COWS Score for Opiate Withdrawal
Quantifies severity of opiate withdrawal.
When to use
Pearls/Pitfalls
Why use
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.
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.
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.
Next
Evidence
Next
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.
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.
Evidence
FORMULA
Addition of the selected points; as above.
FACTS & FIGURES
| Score interpretation |
|---|
| <5 – no active withdrawal |
| 5-12 – mild withdrawal |
| 13-24 – moderate withdrawal |
| 25-36 – moderately severe withdrawal |
| >36 – severe withdrawal |
EVIDENCE APPRAISAL
Original article
- This article presents the COWS scale and discusses the rationale for its development. As described in detail above, the scale consists of an 11-item rating system that can be completed within two minutes by a trained observer and can track opioid withdrawal as differentiated from opioid toxicity through serial measurements. It was designed to be administered quickly and was intended to improve upon existing measurement tools.
Validation study, Maldonado 2015
- This study validated the COWS in comparison to the validated Clinical Institute Narcotic Assessment (CINA) scale. It used a double-blind randomized design to compare opioid withdrawal symptoms for intramuscularly administered placebo vs. naloxone to 46 opioid-dependent participants. COWS and CINA scores during the naloxone challenge session were well correlated with Pearson correlation coefficient of 0.85 (p<0.001) while placebo was not associated with any significant elevation in either score. Additional evidence of concurrent validity was provided by comparing COWS with the self-reporting visual analog scale (VAS); COWS scores correlated well with peak VAS scores of bad drug effect (r=0.57, p<0.001) and feeling sick (r=0.57, p<0.001). Cronbach’s alpha for the COWS was 0.78, indicating good internal consistency (reliability).
LITERATURE
ORIGINAL/PRIMARY REFERENCE
Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS) J Psychoactive Drugs.2003;35:253–259.
VALIDATION
Tompkins DA, Bigelow GE, Harrison JA, Johnson RE, Fudala PJ, Strain EC. Concurrent Validation of the Clinical Opiate Withdrawal Scale (COWS) and Single-Item Indices against the Clinical Institute Narcotic Assessment (CINA) Opioid Withdrawal Instrument. Drug and alcohol dependence 2009;105(1-2):154-159. doi:10.1016/j.drugalcdep.2009.07.001.
OTHER REFERENCES
The National Alliance of Advocates for Buprenorphine Treatment COWS Flow sheet. Published Nov. 2011.
