The Clinical Opiate Withdrawal Scale (COWS) is a clinical tool used by professionals to help determine the severity of an individual’s opioid dependence and withdrawal symptoms. It can be an effective tool both before and during treatment and can help guide the decision-making process.
- The Clinical Opiate Withdrawal Scale (COWS) is an assessment tool used to ascertain the level of opioid dependence and withdrawal symptoms.
- COWS contains 11 items that relate to opioid withdrawal symptoms and are scored between 0 and 4 or 5.
- COWS can help inform clinical decision-making around opioid use disorder treatment.
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What is the Clinical Opiate Withdrawal Scale (COWS)
The Clinical Opiate Withdrawal Scale (COWS) is an 11-item assessment developed by Wesson and Ling (2003). It is designed to be used by a clinical professional to help determine the presence and severity of opioid dependence and withdrawal symptoms. [1]
The COWS includes assessment of 11 common opioid withdrawal symptoms, which can be assessed by the clinician through observation and conversation, and scored to determine the severity of withdrawal. [2]
This assessment is intended for use in clinical settings, including inpatient or outpatient substance use disorder (SUD) services, as well as other clinical settings such as emergency departments (EDs). [3] As it is quick and simple to complete, the COWS can easily be repeated to monitor any changes in symptom severity and help inform clinical decisions. [1]
What symptoms does the COWS measure?
The 11 items on the COWS score for the presence and severity of the following symptoms: [2]
- 1: Resting pulse rate.
- 2: Sweating, chills, or flushing, within the last 30 minutes.
- 3: Gastrointestinal upset over the last 30 minutes, including cramps, nausea, diarrhea, or vomiting.
- 4: Tremor or twitching of the hands (observed during the assessment).
- 5: Restlessness (observed during the assessment).
- 6: Yawning (observed during the assessment).
- 7: Pupil size.
- 8: Anxiety or irritability.
- 9: Bone or joint aches.
- 10: Gooseflesh skin.
- 11: Runny nose or tearing.
The COWS scoring explained
Each item on the COWS is marked from a score of 0 to either four or five, with higher scores indicating more severe withdrawal symptoms. Each item explains how each score correlates to the symptoms. For example, yawning is observed during the assessment and marked as:
- 0 = no yawning
- 1 = yawning once or twice during the assessment
- 2 = yawning three or more times during the assessment
- 4 = yawning several times/minute
Some items scored by observing may be more subjective, such as restlessness, which is scored as:
- 0 = unable to sit still
- 1 = reports difficulty sitting still, but is able to do so
- 3 = frequent shifting or extraneous movements of legs/arms
- 5 = unable to sit still for more than a few seconds
As such, the assessing clinician should be aware of each item and its scoring range, in order to carefully observe movements and behaviors related to these scores.
Total score
Each of these scores is then added together for a final score, which indicates:
- Score of 5-12 = mild withdrawal
- Score of 13-24 = moderate withdrawal
- Score of 25-36 = moderately severe withdrawal
- Score of 36 or higher = severe withdrawal
Guide to administering COWS
COWS can be administered repeatedly, at regular intervals, to help determine the severity of the individual’s withdrawal and to monitor for any changes in their symptoms over time.
A clinician will complete the assessment, with most questions requiring observation of symptoms, which are scored according to the assessment guidelines. Additionally, the clinician can ask about the individual’s symptoms, such as stomach pain and other gastrointestinal upset, which is not easily observable. [3]
It is important for clinicians to be aware of alternative factors that could have specifically influenced sweating, heart rate, and a runny nose. For example, a raised heart rate could be due to exercising prior to the assessment, or a runny nose may be related to cold symptoms. [2]
Can you use COWS at home?
People may wish to self-administer the assessment to help understand the severity of their withdrawal symptoms and decide whether they are in need of professional intervention. Similarly, a friend or family member may wish to utilize the assessment to recognize severe withdrawal symptoms and monitor a loved one going through withdrawal. This could also help with deciding if professional support is necessary.
However, the COWS is intended for use by a professional. Someone administering COWS at home may not have the necessary understanding or perspective to make a clear assessment of withdrawal symptoms. This could lead to under- or over-scoring, which may have implications for the individual’s well-being, particularly if severe symptoms are unrecognized. [1][3]
How COWS is used in treatment
COWS can be a crucial tool in opioid use disorder (OUD) assessment and treatment, and it is typically used to: [1]
- Assess dependence before methadone treatment.
- Monitor the effectiveness of treatment.
- Determine if the individual is suitable for buprenorphine treatment.
As such, it can be used before and during treatment. When used before treatment, it can help clinicians determine the severity of opioid dependence and withdrawal, to help guide treatment decisions, particularly medications. [1][3]
When used during treatment, it can be repeated at regular intervals to help monitor the individual’s progress and is designed to be simple to complete and compare results. [1]
COWS and starting buprenorphine
Buprenorphine is a medication used in OUD treatment to reduce withdrawal symptoms and cravings and as a maintenance treatment. Buprenorphine is a partial opioid agonist, which means that it can precipitate withdrawal if it is administered close to the last dose of an opioid. Precipitated withdrawal can cause a rapid onset of intense symptoms. [1][4]
As such, clinical guidelines recommend that buprenorphine be commenced once the individual is experiencing mild to moderate withdrawal symptoms, to prevent precipitated withdrawal. [4]
Utilizing COWS can help clinicians determine whether an individual is safe to commence buprenorphine treatment. Research suggests that someone with a score of 25 or more on the COWS is not likely to have opioid withdrawal symptoms precipitated with buprenorphine administration. [1]
What comes after the COWS assessment?
As COWS can be used before and during OUD treatment, it can be a helpful tool in the treatment decision-making process. Individuals who have not yet commenced treatment may be advised and referred to OUD treatment services to help with the detox and withdrawal process. [1][4]
Opioid withdrawal can be particularly unpleasant and sometimes dangerous, and can require inpatient care or monitoring to prevent serious consequences, along with medications such as buprenorphine or methadone. [4]
When COWS is utilized during treatment, it can help clinicians to recognize the individual's progress with their recovery, including the effectiveness of any medications or other treatments. COWS can highlight reductions in withdrawal symptoms, which can help guide changes in treatment, such as the commencement of maintenance medications or rehabilitative services. [1]
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