Addiction Medicine

Substance use disorder assessment and de-addiction management

Patient: Suresh Pillai, 38M
UHID: UH-2026-0815
Chief Complaint: Opioid use disorder — seeking de-addiction
Referred by: Family physician

Substance Use History

Heroin (smoked)Daily6 yearsLast: 2 days ago
Severe
AlcoholBinge, weekends10 yearsLast: 3 days ago
Moderate
Nicotine (cigarettes)1 ppd15 yearsLast: Today
Moderate

Withdrawal Assessment (COWS / CIWA)

COWS Score (opioid): 14 — Moderate withdrawal
CIWA-Ar Score (alcohol): 8 — Mild withdrawal
HR (bpm): 102
BP (mmHg): 138/88
Sweating: Present
Anxiety: Moderate
Tremor: Fine tremor both hands

Screening & Assessment

DAST-10 Score: 8/10 — Severe
AUDIT Score: 22 — Severe alcohol use
PHQ-9: 12 — Moderate depression
PTSD screen: Negative

Management Plan