Thursday, 7 January 2021

Sample CASC-Opiate (opioid) Withdrawal Assessment

Opiate Withdrawal History and Physical Examination 

Opiate withdrawal symptoms peak between 36-72 hours. Symptoms run their course in 5-7 days, though craving continues for some time. 

Withdrawal from Heroin

Withdrawal from heroin may begin up to 8 hours after the last use. During the next few hours, the person experiences muscle pain, sneezing, sweating; tearfulness; yawning excessively. At 36 hours after the last use, symptoms are most severe. These symptoms include chills, muscle cramps, flushing, sweating, tachycardia, hypertension, inability to sleep, vomiting & diarrhoea. Symptoms typically continue for about 72 hours & gradually diminish over 5-10 days.


This history part is in Urdu/Hindi. I will add the "Objective Opiate Withdrawal Scale" soon here so anyone can benefit.
For now: COWS 

  1. Aap kia istemal karty
  2. Akhri bar kab lia hai aap ne
  3. Abhi dil chahta ke aap dobara se kar lyn? Kitna had tak? 
  4. Gutno ya baqi jorhon mai dard ho raha hai? Baqi jisam or pat’tho mai takleef? Sar dard? 
  5. Pait ma dard waghera? Ulti ya matli to nai arhaii? Pechas ya ihsal ki shikayat?
  6. Hot and cold flushes? 
  7. Cheenk to naii a rahy baar baar?
  8. Nend kesi hai? Araam se soe rehty han?   
  9. Koi bechainee, pareshani ki keffyat ya ghussa ata ho?  

Physical examination

Start from the hands. 
  1. Inspect the hands and run a hand over the palm. Note any sweating or palmar erythema. 
  2. Note if there is any piloerection if hair visible on the dorsal side of the hands. 
  3. Then check the pulse. 
  4. Inspect the arms for any signs of IV drug abuse. 
  5. Check blood pressure, and then check the temperature. 
  6. Check respiratory rate while checking the above. 
  7. Inspect the face for lacrimation, rhinorrhea and check pupil size for dilation. 
  8. Comment if the patient is shaking or yawning. 
  9. Perform a cardiovascular examination and look for murmurs. 
  10. Examine for the signs of liver failure


  1. Full blood count, liver and renal function tests. 
  2. Serum urea and electrolytes.
  3. Hepatitis screen and a test for human immune virus infection. Before performing a test for the immune virus, counselling a patient is important. 
  4. Urine drug screen helps identify other substances in patients with polysubstance abuse. We can detect heroin in the urine for up to 48 hours and methadone for up to 9 days. Urine screen for opioids in patients who are pregnant and those who use low-dose methadone may return false-negative results. Use of loperamide or quinolines may test positively for opioids, too.
  5. Electrocardiography and chest X-Ray, which may identify endocarditis and pulmonary tuberculosis. 
  6. Echocardiography of the heart if you notice any cardiac murmurs on examination.
  7. Also, get tests for sexually transmitted diseases—other than human immune virus infection—if the patient has been promiscuous and has not been taking precautions.   


Supportive treatment 
  1. Clonidine, an alpha-2 receptor agonist, which helps reverse the excessive sympathetic manifestations of alcohol withdrawal. Lofexidine is a new, safer alternative to clonidine with less potential for hypotension. 
  2. Buprenorphine, a partial opioid agonist, is useful for rapid detoxification. 
  3. Methadone detoxification
  4. Self-help materials are always helpful. 

  1. What makes methadone useful for heroin detoxification and long-term maintenance?
  2. A 40-year-old man who is using IV heroin presented to you with symptoms of endocarditis. What cardiac valves would you look at on the echocardiogram?

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