Clinical Opiate Withdrawal ScaleLoading...Resting Pulse Rate80 bpm or less081-100 bpm+1101-120 bpm+2greater than 120 bpm+4Sweatingno chills/flushing0patient reports chills/flushing+1observed flush/moistness of face+2beads of sweart on brow/face+3sweat streaming off face+4Restlessnessable to sit still0difficult to sit still but able+1frequent shifting/extremity movements+3unable to sit still for more than a few secs+5Pupil Sizepinpoint or normal0larger than normal+1moderately dilated+2dilated to iris rim+5Bone/Joint Painno pain0mild diffuse discomfort+1severe diffuse aching+2unable to sit still due to pain+4Rhinitis/Lacrimationnot present0nasal stuffiness/moist eyes+1nose running/lacrimation+2nose constantly running/tears streaming+4GI Symptomsno symptoms0stomach cramps+1nausea or loose stool+2vomiting or diarrhea+3multiple diarrhea or vomiting+5Tremorsno tremor0felt but not observed+1slight tremor observed+2gross tremor/muscle twitching+4Yawningno yawning0once or twice during assessment+13 or more yawns+2several yawns/minute+4Anxiety/Irritabilitynone0increasing irritability/anxiousness+1Obvious anxiety/irritability+2too irritable/anxious to cooperate+4Piloerectionno piloerection0piloerection can be felt+3prominent piloerection+5IndikationenHinweise & Vorsichtsmaßnahmen