COWS Score for Opiate Withdrawal
Why Use
As stated above, it combines subjective and objective components, limiting the possibility of feigned responses. It can be serially administered to track changes in the severity of withdrawal symptoms over time or in response to treatment.
When to Use
COWS may be used in both inpatient and outpatient settings: During Detox: for the general monitoring of opiate withdrawal during opioid detoxification. During Pain Treatment: for patients receiving opiates for the treatment of acute or chronic pain who may show subtle signs of opiate withdrawal. In the ED & More: for patients requesting methadone for opiate withdrawal symptoms and their enrollment in methadone maintenance treatment has not been verified. COWS is most commonly used in buprenorphine induction, and is recommended specifically for this use.
Formula
Pearls / Pitfalls
The Clinical Opiate Withdrawal Score (COWS) limits possibility of feigned responses by combining subjective symptoms with objective signs. ( Wesson DR 2003 ) COWS was first published in a training manual for buprenorphine treatment. While commonly used for buprenorphine or buprenorphine/naloxone induction, it can also be useful in a variety of office, clinic and hospital settings. Examples include the assessment of acute opiate withdrawal during an opiate detoxification program, methadone maintenance treatment, and the treatment of chronic pain. The scale is designed to be used quickly (< 2 minutes) by clinicians. Be aware that the prescribing of buprenorphine and buprenorphine/naloxone in the context of opioid addiction treatment requires additional credentialing by the DEA.
Management
COWS can help set patient expectations prior to buprenorphine treatment, as they will likely experience a certain amount of discomfort. Opioid detoxification works best with adjunctive treatments such as psychotherapy and support groups.
Critical Actions
Always consider the possibility of comorbid withdrawal conditions from alcohol, benzodiazepine, or sedative-hypnotics, which may be life threatening alone or in combination.
Advice
Using COWS in buprenorphine induction treatment: Buprenorphine is a partial opiate agonist that can precipitate florid opiate withdrawal if administered to a physically-dependent patient. In buprenorphine induction, it is important that a patient is already in mild to moderate opiate withdrawal prior to administration. This would be equivalent to a COWS score >5-6 (>10 preferable). This is important as otherwise patients experience precipitated withdrawal , a rapid and intense onset of withdrawal symptoms initiated by the medication. It is not reliable to use “time since last opioid use” since patients are not always truthful in reporting their last use, and metabolism varies from patient to patient.
More Information
Score interpretation: <5 - no active withdrawal 5-12 - mild withdrawal 13-24 - moderate withdrawal 25-36 - moderately severe withdrawal >36 - severe withdrawal