Transcript Back to Basics: Substance Use/Abuse/Withdrawal

Back to Basics: Substance
Use/Abuse/Withdrawal
Melanie Willows B.Sc. C.C.F.P. C.A.S.A.M. C.C.S.A.M.
Clinical Director
Substance Use and Concurrent Disorders Program
The Royal
Assistant Professor University of Ottawa
LMCC Objectives
• Key Objectives
– Given a patient with an addiction or a substance abuse
problem, be able to identify the issue, potential
consequences and the need to provide immediate and
continuing support and intervention.
– Given a patient with suspected substance withdrawal, the
candidate will diagnose the cause, severity and
complications, and will initiate an appropriate
management plan.
LMCC Objectives
• Objectives
• List and interpret critical investigations including history,
physical exam, drug and alcohol screening, risk of
withdrawal, critical laboratory investigations
• Determine an effective initial management plan which may
include brief intervention, supportive measures, safe
environment, pharmacological interventions, or referral to
specialized services
Addiction
• Addiction may be to substances or may be a process
(behavioral) addiction.
– Depressants: Alcohol, Opioids, Benzodiazepines
– Stimulants: Cocaine, Amphetamines
– Hallucinogens: Marijuana
– Process (behavioural): Gambling
• Sex, Food, Internet (not in the DSM IV)
Addiction
• Reward pathway involves the nucleus accumbens,
ventral tegmental area (VTA) and the prefrontal
cortex
• Drugs of abuse act on the reward centre resulting in
dopamine flooding ....brain either produces less
dopamine or downregulates dopamine receptors...net
result is lower baseline dopamine...need to take more
drug to increase dopamine
Causal Factors/Risk Factors
• Individual: Genetics, Mental Health
• Exposure to drug or experience (gambling)
• Environmental: trauma, poverty, peers
Case
• Mary is a 43 year old woman. Her mother and father
both had alcohol problems. Her home life was filled
with fighting and chaos. She was sexually abused by
her uncle and grandfather. Mary started using drugs
and alcohol when she was 13. She was diagnosed
with schizophrenia at the age of 25.
Taking a History
• What is the purpose of taking a drug and alcohol
history?
• Answer:
– To make a Diagnosis
– Medical and psychosocial history will influence
management
DSM IV Criteria for Substance Dependence
• 3 or more occurring over 12 months
– tolerance
– withdrawal
– larger amounts or longer period of time
– unsuccessful efforts to cut down or control
– time spent obtaining, using, recovering
– activities given up or reduced
– continued use despite problems
DSM IV Criteria for Substance Abuse
• A. A maladaptive pattern of substance use leading to
clinically significant impairment or distress, as manifested
by one (or more) of the following occurring within a 12
month period:
1. recurrent substance use resulting in a failure to fulfill
major obligations at work, school, or home
2. recurrent substance use in situations in which it is
physically hazardous
3. recurrent substance-related legal problems
4. continued use despite persistent or recurrent social or
interpersonal problems caused by or exacerbated by
effects of a substance
B. The symptoms have never met the criteria for substance
dependence for this class of substance.
Taking a Drug and Alcohol History
History of Substance Use
• Past substance abuse treatment history: type of
program, ?completed, attendance at AA or NA.
• Substances used: alcohol, marijuana, cocaine,
heroin, tobacco, prescription/OTC drugs (opiates,
benzodiazepines, gravol), ecstasy, crystal meth
• For each substance used: first use, current use,
pattern of use, route, and last use
Quantifying Alcohol and Drug Use
• Alcohol
• One standard drink= 13.6 grams of alcohol
– 5 oz/142ml wine (12% alcohol)
– 1.5 oz/43ml hard liquor (40% alcohol)
– 12 oz/341 ml beer (5% alcohol)
• Hard Liquor: 1 bottle
-13 oz. Mickey = 8 standard drinks
-26 oz./750 ml = 17 standard drinks
-40 oz./1.14L = 27 standard drinks
• Wine: 1 Bottle
-26 oz./750ml = 5 standard drinks
• Beer: ask what size? 500ml, 710ml (=2 standard drinks)
One Standard Drink (equivalent to
13.6 grams of alcohol)
341 ml (12 oz.) bottle
of 5% alcohol beer,
cider or cooler
142 ml (5 oz.) glass
of 12% alcohol
wine
43 ml (1.5 oz.) serving
of 40% distilled
Quantifying Alcohol and Drug Use
Marijuana
• Measured in grams, 1 ounze equals 28 grams
• How many grams? Pattern of use.
Cocaine
 Powder(snort or IV) or crack/freebase/rock form
(smoke)
 8 ball equals 3.5 grams; speedball is cocaine and
heroin
Quantifying Alcohol and Drug Use
Benzodiazepines
• Total amount used per day, how many years taking
(assessing for risk of withdrawal)
• Source of medication
Opioids
 Which opioid? Oxy, Dilaudid (hydromorph), Fentanyl,
morphine, codeine, heroin
 How much? What route? (IV, smoked, snorted,
chewed, swallowed) How often?
Taking an Alcohol and Drug History
• Ask about blackouts, loss of control of use.
• Withdrawal symptoms when stopping use: Alcohol
(shakes, seizures, DTs, hallucinations); Opioids (
nausea, vomiting, abdominal cramps, diarrhea,
chills/hot flashes, myalgias/arthralgias, pilo-erection)
• Tolerance
• Consequences of Using: health problems (physical,
mental), work or school problems, legal problems,
involvement with CAS, effect on
family/friends/children, financial problems.
Case 2
• Lisa started smoking marijuana and drinking alcohol
when she was 13. She started using cocaine when
she was 15. She currently smokes 2 grams of
marijuana a day. Smokes crack cocaine 2-3 times per
week usually a 40 piece. She drinks 6 tall beers
(710ml) per day. Four years ago she was prescribed
oxycodone for injuries she sustained when she was
beaten up by a boyfriend. Within one month she was
snorting 160mg daily and has now switched to
smoking a 50ug fentanyl patch per day.
Taking a Drug and Alcohol History
Family History
• family history of alcohol or drug problems in blood relatives
(biggest risk factor for development of addiction)
Social History
• marital status, current relationship, children
• living arrangements, use of alcohol/drugs in the home
• education level, current employment/disability
• family of origin: marital status of parents, relationship with
parents and siblings, abusive environment
Legal History
• past or current legal charges or convictions (DUI, assault,
theft, possession, trafficking etc.)
Taking a Drug and Alcohol History
Past Psychiatric History
• inpatient admissions, outpatient counseling, suicide
attempts
• any diagnosis ever given: trauma, anxiety, depression
• medications prescribed in past and present
Medical History
• all medical problems and surgeries
• HIV and Hepatitis C
• accidents related to substance use
Medications
• list of all current medications and dosing
• ask about use/abuse of over the counter medication
Case 2
• Lisa is Hepatitis C positive. She lives in subsidized
housing. She frequently uses with her next door
neighbour who is addicted to crack cocaine. She has
no family in town. She has two children who were
taken from her care 15 years ago because of her drug
use and mental health instability.
Screening Questionnaires
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CAGE
CRAFFT (adolescents)
AUDIT (Alcohol Use Disorders Identification Test)
DAST (The Drug Abuse Screening Test)
CAGE Questionnaire
(Screening Questionnaire for Alcohol Disorders)
• Have you ever felt you should CUT DOWN on your
drinking?
• Have people ANNOYED you by criticizing your
drinking?
• Have you ever felt bad or GUILTY about your
drinking?
• Have you ever had a drink first thing in the morning
to steady your nerves or to get rid of a hangover
(EYE-OPENER)
• Score of 2 or more indicates a problem
• Sensitivity 75-85%
How do addiction issues present?
• Sometimes patients do not initially disclose that they
have a substance problem
• It is sometimes only by reviewing their clinical
presentation that we start to suspect they may have
a substance problem
Potential Clinical Presentation of Alcohol
and Drug Problems
• Cardiovascular: hypertension, cardiomyopathy
• GI: fatty liver, hepatitis, cirrhosis, gastritis, pancreatitis,
dyspepsia, recurrent diarrhea
• Neurological: ataxia, tremor, peripheral neuropathy,
cerebellar disease, dementia, Wernicke-Korsakoff’s
syndrome
• Infections (injection drug use): cellulitis, abscess,
Hepatitis C, endocarditis
Potential Clinical Presentation of Alcohol
and Drug Problems
• Trauma: accidents, violence, suicide
• Psychiatric: fatigue, insomnia, depression, anxiety,
psychosis
• Behavioural: missed appointments, non-compliance,
drug-seeking
• Social: deterioration in social functioning, spousal
abuse, violence, legal problems
• Other: weight loss, loss of libido
Case 3
• John is a 53 year old man who has been drinking
alcohol daily for 25 years. He is currently drinking 20
oz of hard liquor per day.
• He presents today with uncontrolled hypertension,
complaints of insomnia, abdominal pain, diarrhea,
anxiety, and depression.
Physical Examination in Cases of Suspected
Alcohol or Drug Abuse/Dependence
• BP, heart rate, pupils
• Level of consciousness, Mental Status Exam
• Signs of liver disease (hepatomegaly, spider nevae,
jaundice, ascites)
• Signs of withdrawal/intoxication
• Injection marks and bruising in arms, wrists, legs,
ankles, neck, inguinal region
• Long history of alcohol use (10+ years): hypertension,
cardiomyopathy, dementia, gait (cerebellar
dysfunction), distal polyneuropathy
Case 3
• John comes to see you three years later after a
recent hospitalization. You barely recognize him as
he walks into your office with a walker. He is
jaundiced, his face is very thin and his abdomen is
distended.
Laboratory Investigations in Cases of
Suspected Alcohol or Drug Abuse or
Dependency
• CBC (increased MCV, decreased platelets), GGT (to
detect heavy alcohol consumption)
• AST, ALT (to detect alcoholic or viral hepatitis)
• Cirrhosis: INR, albumin, bilirubin
• Urine drug screen
• Hepatitis B, C, and HIV (ask permission first)
Case
• John has been diagnosed with cirrhosis and
continues to drink. His MCV is elevated at 103(8097). His platelets are depressed at 70(145-450). GGT
is 342(<60). AST is 370(<37) and ALT is 240(<46).
• His INR is increased to 1.3, albumin is decreased at
24 (34-48) and her bilirubin is increased at 35(<23).
Urine Drug Testing Methods
• Immunoassay: Based on the principle of competitive
binding. An antibody reacts to a portion of a drug or
its metabolite.
– Point of care testing possible
– Not as specific
• Gas Chromotography with mass spectroscopy
(GC/MS): couples the separation potential of gas
chromatography with the precise detection and
identification capability of mass spectroscopy.
– More expensive
– Gold Standard
Drug
Minimum detection (hours)
Maximum detection
Ethanol
0 to 4
<=6-12 hours
Benzodiazepines
2 to 7
Infrequent User- 3 days
Chronic User- 4-6 weeks
Marijuana metabolite
6 to 18
Infrequent User – up to 10 days
Chronic User – 30 days or longer
Cocaine metabolite
1 to 4
2 to 4 days
Amphetamines
2 to 7
2 to 4 days
Methamphatamine
1 to 3
2 to 4 days
MDMA (Ecstasy)
1
2 to 3 days
Opiates (codeine, morphine, heroin)
2
2 to 3 days
Oxycodone
1
1 to 2 days
Methadone
2
2 to 6 days
Treatment for Substance Use or Abuse
• Advise of concern and in the case of alcohol advise of
low risk drinking guidelines
• Motivational interviewing to determine and set goals
to reduce harm
• Follow up and monitoring for any progression to
substance dependence (addiction)
Canada’s Low-Risk Alcohol Drinking
Guidelines
• Women ≤ 10 drinks/week (≤ 2 drinks/day most days)
• Men ≤ 15 drinks/week (≤ 3 drinks/day most days)
• In one sitting:
• Women, no more than 3 drinks
• Men, no more than 4 drinks
– Plan a few non drinking days each week to avoid
developing a habit
Stages of Change Model (Prochaska & Diclemente)
Precontemplation
Increase awareness of need to change
Contemplation
Motivate and increase confidence
in ability to change
Relapse
Preparation
Assist in Coping
Negotiate a plan
Maintenance
Encourage active
problem-solving
Termination
Action
Reaffirm commitment
and follow-up
Motivational Interviewing
• Four General Principles
1. Express Empathy
• Acceptance facilitates change
2. Develop Discrepancy
• Between behaviour and personal goals
3. Roll with resistance
• Patient primary source for solutions
4. Support self-efficacy
• Patient responsible for choosing and carrying out
change
FRAMES brief intervention interviewing
technique
• Feedback: specifically address concerns about use (i.e. I am
concerned about how alcohol is affecting your liver)
• Responsibility: Emphasize that change is up to the patient.
(Only you can decide to make your life better)
• Advice: Give specific goals you have for the patient (I want
you to be evaluated at a treatment center)
• Menu: Offer alternatives to advice (You could alternatively go
to an AA meeting)
• Empathy: I know you find talking about this difficult
• Self-efficacy: you deserve better – you can be better with help
Treatment Decision Tree for Substance
Dependence (Addiction)
Want to
stop?
No
Motivational
interviewing
Yes
Is it safe to
stop?
No
Medically
supervised
detox
Inpatient or
outpatient
Yes
Can they
stop?
Yes
Explore
addiction
treatment
options
No
Community
withdrawal
Or
Residential
Withdrawal
Management
level 2
Case
• 54 year old man presents with diagnosis of
alcohol dependence. Patient desperately wants
to stop drinking but is afraid of the withdrawal.
Patient has experienced 2 previous withdrawal
seizures. Patient has hypertension, and coronary
artery disease and has had 2 previous MI’s.
Patient is drinking 26 oz. of alcohol per day,
usually having his first drink at 5a.m. to take away
the shakes.
Withdrawal Assessment Tools
• Alcohol: CIWA (Nausea & Vomiting, Tactile
Disturbances, Tremor, Auditory Disturbances,
Paroxysmal Sweating, Visual Disturbances, Anxiety,
Headache/Fullness in the Head, Agitation,
Orientation and Clouding of Sensorium
• Opioids: COWS: (Resting Heart Rate, Sweating,
Restlessness, Pupil Size, Bone or Joint Aches, Nose
Running or Tearing, GI upset, Tremor, Yawning,
Anxiety or Irritability, Gooseflesh Skin)
Treatment of Withdrawal
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Alcohol
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Benzodiazepines
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May be life-threatening
May require benzodiazepines
Inpatient or outpatient
Vitamin B1 (Thiamine)
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Requires tapering (weeks to
months)
Inpatient or outpatient
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Opioids
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Withdrawal not life-threatening
but very distressing
Likely will require supportive
medications +/- opioids
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Cannabis
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No medications required
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Amphetamines/Cocaine
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No medications required
Suicide Risk Assessment
Pharmacological Interventions
• Alcohol
– Thiamine (B1) 100mg IM then po to prevent WernickeKorsakoff
– Diazepam, Chlorodiazepoxide: long acting for management
of withdrawal and prevention of seizures, DT’s
– Lorazepam: short acting, used if respiratory or hepatic
compromised
Pharmacological Interventions
• Antabuse (Disulfiram):
• binds irreversibly to aldehyde dehydrogenase
• Daily dose of 250mg to 500mg
• Must not drink alcohol within 7 days of taking
• Common effects with drinking include: flushed face,
vomiting, headache, chest pain, palpitations.
• Serious effects include: seizures, hypotension, vagally
induced dysrhythmias.
• Contra-indications: unstable angina, recent MI,
schizophrenia and other psychotic states, pregnancy,
severe cirrhosis of the liver
• Liver enzymes monitored at quarterly intervals, monitored
for visual changes and symptoms of peripheral neuropathy
Pharmacological Interventions
• Naltrexone (Revia)
– Competitive opioid antagonist
– Usual dose 50mg po daily
• Indications:
– alcohol dependence (reduce craving and intensity and frequency of
alcohol binges) and for
– Opioid dependence(for those who wish to remain abstinent from all
opioids)
• Side effects: nausea, GI symptoms, headache, dizziness, lightheadedness, weakness
• Contra-indications: acute hepatitis, liver failure, opioids
should be discontinued 10 days prior to starting naltrexone,
naltrexone should be discontinued 3 days prior to elective
surgery
• Monitor ALT, AST and bilirubin
Pharmacological Interventions
• Campral (Acamprosate):
– amino acid derivative that increases GABA and has
complex effects on excitatory amino acid (i.e. Glutamate)
neurotransmission
– Positive and negative studies
– Dosing 2 333mg tablets TID
– Side effects: GI (diarrhea, bloating), pruritis
– Excreted unmetabolized thorugh the kidney’s, must
evaluate renal function prior to initiations
Pharmacological Interventions
• Opioids
– Dimenhydrinate (vomiting, nausea), Immodium (diarrhea),
ibuprofen (aches and pain), meds for insomnia
– Clonidine: Alpha 2 Adrenergic agonist
• 0.05-0.2mg po TID prn
• Most effective in suppressing autonomic signs and symptoms of
opioid withdrawal
• warn of sedation and orthostatic hypotension
• BP must be greater than 90/60 to take
Pharmacological Interventions
• Opioids
– Methadone: long-acting (>24 hours) synthetic opioid
agonist, require methadone exemption to prescribe
– Buprenorphine/Naloxone (Suboxone): long acting
synthetic partial opioid agonist, naloxone component
present to prevent IV abuse
– Naloxone: opioid antagonist, used in opioid overdose kits
Pharmacological Interventions
• Nicotine
– NRT (patch, gum, lozenge, inhaler)
– Zyban (Wellbutrin, Bupropion)- not if seizure d/o
– Champix (Varenicycline)-monitor for psych symptoms
Types of Treatment Options
• Mutual Help Groups: Alcoholics Anonymous, Narcotics
Anonymous, Women for Sobriety, SMART recovery
• Withdrawal Management
• Outpatient Treatment (once weekly, daily)
• Residential Treatment programs (ranging from 21 days to
9 months+)
• Medically Supervised Treatment programs
• Individual Counseling
• Opioid Substitution Therapy
• Harm Reduction approaches
References
• DSM IV Diagnostic & Statistical Manual of Mental
Disorders 4th Ed. Test Revision 2000
• Substance Abuse: A Comprehensive Textbook 4th Ed.
Lewinson et al. 2005
• Management of Alcohol, Tobacco, & Other Drug
Problems, Edited by Bruno Brands Phd. Addiction
Research Foundation 2000
• Principles of Addiction Medicine 4th ed. , American
Society of Addiction Medicine. 2009
References
• NIDA National Institute on Drug Abuse
• NIAAA National Institute on Alcohol Abuse and Alcoholism
• Butt, P., Beirness, D., Cesa, F., Gliksman, L., Paradis, C., &
Stockwell, T. (2011). Alcohol and health in Canada: A summary
of evidence and guidelines for low-risk drinking. Ottawa, ON:
Canadian Centre on Substance Abuse.
Differentiating between substance
dependence and substance abuse
 Criteria for substance abuse does not include
tolerance, withdrawal, or a pattern of compulsive
use
 Although not listed as a criterion item, CRAVING
(a strong subjective drive to use the substance) is
likely to be experienced by most individuals with
substance dependence
 High blood levels of the substance coupled with
little evidence of intoxication suggests tolerance is
likely
Differentiating between substance
dependence and substance abuse
 Criteria for substance abuse does not include
tolerance, withdrawal, or a pattern of compulsive
use
 Although not listed as a criterion item, CRAVING
(a strong subjective drive to use the substance) is
likely to be experienced by most individuals with
substance dependence
 High blood levels of the substance coupled with
little evidence of intoxication suggests tolerance is
likely
Canadian Guidelines for Low Risk Drinking
1.Reduce your long-term health risks by drinking no
more than:
 10 drinks a week for women, with no more than 2 drinks
a day most days
 15 drinks a week for men, with no more than 3 drinks a
day most days
Plan non-drinking days every week to avoid
developing a habit.
2. Reduce your risk of injury and harm by drinking
no more than 3 drinks (for women) and 4 drinks
(for men) on any single occasion.
Canadian Guidelines for Low Risk Drinking
3. Do not drink when you are:
• driving a vehicle or using machinery and tools
• taking medicine or other drugs that interact with
alcohol
• doing any kind of dangerous physical activity
• living with mental or physical health problems
• living with alcohol dependence
• pregnant or planning to be pregnant
• responsible for the safety of others
• making important decisions
Canadian Guidelines for Low Risk Drinking
• 4. If you are pregnant, planning to become
pregnant, or before breastfeeding, the safest
choice is to drink no alcohol at all.
• 5. If you are a child or youth, you should delay
drinking until your late teens. Talk with your
parents about drinking. Alcohol can harm the way
your brain and body develop.
If you are drinking, plan ahead, follow local
alcohol laws and stay within the limits outlined in
Guideline 1.
Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA-Ar)
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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
stomach? Have you vomited?" Observation.
0 no nausea and no vomiting
1 mild nausea with no vomiting
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3
4 intermittent nausea with dry heaves
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7 constant nausea, frequent dry heaves and vomiting
Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA-Ar)
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TACTILE DISTURBANCES -- Ask "Have you any itching, pins and
needles sensations, any burning, any numbness, or do you feel bugs
crawling on or under your skin?" Observation.
0 none
1 very mild itching, pins and needles, burning or numbness
2 mild itching, pins and needles, burning or numbness
3 moderate itching, pins and needles, burning or numbness
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations
Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA-Ar)
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TREMOR -- Arms extended and fingers spread apart.
Observation.
0 no tremor
1 not visible, but can be felt fingertip to fingertip
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4 moderate, with patient's arms extended
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7 severe, even with arms not extended
Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA-Ar)
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AUDITORY DISTURBANCES -- Ask "Are you more aware of
sounds around you? Are they harsh? Do they frighten you? Are you
hearing anything that is disturbing to you? Are you hearing things you
know are not there?" Observation.
0 not present
1 very mild harshness or ability to frighten
2 mild harshness or ability to frighten
3 moderate harshness or ability to frighten
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations
Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA-Ar)
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PAROXYSMAL SWEATS -- Observation.
0 no sweat visible
1 barely perceptible sweating, palms moist
2
3
4 beads of sweat obvious on forehead
5
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7 drenching sweats
Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA-Ar)
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VISUAL DISTURBANCES - Ask "Does the light appear to be too
bright? Is its color different? Does it hurt your eyes? Are you seeing
anything that is disturbing to you? Are you seeing things you know are
not there?" Observation.
0 not present
1 very mild sensitivity
2 mild sensitivity
3 moderate sensitivity
4 moderately severe hallucinations
5 severe hallucinations
6 extremely severe hallucinations
7 continuous hallucinations
Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA-Ar)
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ANXIETY -- Ask "Do you feel nervous?" Observation.
0 no anxiety, at ease
1 mild anxious
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4 moderately anxious, or guarded, so anxiety is inferred
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7 equivalent to acute panic states as seen in severe delirium or
acute schizophrenic reactions
Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA-Ar)
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HEADACHE, FULLNESS IN HEAD -- Ask "Does your head feel
different? Does it feel like there is a band around your head?" Do not
rate for dizziness or lightheadedness. Otherwise, rate severity.
0 not present
1 very mild
2 mild
3 moderate
4 moderately severe
5 severe
6 very severe
7 extremely severe
Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA-Ar)
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AGITATION -- Observation.
0 normal activity
1 somewhat more than normal activity
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4 moderately fidgety and restless
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7 paces back and forth during most of the interview, or constantly
thrashes about
Clinical Institute Withdrawal Assessment of Alcohol
Scale, Revised (CIWA-Ar)
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ORIENTATION AND CLOUDING OF SENSORIUM -- Ask
"What day is this? Where are you? Who am I?"
0 oriented and can do serial additions
1 cannot do serial additions or is uncertain about date
2 disoriented for date by no more than 2 calendar days
3 disoriented for date by more than 2 calendar days
4 disoriented for place/or person
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.
COWS (Clinical Opioid Withdrawal Scale)
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Resting Pulse Rate:
_________beats/minute
Measured after 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
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Sweating: over past ½ hour not accounted for by room temperature or patient activity.
0 no report 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
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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
COWS (Clinical Opioid Withdrawal Scale)
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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
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Bone or Joint aches If patient was having pain previously, only the additional component
attributed to opiates 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
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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
COWS (Clinical Opioid Withdrawal Scale)
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GI Upset: over last ½ hour
0 no GI symptoms
1 stomach cramps
2 nausea or loose stool
3 vomiting or diarrhea
5 Multiple episodes of diarrhea or vomiting
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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
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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
COWS (Clinical Opioid Withdrawal Scale)
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•
•
•
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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
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•
•
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Gooseflesh skin
0 skin is smooth
3 piloerrection of skin can be felt or hairs standing up on arms
5 prominent piloerrection
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Total 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; more than 36 = severe
withdrawal
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Pathological Gambling
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•
•
•
•
•
•
•
•
•
•
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Persistent and recurrent maladaptive gambling behaviour as indicated by five (or
more) of the following:
1. is preoccupied with gambling (e.g. preoccupied with reliving past gambling
experiences, handicapping or planning the next venture, or thinking of ways to get
money with which to gamble)
2. Needs to gamble with increasing amounts of money in order to achieve the
desired excitement.
3. Has repeated unsuccessful efforts to control, cut back or stop gambling
4. is restless or irritable when attempting to cut down or stop gambling
5. gambles as a way of escaping from problems or of relieving a dysphoric mood
(e.g. feelings of helplessness, guilt, anxiety, depression)
6. after losing money gambling, often returns another day to get even (“chasing
one’s losses”)
7. Lies to family members, therapist or others to conceal the extent of involvement
with gambling
8.Has committed illegal acts such as forgery, fraud, theft or embezzlement to
finance gambling
9. Has jeopardized or lost a significant relationship, job, or educational or career
opportunity because of gambling
10 relies on others to provide money to relieve a desperate financial situation
caused by gambling
B. The gambling behaviour is not better accounted for by a Manic Episode.
Drug Testing - Opioids
Immunoassay: detects morphine, does not differentiate
between opioids and has poor sensitivity for
oxycodone and meperidine; 3-4 day detection period
Chromotography required to identify specific opioids,
but only 1-2 day detection period
Heroin: metabolite 6-monoacetylmorphine detected by
chromatography for <12 hours
Methadone: chromatography required detection for 14 days