapted from Wesson et al. 1999. Reprinted with permission.

From: Appendix B Assessment and Screening Instruments

Cover of Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction
Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction.
Treatment Improvement Protocol (TIP) Series, No. 40.
Center for Substance Abuse Treatment.

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