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    COWS Score for Opiate Withdrawal

    Quantifies severity of opiate withdrawal.
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    • 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.
    • 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.
    • 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.
    ≤80
    0
    81-100
    +1
    101-120
    +2
    >120
    +4
    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
    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
    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
    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
    Not present
    0
    Nasal stuffiness or unusually moist eyes
    +1
    Nose running or tearing
    +2
    Nose constantly running or tears streaming down cheeks
    +4
    No GI symptoms
    0
    Stomach Cramps
    +1
    Nausea or loose stool
    +2
    Vomiting or diarrhea
    +3
    Multiple episodes of vomiting or diarrhea
    +5
    No tremor
    0
    Tremor can be felt, but not observed
    +1
    Slight tremor observable
    +2
    Gross tremor or muscle twitching
    +4
    No yawning
    0
    Yawning once or twice during assessment
    +1
    Yawning three or more times during assessment
    +2
    Yawning several times/minute
    +4
    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
    Skin is smooth
    0
    Piloerection of skin can be felt or hairs standing up on arms
    +3
    Prominent piloerection
    +5

    Result:

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    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.

    About the Creator
    Dr. Donald R. Wesson
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