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HOME
ADDICTION CALCULATOR
CIWA-AR
SMAST
COWS
ORT
MME
BAWS
AUDIT-C
CAGE
EMBED
SOBRIETY
CIWA-AR
SMAST
COWS
ORT
MME
BAWS
AUDIT-C
CAGE
EMBED
SOBRIETY
GET REHAB HELP
Recovery Terminology
Medication in Rehab
Recovery Terminology
Medication in Rehab
BLOG
ABOUT US
Meet the Staff
Meet the Staff
CONTACT US

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HOME
ADDICTION CALCULATOR
- CIWA-AR
- SMAST
- COWS
- ORT
- MME
- BAWS
- AUDIT-C
- CAGE
- EMBED
- SOBRIETY
GET REHAB HELP
- Recovery Terminology
- Medication in Rehab
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- Meet the Staff
CONTACT US

Category: CAGE

CAGE Substance Abuse Assessment Tool

closeup photo of medical personnel writing in front of patient

Discover the CAGE Substance Abuse Assessment, a vital tool for identifying alcohol abuse. Learn about the questions and interpretation in this guide.

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Phoenix, AZ 85050

OUD Present
Ask the patient the following questions about his/her use of opioids in the past 12 months to determine a diagnosis. Select all that apply:

COWS Score for Opiate Withdrawal

This assessment quantifies the severity of opiate withdrawal. For each item, select the appropriate description of the patient’s signs or symptoms.

Resting Pulse Rate (BPM) Measure pulse rate after patient is sitting or lying down for 1 minute

≤80 ( +0 )81-100 ( +1)101-120 ( +2 )>120 ( +4 )

Sweating. Sweating not accounted for by room temperature or patient activity over the last 0.5 hours

No report of chills or flushing ( +0 )Subjective report of chills or flushing ( +1)Flushed or observable moistness on face ( +2 )Beads of sweat on brow or face ( +3 )Sweat streaming off face ( +4 )

Restlessness observation during assessment

Able to sit still ( +0 )Reports difficulty sitting still, but is able to do so ( +1)Frequent shifting or extraneous movements of legs/arms ( +3 )Unable to sit still for more than a few seconds ( +5)

Pupil size

Pupils pinned or normal size for room light ( +0 )Pupils possibly larger than normal for room light ( +1)Pupils moderately dilated ( +2 )Pupils so dilated that only the rim of the iris is visible ( +5)

Bone or joint aches If patient was having pain previously, only the additional component attributed to opiate withdrawal is scored

Not present ( +0 )Mild diffuse discomfort ( +1)Patient reports severe diffuse aching of joints/ muscles ( +2 )Patient is rubbing joints or muscles and is unable to sit still because of discomfort ( +4)

Runny nose or tearing Not accounted for by cold symptoms or allergies

Not present ( +0 )Nasal stuffiness or unusually moist eyes ( +1)Nose running or tearing ( +2 )Nose constantly running or tears streaming down cheeks ( +4)

GI Upset Over last 0.5 hours

No GI symptoms ( +0 )Stomach Cramps ( +1)Nausea or loose stool ( +2 )Vomiting or diarrhea ( +3)Multiple episodes of vomiting or diarrhea ( +5)

Tremor observation of outstretched hands

No tremor ( +0 )Tremor can be felt, but not observed ( +1)Slight tremor observable ( +2 )Gross tremor or muscle twitching ( +4)

Yawning observation during assessment

No yawning ( +0 )Yawning once or twice during assessment ( +1)Yawning three or more times during assessment ( +2 )Yawning several times/minute ( +4)

Anxiety or irritability

None ( +0 )Patient reports increasing irritability or anxiousness ( +1)Patient obviously irritable/anxious ( +2 )Patient so irritable or anxious that participation in the assessment is difficult ( +4)

Gooseflesh skin

Skin is smooth ( +0 )Piloerection of skin can be felt or hairs standing up on arms ( +3 )Prominent piloerection ( +5 )

points

No active withdrawal

points

Mild withdrawal

points

Moderate withdrawal

points

Moderately severe withdrawal

points

Severe withdrawal