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Organ System


COWS Score for Opiate Withdrawal

Quantifies severity of opiate withrawal.


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.


  • 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.