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The Clinical Opiate Withdrawal Scale (COWS)

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Journal of Psychoactive Drugs
ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20
The Clinical Opiate Withdrawal Scale (COWS)
Donald R. Wesson & Walter Ling
To cite this article: Donald R. Wesson & Walter Ling (2003) The Clinical Opiate Withdrawal Scale
(COWS), Journal of Psychoactive Drugs, 35:2, 253-259, DOI: 10.1080/02791072.2003.10400007
To link to this article: http://dx.doi.org/10.1080/02791072.2003.10400007
Published online: 07 Sep 2011.
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The Clinical Opiate
Withdrawal Scale (COWS)
Donald R. Wesson, M.D.* & Walter Ling, M.D.**
Abstract-The clinical opiate withdrawal scale (COWS) is a clinician-administered, pen and paper
instrument that rates eleven common opiate withdrawal signs or symptoms. The summed score of
the eleven items can be used to assess a patient's level of opiate withdrawal and to make inferences
about their level of physical dependence on opioids. With increasing use of opioids for treatment of
pain and the availability of sublingual buprenorphine in the United States for treatment of opioid
dependence, clinical assessment of opiate withdrawal intensity has received renewed interest.
Buprenorphine, a partial opiate agonist at the mu receptor, can precipitate opiate withdrawal in patients
with a high level of opioid dependence who are not experiencing opioid withdrawal. Since development
of the first opiate withdrawal scale in the mid-1930s, many different opioid withdrawal scales have
been used in clinical and research settings. This article reviews the history of opiate withdrawal
scales and the context of their initial use. A template version of the COWS that can be copied and
used clinically is appended. PDF formatted versions of the COWS are also available from the websites
of the American Society of Addiction Medicine, the California Society of Addiction Medicine, the
UCLA Integrated Substance Abuse Programs, and AlcoholMD.com.
Keywords-buprenorphine induction, chronic pain, Himmelsbach scale, history of opiate withdrawal
scales, measurement of opioid withdrawal signs and symptoms
Assessment of opioid1 withdrawal usually employs
some combination of observable behaviors (e.g., yawning,
restlessness, rhinorrhea), physiological measures (e.g., pulse
rate, blood pressure, or pupil size), and patients' subjective
rating of opiate withdrawal symptoms. Observable behav­
iors (more conventionally called "signs" in medical
parlance) are generally considered more valid than addicts'
self-report of symptoms. The enhanced validity, however,
can be illusionary, as all the usually observed behaviors
with the exception of piloerrection (gooseflesh skin) can
be fe igned. Some clinicians have proposed incorporating
*Consultant, CNS Medications Development, Oakland, California;
Chairman, Medications Development Committee, American Society of
Addiction Medicine.
**Professor of Psychiatry and Director, Integrated Substance Abuse
Programs, Department of Psychiatry and Biobehavioral Sciences, David
Geffen School of Medicine at University of California Los Angeles.
Please address correspondence and reprint requests to Donald R.
Wesson, M.D., 28 Sereno Circle, Oakland, CA, 93619; email:
dwesson@ mindspring.com.
lou mal of Psychoactive Drugs 253
physiological measures (e.g., heart rate, temperature, in­
strument-measured hand tremor, trapezius electromyogram)
in an effort to increase the sensitivity and validity of opiate
withdrawal measurement.
Opioid withdrawal intensity is a function of: (1) the
severity of physical dependence on opioids, and (2) the rela­
tive occupancy of the mu opiate receptor at a point in time.
To show spontaneous opioid withdrawal, a patient must be
physically dependent (a neuroadaption process) and have
a relative abstinence of opioids occupying the mu opiate
Some medications (for example, opioid antagonists
such as naloxone, naltrexone, nalmefene and partial opioid
agonists such as buprenorphine) can precipitate opioid with­
drawal in a patient who is physically dependent on opioids.
They do so by displacing the full agonist (e.g., heroin, mor­
phine, methadone) from the mu opiate receptor with a
substance with higher affinity for the receptor than the full
Vo lume 35 (2), April - June 2003

Wesson & Ling Clinical Opiate Withdrawal Scale
Himmelsbach's Point System for Measuring Opioid Abstinence Syndrome Intensity by the Day or Hour
(Himmelsbach 1941)
Sign or Symptom
Anorexia (40% decrease in caloric intake)
Emesis (each spell)
Fever (for each 0. 1° C. rise over mean addiction level)
Hyperpnea (for each resp./min rise over mean addiction level)
By Day (D)
Points Limit
By Hour (H)
Points Limit
Rise in a.m. systolic B.P. (for each 2 mm. Hg over mean addiction level)
Weight loss (a.m.) (for each lb. from last day of addiction)
Total abstinence syndrome intensity score per day or per hour is the sum of the points scored in the (D) or (H) columns, respectively, with due
attention to the limits.
agonist, but with no (antagonist) or less (partial agonist)
intrinsic opiate activity.
Opiate withdrawal scales have been developed to com­
pare the efficacy of treatments for withdrawal, to assess the
degree of physical dependence before methadone induc­
tion, and to assess physiological patients' readiness for
buprenorphine induction. Most often they have been used
in a research context; however, with the increasing use of
best-practice and standardized protocols to guide treatment,
their use in clinical practice is likely to increase.
Since one use of opiate withdrawal scales is for induc­
tion of patients on methadone or buprenorphine, an
instrument should discriminate clearly between symptoms
of opiate toxicity and opiate withdrawal. Confusion of opi­
ate toxicity with opiate withdrawal can have disastrous
clinical results. Fatal methadone overdoses have apparently
been the result of such confusion by patients or clinicians.
Nausea, for example, can result from opiate withdrawal or
be caused by opiate intoxication.
The following section traces the history of some of the
more well-known opiate withdrawal rating scales and describes
the context in which they were developed.
The Himmelsbach Scale
The first rating scale to assess the severity of opiate
withdrawal was developed at the Federal Addiction Research
Joumal of Psychoactive Drugs 254
Center in Lexington, Kentucky. Lawrence Kolb and C. K.
Himmelsbach described the scale at the ninety-third annual
meeting of the American Psychiatric Association in 1937.
Their paper was subsequently published in the Journal of
Clinical Psychiatry (Kolb & Himmelsbach 1938). Several
years later, Himmelsbach published a more detailed descrip­
tion of the instrument in the Annals of Internal Medicine
(Himmelsbach 1941 ), and the scale became commonly
cited as the Himmelsbach scale. Most opiate withdrawal
scales are modeled to some extent on this scale. However,
some of the rating criteria in the Himmelsbach scale, such
as weight-loss and caloric intake, require observation over
a 24-hour period and are not applicable to symptomatic
assessment at any single point in time (see Table 1 ).
In the late 1960s other investigators at the Addiction
Research Center developed instruments that focused on
the subjective effects of opiate withdrawal. First was the
Opiate Withdrawal Subjective Experience Scale (OPW),2
which consisted of items culled from a 550-item, true-false
questionnaire developed at the Addiction Research Center
Inventory (the Addiction Research Center in Lexington,
Kentucky was part of a federal prison operated by the U.S.
Department of Public Health). Items were selected which
discriminated subjects who reported that they were or were
not experiencing opiate withdrawal (Haertzen & Meketon
1968). Later refinements included the Strong Opiate With­
drawal Scale (SOW) for measuring withdrawal from high
levels of physical dependence and the Weak Opiate With­
drawal Scale (WOW) for measuring Jess intense
withdrawal symptoms (Haertzen, Meketon & Hooks 1970).
Vo lume 35 (2). April - June 2003

Wesson & Ling Clinical Opiate Withdrawal Scale
The Subjective Opiate Withdrawal Scale (Handelsman et al. 1987)
l. I feel anxious
2. I feel like yawning
3. I'm perspiring
4. My eyes are tearing
5. My nose is running
6. I have goose flesh
7. I am shaking
8. I have hot flashes
9. I have cold flashes
10. My bones and muscles ache
II. I feel restless
12. I feel nauseous
13. I feel like vomiting
14. My muscles twitch
15. I have cramps in my stomach 16. I feel like shootjn� up now
Not at All
A Little
Quite a Bit
Patients are asked to score each item on how they feel at the time they are completing the rating sheet. The scale score is the total of all
item scores.
With the advent of methadone maintenance treatment
in the early 1970s, clinicians needed a practical and reli­
able method for determining whether patients were
physically dependent on opiates. Opiate use history alone
was not sufficient, since addicts sometimes exaggerate or
minimize the severity of their drug problem. To devise more
objective diagnostic tests fo r assessing level of physical
dependence, protocols were developed and widely dissemi­
nated using the short-acting, opiate antagonist naloxone
(Blachly 1973a, b; Blachly & Vandam 1972). In patients
who are physically dependent on opiates, intravenous or
intramuscular administration of naloxone precipitates acute
opiate withdrawal. As a diagnostic procedure, this became
known as the "naloxone challenge."
Some naloxone protocols focused on nonambiguous
signs of opiate withdrawal such as gooseflesh. Although
not experienced by all addicts undergoing precipitated with­
drawal, when present gooseflesh is considered a very
reliable sign since it cannot be fe igned (Blachly 1973a).
Richard Wa ng and colleagues at the Ve terans Administra­
tion Drug Treatment Center in Milwaukee used a list of 10
items adapted from the Himmelsbach scale to measure signs
and symptoms before and after an intramuscular injection
of 0.8 mg naloxone (Wang et al. 1974). The items included
the usual signs of opiate withdrawal except mydriasis, and
added such symptoms as "feeling of change in tempera­
ture," "stomach pain," and "muscle aching."
The Opiate Withdrawal Scale (OWS)
In England, a group of investigators studying the role
of conditional withdrawal in precipitating relapse to opiates
developed the Opiate Withdrawal Scale (OWS), a 32-item
Jouma/ of Psychoactive Drugs 255
inventory of opiate withdrawal signs and symptoms from
medical literature (Bradley, et al. 1987). Patients rated the
intensity of each sign or symptom occurring during the
previous 24 hours on a four-point scale-nil (0), mild
(1), moderate (2), and severe (3)-yielding a total score
ranging from 0 to 96. The investigators used principal
component analysis to assess the contribution of each
item to the overall score. They also compared scores on
the OWS to an unspecified observer-rated scale completed
by nurses and found that where withdrawal distress was
fai rly low, the observer-rated scale was fa irly insensitive,
but when distress was marked, the two scales were well
Subjective Opiate Withdrawal Scale (SOWS)
Noting that the Himmelsbach scale had only been vali­
dated in patients with high levels of physical dependence,
clinical investigators at the Ve terans Administration Medi­
cal Center in the Bronx and the Department of Psychiatry
at the Mount Sinai School of Medicine in New York exam­
ined the validity and interrater reliability of two new opiate
withdrawal scales: the Subjective Opiate Withdrawal
Scale (SOWS) and the Objective Opiate Withdrawal
Scale (OOWS, described below). The purpose of the new
withdrawal scales was to provide researchers with more
sensitive and validated instruments that could be used in
measuring clinical effectiveness of medications used for
treatment of opiate withdrawal. The scales were validated
by comparing patients' scores before and two days after
beginning methadone. Opiate abusers scale scores were also
examined before and after being challenged with either
placebo or 0.4 mg of naloxone.
Vo lume 35 (2), April - June 2003

Wesson & Ling Clinical Opiate Withdrawal Scale
The Objective Opiate Withdrawal Scale (Handelsman et al. 1987)
I. Yawning
(Frequency = #of yawns per observation period)
2. Rhinorrhea
(Frequency = #of sniffs per observation period)
3. Piloerection
(Gooseflesh-observe patient's arm)
4. Perspiration
5. Lacrimation
6. Mydriasis
7. Tremors (hands)
8. Hot and cold flashes
(Shivering or huddling for warmth)
9. Restlessness
10. Vomiting
II. Muscle Twitches
12. Abdominal cramps
(Holding stomach)
13. Anxiety
(Range: mild to severe)
Mild: observable manifestations-foot shaking,
fidgeting, finger tapping
Score One Point for Each Item if:
One or more
Three or more
Moderate to severe: agitation, unable to sit, trembling, panicky;
complains of difficulty in breathing, choking sensations, palpitations.
The Short Opiate Withdrawal Scale (Gossop 1990)
Feeling sick
Stomach cramps
Muscle spasms/twitching
Feelings of coldness
Heart pounding
Muscular tension
Aches and pains
Runny eyes
Insomnia/problems sleeping
Patients were asked to put a check in the column if they had suffered from any of the following conditions within the past 24 hours.
On the Subj ective Opiate Withdrawal Scale (SOWS),
patients rate each of 16 items on a five-point scale, yield­
ing a total score ranging from zero to 64. Table 2 shows a
version of the instrument constructed from the description
(Handelsman et al . 1987).
Objective Opiate Withdrawal Scale (OOWS)
The Objective Opiate Withdrawal Scale (OOWS) is a
13-item scale on which each sign is rated as absent or present
during a time period during which the patient is observed
(see Table 3). Subsequent investigators have referred to the
Journal of Psychoactive Drugs 256
OOWS but do not necessarily include the same items (as
an example see Turkington & Drummond 1989).
Short Opiate Withdrawal Scale (SOWS)
One of the investigators involved in development of
the 32-item OWS published a shortened version (Gossop
1990; see Table 4). Some items were eliminated because
they had low loading on factor analysis or because they
were unclear to addicts (e.g., "feelings of unreality").
Ultimately the scale was winnowed to 10 items. In a sample
of 68 opiate addicts studied during withdrawal from
Vo lume 35 (2), April - June 2003

Wesson & Ling Clinical Opiate Withdrawal Scale
The Subjective Opiate Withdrawal Questionnaire (Loimer, Linzmayer & Grunberger 1991)
I. I feel very good
2. My conecntration is poor
3. I cannot think clearly
4. I have a good appetite
5. My thoughts revolve around drugs
6. I am optimistic
7. I feel active
8. I have feelings of anxiety
9. I am indifferent
10. I sleep very well
11. I feel restless
12. My mood is changeable
13. I am depressed
14. I am tired and weak
15. I have severe withdrawal symptoms
16. I am irritable and grumpy
17. I have no pain
18. Sex interests me greatly
19. I have severe diarrhea
20. I am sweating heavily
I feel very bad
My concentration is good
I can think clearly
I have a poor appetite
Drugs do not preoccupy me
I feel pessimistic
I feel apathetic
I have no feelings of anxiety
I take an interest in my environment
I sleep very badly
I am at peace with myself
My mood scarcely changes
I am in good humor
I am lively and awake
I have no severe withdrawal symptoms
Nothing upsets me
I have severe pain
Sex does not interest me
I am severely constipated
I am not sweating
Each of the 20 items was rated on a I 00 mm. line anchored on one end by the items on column I and on the other end by the items
in column 2. The total score was the sum of analogue scores for all 20 items.
methadone, the 32-item scale and the 10-item scale showed
a 0.97 correlation (Gossop 1990).
The Subjective Opiate Withdrawal Questionnaire
Investigators at the University of Vienna studying rapid
opiate detoxification devised the Subjective Opiate With­
drawal Questionnaire (SOWQ), a dichotomous, 20-item
survey to assess patients' symptoms before and after detoxi­
fication (Loimer, Linzmayer & Grunberger 1991). The
SOWQ was not based on the Himmelsbach scale and included
such domains as mood, which were not assessed in other
scales (see Table 5).
The Clinical Opiate Withdrawal Scale
The Clinical Opiate Withdrawal Scale (COWS) was
first published in a training manual for buprenorphine treat­
ment (Wesson et al. 1999; see Appendix 1). The items
included have been validated in other assessment instru­
ments. The rating system for each item takes into account
that some signs and symptoms may occur along a con­
tinuum. For example, stomach cramping may be subjective
at low levels of intensity but become a sign at higher levels
(e.g., vomiting or diarrhea).
The COWS format and item rating system were mod­
eled after the Clinical Institute Withdrawal Assessment of
Alcohol Scale revised (CIWA-Ar; Sullivan et al. 1989). The
instrument can be completed in about two minutes while
Journal of Psychoactive Drugs 257
talking with a patient and observing for opioid withdrawal
signs. It can be serially administered to track changes in
the severity of opiate withdrawal symptoms over time or
in response to treatment.
The score for each item reflects the severity of the sign
or symptom, and the total scores are grouped as "mild (5 to
12 points)," "moderate (13 to 24)," "moderately severe (25
to 36), and "severe (more than 36).
Use of the COWS in Buprenorphine Induction
Buprenorphine is a partial opiate agonist that can
precipitate opiate withdrawal if administered to a physically­
dependent patient. Buprenorphine is a partial opiate agonist.
Unlike full opiate agonists, such as heroin, methadone, or
morphine, whose opiate effects continue to increase as the
dose increases, buprenorphine has a ceiling effect, beyond
which additional buprenorphine has no additional opiate
effects (including respiratory depression). Since, however,
buprenorphine has a higher affinity for the mu opiate receptor
than do full opiate agonists, it can displace them from the
receptor. If the opiate effects of buprenorphine are not as
great as the full opiate agonist displaced, opiate withdrawal
will be precipitated.
Clinical guidelines for buprenorphine induction gen­
erally mention that a patient thought to be physically
dependent on opioids should be in mild to moderate with­
drawal or that some number of hours should have occurred
since last use of an opioid such as heroin or methadone
Vo lume 35 (2), April - June 2003

Wesson & Ling
before giving the first dose of buprenorphine. Using time
as a criterion for the first dose of buprenorphine is prob­
lematic because patients are not always truthful in reporting
their last use and the rate of opioid metabolism varies con­
siderably from patient to patient. A safer approach is to wait
until the patient is experiencing moderate to severe opiate
withdrawal. Clinical experience with the COWS suggests
that buprenorphine is unlikely to precipitate withdrawal in
subjects who are physically dependent on opioids with with­
drawal ratings of 25 or greater. Some patients with mild or
moderate ratings will not have opiate withdrawal symptoms
precipitated. These are possibly patients with a lower level
of physical dependence. The validity of the COWS in pre­
dicting precipitated withdrawal at the low end of the scale
needs additional study.
The COWS is an easy to administer clinical tool to
assess opiate withdrawal signs and symptoms. In patients
Clinical Opiate Withdrawal Scale
who are physically dependent on opioids, the total score is
a good index of patients' opiate withdrawal intensity.
The scale can be applied to patients in a variety of office,
clinic and hospital settings, and used with patients under­
going treatment for opioid addiction as well as patients
with chronic pain who may be physically dependent on
l. An opioid is any drug or medication (either natu­
rally occurring or synthetic) with morphine-like effects.
An opiate is a drug or medication that is derived from the
opium poppy. Opiate is also used to refer to mu and other
endogenous opiate receptors.
2. The designation of this scale by its acronym began
a tradition for naming opioid withdrawal scales. The acro­
nyms can be confusing as they are not always unique; see
the two different SOWS below.
Blachly, P. H. 1973a. Naloxone for diagnosis in methadone programs.
Journal of the American Medical Association 224 {3, April l6): 334-35.
Blachly, P. H. 1973b. Naloxone for diagnosis of physical dependence in
applicants to methadone programs. Proceedings of the National
Conference on Methadone Treatment 2: 1465-68.
Blachly, P. H. & Vandam, L.D. 1972. Va lue of naloxone. New England
Journal of Medicine 286 ( 17): 95 1.
Bradley, B.P.; Gossop, M.; Phillips, G.T. & Legarda, J.J. 1987. The
development of an opiate withdrawal scale (OWS). British Journal
of Addiction to Alcohol and Other Drugs 82 ( 10): 1139-42.
Gossop, M. 1990. The development of a Short Opiate Withdrawal Scale
(SOWS). Addictive Behaviors 15 (5): 487-90.
Haertzen, C.A. & Meketon, M.J. 1968. Opiate withdrawal as measured
by the Addiction Research Center Inventory (ARC!). Diseases of
the Nervous System 29 (7): 450-55.
Haertzen, C.A.; Meketon, M.J. & Hooks, N.T., Jr. 1970. Subjective
experiences produced by the withdrawal of opiates. British Journal
of Addiction to Alcohol and Other Drugs 65 (3): 245-55.
Handelsman. L.; Cochrane, K.J.; Aronson, M.J.; Ness, R.; Rubinstein,
K.J. & Kanof, P. O. 1987. Two new rating scales for opiate
withdrawal. American Journal of Drug and Alcohol Abuse 13 (3):
Himmelsbach, C.K. 1941. The morphine abstinence syndrome, its nature
and treatment. Annals of Internal Medicine 15: 829-39.
Journal of Psychoactive Drugs 258
Kolb, L. & Himmelsbach, C.K. 1938. Clinical studies of drug addiction.
III. A critical review of withdrawal treatments with methods of
evaluating abstinence syndromes. American Journal of Psychiatry
94: 759-97.
Loimer, N.; Linzmayer, L. & Grunberger, J. 1991. Comparison between
observer assessment and self rating of withdrawal distress during
opiate detoxification. Drug and Alcohol Dependence 28 (3): 265-
Sullivan, J.T.; Sykora, K.; Schneiderman, J.; Naranjo, C.A. & Sellers,
E.M. 1989. Assessment of alcohol withdrawal: The Revised Clinical
Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar).
British Journal of the Addictions 84 (II): 1353-57.
Turkington, D. & Drummond, D.C. 1989. How should opiate withdrawal
be measured? Drug and Alcohol Dependence 24 (2): 151-53.
Wang, R.I.; Wiesen, R.L.; Lamid, S. & Roh, B.L. 1974. Rating the
presence and severity of opiate dependence. Clinical Pharmacology
and Therapeutics 16 (4): 653-58.
Wesson, D.R.; Ling, W.; Jara, G. & the Committee on Treatment of Opiate
Dependence. 1999. Buprenorphine in Pharmacotherapy of Opioid
Addiction: Implementation in Office-Based Medical Practice;
Translating the Experience of Clinical Trials into Clinical Practice.
San Francisco, California: California Society of Addiction
Volume 35 (2), April - June 2003

Wesson & Ling Clinical Opiate Withdrawal Scale
Clinical Opiate Withdrawal Scale
For each item, circle the number that best describes the patient's signs or symptom. Rate on just the
apparent relationship to opiate withdrawal. For example, if heart rate is increased because the patient
was jogging just prior to assessment, the increase pulse rate would not add to the score.
Patient's Name: Date and Time _! __ !_
Reason for this assessment:
Resting Pulse Rate: beats/minute GI Upset: over last 112 hour
Measured after patient is sitting or lying fo r one minute 0 no GI symptoms
0 pulse rate 80 or below 1 stomach cramps
1 pulse rate 81-100 2 nausea or loose stool
2 pulse rate 101-120 3 vomiting or diarrhea
4 pulse rate greater than 120 5 multiple episodes of diarrhea or vomiting
Sweating: over past 112 hour not accounted fo r by Tremor observation of outstretched hands
room temperature or patient activity. 0 no tremor
0 no report of chills or flushing 1 tremor can be fe lt, but not observed
l subjective report of chills or fl ushing 2 slight tremor observable
2 flushed or observable moistness on face 4 gross tremor or muscle twitching
3 beads of sweat on brow or face
4 sweat streaming off face
Restlessness Observation during assessment Yawning Observation during assessment
0 able to sit still 0 no yawning
l reports difficulty sitting still, but is able to do so l yawning once or twice during assessment
3 frequent shifting or extraneous movements of legs/arms 2 yawning three or more times during assessment
5 unable to sit still for more than a few seconds 4 yawning several times/minute
Pupil size Anxiety or Irritability
0 pupils pinned or normal size fo r room light 0 none
l pupils possibly larger than normal for room light l patient reports increasing irritability or anxiousness
2 pupils moderately dilated 2 patient obviously irritable or anxious
5 pupils so dilated that only the rim of the iris is visible 4 patient so irritable or anxious that participation in
the assessment is difficult
Bone or Joint aches if patient was having pain Gooseflesh skin
previously, only the additional component attributed 0 skin is smooth
to op iates withdra wal is scored 3 piloerrection of skin can be felt or hairs standing up
0 not present on arms
l mild diffuse discomfort 5 prominent piloerrection
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
Runny nose or tearing Not accounted fo r by cold
-symptoms or allergies
Total Score
0 not present
l nasal stuffiness or unusually moist eyes The total score is the sum of all 11 items
2 nose running or tearing Initials of person
4 nose constantly running or tears streaming down cheeks completing assessment:
Score: 5- 12 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal
This version may be copied and used clinically.
Journal of Psychoactive Drugs 259 Vo lume 35 (2), April - June 2003