Withdrawal Management Services Toolkit

This toolkit was created for providers working in residential community-based withdrawal management services (WMS) to standardize care, improve documentation and information sharing, and provide quick access to relevant information. You can download the entire toolkit or the individual tools (see below).

Introduction to the WMS toolkit

Intake

Pre-Arrival Screening Tool

A tool for screening potential clients prior to withdrawal management services (WMS) admission.
Part of WMS toolkit
Version date: 25 January 2024

PDF
Client Risk Assessment on Arrival

A template for assessing a client’s risk of medical complications upon admission to withdrawal management services (WMS).
Part of WMS toolkit
Version date: 25 January 2022

PDF
Medical Intake Form

A form for collecting a client’s medical history on admission to withdrawal management services (WMS).
Part of WMS toolkit
Version date: 25 January 2024

PDF
Consent to Release Personal Health Information

A consent form for a withdrawal management service (WMS) to share or receive a client’s personal health information.
Part of WMS toolkit
Version date: 25 January 2022

PDF

Treatment

Clinical Pathway for Medical Management of Alcohol Withdrawal in WMS

A decision-making tool for managing alcohol withdrawal in withdrawal management services (WMS).
Part of WMS toolkit
Version date: 25 January 2024

PDF
Order Set for Alcohol Withdrawal

An order set for the management of alcohol withdrawal in withdrawal management services (WMS).
Part of WMS toolkit
Part of RAAM clinic toolkit
Version date: 25 January 2024

PDF
Clinical Pathway for Management of Opioid Withdrawal

A decision-making tool for managing opioid withdrawal and initiating opioid agonist therapy (OAT) in withdrawal management services (WMS).
Part of WMS toolkit
Version date: 25 January 2024

PDF
Order Set for Opioid Withdrawal

An order set for the management of opioid withdrawal and initiation of opioid agonist therapy (OAT) in withdrawal management services (WMS).
Part of WMS toolkit
Part of RAAM clinic toolkit
Version date: 25 January 2024

PDF
Declining Opioid Agonist Therapy

A form for clients who decline opioid agonist therapy (OAT) in withdrawal management services (WMS).
Part of WMS toolkit
Version date: 25 January 2024

PDF
Management of Stimulant Use

An algorithm for managing stimulant use in withdrawal management services (WMS).
Part of WMS toolkit
Version date: 25 January 2024

PDF
Management of Benzodiazepine Use

An algorithm for managing benzodiazepine use in withdrawal management services (WMS).
Part of WMS toolkit
Version date: 25 January 2024

PDF
Management of Cannabis Use

An algorithm for managing cannabis use in withdrawal management services (WMS).
Part of WMS toolkit
Version date: 25 January 2024

PDF
Medical Directive: Point of Care Testing

A medical directive form authorizing nurse practitioners, registered nurses, and registered practical nurses to use a breathalyzer and perform urine dipstick analysis in withdrawal management services (WMS).
Part of WMS toolkit
Version date: 25 January 2022

PDF
Special Considerations

Recommendations for managing unique concerns for withdrawal management services (WMS) clients.
Part of WMS toolkit
Version date: 25 January 2024

PDF

Emergency department

When to Transfer to the Emergency Department

An algorithm for determining when a withdrawal management services (WMS) client needs to be transferred to the emergency department (ED).
Part of WMS toolkit
Version date: 25 January 2024

PDF
Emergency Department to WMS Transfer Checklist

A checklist for client transfer from emergency department (ED) to withdrawal management services (WMS).
Part of WMS toolkit
Version date: 25 January 2024

PDF

Discharge

Discharge form

A form for a client’s discharge from withdrawal management services (WMS).
Part of WMS toolkit
Version date: 25 January 2024

PDF
Buprenorphine/Naloxone Discharge Information for Primary Care

A template for a discharge note to primary care after a client has been started on buprenorphine (Suboxone) in withdrawal management.
Part of WMS toolkit
Version date: 25 January 2024

PDF
Acknowledgment of Loss of Opioid Tolerance Following Withdrawal

A form advising clients of a loss of opioid tolerance on discharge from withdrawal management.
Part of WMS toolkit
Version date: 25 January 2024

PDF
Naltrexone Discharge Information for Primary Care

A template for a discharge note to primary care after a client has been started on naltrexone in withdrawal management.
Part of WMS toolkit
Version date: 25 January 2024

PDF
Gabapentin Discharge Information for Primary Care

A template for a discharge note to primary care after a client has been started on gabapentin in withdrawal management.
Part of WMS toolkit
Version date: 25 January 2024

PDF
Buprenorphine Extended-Release Injection Discharge Information for Primary Care

A template for a discharge note to primary care after a client has been started on depot buprenorphine (Sublocade) in withdrawal management.
Part of WMS toolkit
Version date: 25 January 2024

PDF

Sample Policies

Sample Medication Policy

A sample document for withdrawal management services (WMS) outlining the suggested policies and procedures for the storing, dispensing, and disposal of client medications.
Part of WMS toolkit
Version date: 25 January 2024

PDF
Sample Cannabis Policy

A sample document for withdrawal management services (WMS) outlining the suggested policies and procedures for cannabis use onsite.
Part of WMS toolkit
Version date: 25 January 2022

PDF
Sample Nicotine Replacement Therapy Policy

A sample document for withdrawal management services (WMS) outlining the suggested policies and procedures regarding smoking and nicotine replacement therapy (NRT) onsite.
Part of WMS toolkit
Version date: 25 January 2022

PDF

Scales

Subjective Opioid Withdrawal Scale

The subjective opioid withdrawal scale (SOWS) is used to quantify the severity of someone’s opioid withdrawal.
Part of WMS toolkit
Version date: 25 January 2022

PDF
Level of agitation scale

The level of agitation scale is used to quantify the degree to which a client is agitated/distressed.
Part of WMS toolkit
Version date: 25 January 2022

PDF
Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) Scale

The CIWA-Ar is a validated scale for measuring the severity of alcohol withdrawal, for use in in various settings, including withdrawal management and the emergency department (ED).
Part of WMS toolkit
Part of RAAM clinic toolkit
Version date: 25 January 2022

PDF

Appendices

Withdrawal Management Services Toolkit

This toolkit was created for providers working in residential community-based withdrawal management services (WMS) to standardize care, improve documentation and information sharing, and provide quick access to relevant information.
Authors: Katie Dunham, Mareena Mathew, Karan Cheema, Laura Jones, Kristine Rivest, Jared Bonis, Meldon Kahan, and Jennifer Wyman
Version date: 25 January 2024

PDF

Katie Dunham BSc, BScN, MN, NP-PHC 
Mareena Mathew NP-Adult
Karan Cheema BScN, MN, NP-PHC
Melanie Vandewiel MN, NP-PHC
Laura Jones BSc, BScN, MN, NP-Adult 
Kristine Rivest BScInf, MScN, NP-PHC
Jared Bonis BscN, MScN, TITC-CT, NP-PHC
Meldon Kahan MD, CCFP, FRCPC
Jennifer Wyman MD, FCFP, DABAM, MPH

Rachel Alexander, Peer Advisor, META:PHI
Cassel Busse RN, PhD
Jarel Calumpang RN, BScN, MN
Christina Henry RN, BScN, BA
Nina Kovacic BA, MSW
Larry Nijmeh MD, CCFP(EM) FCFP
Robyn Nocilla BScN, MSc, NP-PHC
Rose Patterson BscN, MN, NP-PHC
Josh Richardson RP, RPN, PNC, BA-Hons
Rosanra (Rosie) Yoon MN, NP-Adult
Maria Zhang RPh, BScPhm, PharmD, MSc