Clinical guidelines and procedures for the use of methadone in the maintenance treatment of opioid dependence

Appendix 3: Assessment of withdrawal from commonly used drugs

Page last updated: August 2003

The Subjective Opiate Withdrawal Scale (SOWS)
Objective Opioid Withdrawal Scale (OOWS)
Neonatal withdrawal scoring chart (term infants) MR 520
Withdrawal states from commonly used drugs

The Subjective Opiate Withdrawal Scale (SOWS)

Date:
Time:

Please score each of the 16 symptoms below according to how you feel now (circle one number).
  1. I feel anxious
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  2. I feel like yawning
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  3. I am perspiring
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  4. My eyes are teary
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  5. My nose is running
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  6. I have goosebumps
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  7. I am shaking
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  8. I have hot flushes Top of page
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  9. I have cold flushes
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  10. My bones and muscles ache
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  11. I feel restless
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  12. I feel nauseous
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  13. I feel like vomiting
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  14. My muscles twitch
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  15. I have stomach cramps
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

  16. I feel like using now
    0 (Not at all) 1 (A little) 2 (moderately) 3 (Quite a bit) 4 (Extremely)

Range 0-64. Handelsman, L., Cochrane, K. J., Aronson, M. J. et al. (1987) Two New Rating Scales for Opiate Withdrawal, American Journal of Alcohol Abuse, 13, 293-308.

Objective Opioid Withdrawal Scale (OOWS)

Date:
Time:

Observe the patient during a 5 minute observation period then indicate a score for each of the opioid withdrawal signs (items 1-13) listed below. Add the scores for each item to obtain the total score.
  1. Yawning Top of page
    0 (no yawns) 1 (1 or more yawns)

  2. Rhinorrhoea
    0 (less than 3 sniffs) 1 (3 or more sniffs)

  3. Piloerection (observe arm)
    0 (absent) 1 (present)

  4. Perspiration
    0 (absent) 1 (present)

  5. Lacrimation
    0 (absent) 1 (present)

  6. Tremor (hands)
    0 (absent) 1 (present)

  7. Mydriasis
    0 (absent) 1 (3 mm or more)

  8. Hot and Cold flushes
    0 (absent) 1 (shivering / huddling for warmth)

  9. Restlessness
    0 (absent) 1 (frequent shifts of position)

  10. Vomiting
    0 (absent) 1 (present)

  11. Muscle twitches
    0 (absent) 1 (present)

  12. Abdominal cramps
    0 (absent) 1 (holding stomach)

  13. Anxiety Top of page
    0 (absent) 1 (mild - severe)

Total score:

Range 0-13 Handelsman, L., Cochrane, K. J., Aronson, M. J. et al. (1987) Two New Rating Scales for Opiate Withdrawal, American Journal of Alcohol Abuse, 13, 293-308

Neonatal withdrawal scoring chart (term infants) MR 520

Royal Prince Alfred Hospital
King Geroge V Hospital
John Spence Nursery

Ward:
MRN:
Surname:
Other names:
DOB/Sex:

Provide the date and time in hours for each sign / symptom below:
Central nervous system disturbances - signs & symptoms:
  • Crying

    • High-pitched (Score 2)
    • Continuous high-pitched (Score 3)

  • Sleeps after feeding

    • Less than 1 hour (Score 3)
    • Less than 2 hours (Score 2)
    • Less than 3 hours (Score 1)

  • Tremors Top of page

    • Mild & disturbed (Score 1)
    • Mod-severe & disturbed (Score 2)
    • Mild undisturbed (Score 3)
    • Mod-severe & undisturbed (Score 4)

  • Increased Muscle Tone (Score 2)

  • Excoriation (Specify area) (Score 1)

  • Myoclonic jerks (Score 3)

  • Generalised convulsions (Score 5)
Metabolic/vasomotor/respiratory system disturbances - signs & symptoms:
  • Fever

    • Between (37.3o-38.3oC) (Score 1)
    • Above (38.4oC) (Score 2)

  • Frequent yawning (greater than 3-4 times) (Score 1)

  • Nasal Stuffiness (Score 1)

  • Sneezing (greater than 3-4 times) (Score 1)

  • Nasal Flaring (Score 2)

  • Respiratory rate

    • Greater than 60/min (Score 1)
    • Greater than 60/min with retractions (Score 2)Top of page
Gastrointestinal system disturbances - signs & symptoms:
  • Excessive sucking (Score 1)

  • Poor feeding (Score 2)

  • Regurgitation (Score 2)

  • Projectile vomiting (Score 3)

  • Loose stools (Score 2)

  • Watery stools (Score 3)
Total score:

Scorer's initials:

From NSW Methadone Maintenance Treatment Clinical Practice Guidelines. Used with permission.

Withdrawal states from commonly used drugs

Opioids

  • Onset: 8-12 hours (short acting). Delayed for longer acting opioids

  • Duration:
    • Peaks 2-4 days.
    • Ceases 7-10 days (short acting). Longer for long acting opioids.

  • Symptoms:
    • Anxiety
    • Muscle tensionTop of page
    • Muscle and bone ache
    • Muscle cramps
    • Sleep disturbance
    • Sweating
    • Hot and cold flushes
    • Piloerection (goosebumps)
    • Yawning
    • Lacrimation
    • Rhinorrhea
    • Abdominal cramps
    • Nausea
    • Vomiting
    • Diarrhoea
    • Palpitations
    • Elevated blood pressure
    • Elevated pulse
    • Dilated pupils

Alcohol

  • Onset: As blood alcohol falls, depends on rate of fall and hours after last drink.

  • Duration: 5-7 days

  • Symptoms
    • Anxiety
    • Agitation
    • Sweating
    • Tremor
    • Nausea
    • Vomiting
    • Abdominal cramps
    • Diarrhoea
    • Anorexia
    • Craving
    • Insomnia
    • Elevated blood pressure
    • Elevated pulse
    • Temperature
    • Headache
    • SeizuresTop of page
    • Confusion
    • Perceptual distortions
    • Disorientation
    • Hallucinations
    • Hyperpyrexia

Benzodiazepines

  • Onset: 1-10 days depending on half-life

  • Duration: 3-6 days

  • Symptoms
    • Anxiety
    • Insomnia
    • Muscle aching and twitching
    • Perceptual changes
    • Feelings of unreality
    • Depersonalisation
    • Seizures

Stimulants

  • Onset: 8-36 hours

  • Duration: Several days, occasionally 2-3 weeks

  • SymptomsTop of page
    • Lethargy
    • Depression
    • Iirritability
    • Hyperphagia
    • Anhedonia
    • Dysphoria
    • Desire for sleep increased

Cannabis

  • Onset: Usually days

  • Duration: Weeks

  • Symptoms
    • Irritability
    • Anxiety
    • Insomnia
    • Anorexia
    • Sweating
    • Muscle spasms
    • Headaches

From NSW Methadone Maintenance Treatment Clinical Practice Guidelines. Used with permission.