Clinical calculator

COWS Score for Opiate Withdrawal

Severity of opiate withdrawal.

id

1985

full_title

short_title

COWS Score

med_description

Quantifies severity of opiate withdrawal.

description

The COWS Score for Opiate Withdrawal quantifies severity of opiate withdrawal.

keywords

COWS Score for Opiate Withdrawal, cows, cows score, cows opiate, cows opioid, cows withdrawal, cows prognosis, withdrawal prognosis, opiate withdrawal, opiate withdrawal prognosis, opiate w/drawal, opiate withdrawal score, opiate score, Cows opiate score, withdrawal severity, opiate withdrawal severity, withdrawal severity opiate, clinical opiate withdrawal score

complaint

[ "Anxious", "Diarrhea", "Headache", "Vomiting" ]

formula

Addition of the selected points; as above.

evidence

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

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).

measurements

[]

information

Score interpretation:

<5 - no active withdrawal
5-12 - mild withdrawal
13-24 - moderate withdrawal
25-36 - moderately severe withdrawal
>36 - severe withdrawal

refrences

{ "Clinical Practice Guidelines": [], "Manufacturer Website": [], "Original/Primary Reference": [ { "href": "https://www.ncbi.nlm.nih.gov/pubmed/12924748", "text": "Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS) J Psychoactive Drugs.2003;35:253–259." } ], "Other References": [ { "href": "https://www.naabt.org/documents/cows_induction_flow_sheet.pdf", "text": "The National Alliance of Advocates for Buprenorphine Treatment COWS Flow sheet. Published Nov. 2011." } ], "Outcomes": [], "Validation": [ { "href": "https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2774236/", "text": "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." } ], "Validations": [] }

pearls

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.

usecase

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.

reasons

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_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.

next_actions

Always consider the possibility of comorbid withdrawal conditions from alcohol, benzodiazepine, or sedative-hypnotics, which may be life threatening alone or in combination.

next_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.

diseases

[ "Drug/Alcohol Use", "Ingestion/Overdose", "Substance Withdrawal" ]

instructions

published

2022-04-21T20:29:04.869Z

purpose

[ "Diagnosis" ]

search_terms

[ "cows", "COWS", "opiates", "drug abuse", "drugs", "withdrawal", "w/d", "piloerection", "pulse", "sweating", "anxiety", "clinical opiate severity score", "opioid" ]

seo

{ "keywords_en": "COWS Score for Opiate Withdrawal, cows, cows score, cows opiate, cows opioid, cows withdrawal, cows prognosis, withdrawal prognosis, opiate withdrawal, opiate withdrawal prognosis, opiate w/drawal, opiate withdrawal score, opiate score, Cows opiate score, withdrawal severity, opiate withdrawal severity, withdrawal severity opiate, clinical opiate withdrawal score", "meta_description_en": "The COWS Score for Opiate Withdrawal quantifies severity of opiate withdrawal." }

specialty

[ "Emergency Medicine", "Family Practice", "Geriatrics", "Internal Medicine", "Pain Management", "Palliative Care/Hospice", "Primary Care", "Psychiatry", "Toxicology" ]

departments

[ "Psychiatric" ]

version_number

versions

[]

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ismed

true

section

[ "whenToUseViewed", "pearlsPitfallsViewed", "whyUseViewed", "nextStepsViewed", "evidenceViewed" ]

cleaned_departments

[ "psychiatry" ]

cleaned_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.", "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." ]

pub