The Clinical Opiate Withdrawal Scale (COWS) is a tool designed to assist healthcare professionals in customizing opioid withdrawal management for individuals. This scale is utilized in various settings, including inpatient and outpatient rehabilitation, to gauge the intensity of opioid withdrawal symptoms and track their progression during treatment.
The 11 Withdrawal Symptoms on the COWS Scale
COWS evaluates 11 common symptoms of opioid withdrawal, assessing their severity. Symptoms often resemble those of a cold or flu, but additional factors like pulse and blood pressure are also considered for a more comprehensive evaluation.
- Resting Pulse Rate: Ranges from 80 or below to over 120 beats per minute.
- Gastrointestinal Upset: Assessed based on recent symptoms, with ratings from no symptoms to multiple episodes of vomiting or diarrhea.
- Sweating: Evaluated over the last 30 minutes, without considering physical activity or room temperature, ranging from no symptoms to sweat streaming off the face.
- Tremor: Observed in the patient’s outstretched hands, from no tremor to gross tremor or muscle twitching.
- Restlessness: Observable and ranging from being able to sit still to being unable to do so.
- Yawning: Counted during the assessment, from none to several times per minute.
- Pupil Size: Based on a visual exam, from normal to extremely dilated.
- Anxiety and Irritability: Mostly self-reported, from none to severe.
- Bone or Joint Aches: Attributable to opiate withdrawal, from none to severe.
- Goosebumps: Described from smooth skin to prominent piloerection.
- Runny Nose and Watering Eyes: Specific to withdrawal, from none to constant runniness and tear streaming.
Some clinics incorporate buprenorphine introduction during the COWS assessment.
Each symptom is assigned a numerical value, with the total score indicating the withdrawal severity – from mild (scores of 5-12) to severe (scores of 36 or more).
COWS Table
| Symptom | Assessment Criteria | Scoring |
|---|---|---|
| Resting Pulse Rate | 80 or below, 81-100, 101-120, greater than 120 bpm | 0, 1, 2, 4 |
| Gastrointestinal Upset | No symptoms, stomach cramps, nausea or loose stool, vomiting or diarrhea, multiple vomiting/diarrhea | 0, 1, 2, 3, 4 |
| Sweating | No symptoms, self-reported chills/flushing, observable sweat, sweat on brow/face, streaming sweat | 0, 1, 2, 3, 4 |
| Tremor | No tremor, felt but not seen, slight observable, gross tremor or muscle twitching | 0, 1, 2, 4 |
| Restlessness | Able to sit still, difficulty sitting still, frequent shifting, unable to sit still | 0, 1, 2, 3 |
| Yawning | None, once or twice, three or more times, several times per minute | 0, 1, 2, 3 |
| Pupil Size | Pinned or normal, larger than normal, moderately dilated, extremely dilated | 0, 1, 2, 3 |
| Anxiety and Irritability | None, increasing irritability/anxiousness, obvious irritability/anxiousness, difficult participation | 0, 1, 2, 4 |
| Bone or Joint Aches | None, mild discomfort, severe aches, visibly sore | 0, 1, 2, 3 |
| Goosebumps | Skin smooth, piloerection felt, piloerection visible | 0, 1, 2 |
| Runny Nose and Watering Eyes | None, nasal stuffiness/moist eyes, constant runniness/tear streaming | 0, 1, 2 |
Historical Context and Treatment Approaches
The COWS was developed in response to the rising heroin addiction issues in the US and Europe. It was inspired by the CIWA-Ar, a scale for alcohol withdrawal. Introduced in the 1930s, COWS has influenced the development of other scales for various substance withdrawals.
Subjective Opiate Withdrawal Scale
The Subjective Opiate Withdrawal Scale (SOWS) is a self-reported scale, encompassing a wider range of symptoms. Clinicians may use both COWS and SOWS to get a comprehensive understanding of a patient’s withdrawal experience, which can be crucial for predicting cravings, psychological withdrawal, and relapse potential. The list of SOWS includes:
- Sweating
- Watering of the eyes
- Runny nose
- Yawning
- Hot and cold flashes
- Anorexia, or loss of appetite
- Abdominal cramps
- Nausea
- Vomiting and diarrhea
- Shaking or tremor
- Insomnia
- Restlessness
- General aches and pains
- Tachycardia
- Hypertension
- Goosebumps
- Dilated pupils
- Bowel sounds
Medically Managed Detox with COWS
COWS aids clinicians in deciding whether medication like buprenorphine is needed for managing opioid addiction. It’s crucial in preventing protracted withdrawal and easing the transition off physical drug dependence. Accompanying medication scales guide appropriate dosing, considering factors like pregnancy and individual recovery needs.
The medication scale also has notes regarding other medications that can be used during detox. These include:
- Clonidine, a benzodiazepine to ease anxiety
- Dicyclomine, which helps relieve abdominal discomfort
- Loperamide, for improved bowel movements
- Zofran, to address nausea and vomiting
- Doxepin or trazodone, for insomnia in male or female patients, respectively
- Ibuprofen and Tylenol, in prescription doses, for aches and pains
COWS and similar scales play a vital role in rehabilitation, combining self-reporting and medical measurements for personalized treatment, paving the way for successful therapy and sobriety management. Detox is a critical initial step in overcoming addiction, and its proper management is key to effective and comprehensive therapy.
CIWA vs COWS
The Clinical Institute Withdrawal Assessment (CIWA) is tailored for alcohol withdrawal, focusing on symptoms like tremors and agitation, while the Clinical Opiate Withdrawal Scale (COWS) is specific to opiate withdrawal, assessing factors like pulse rate and pupil size. While both tools share the goal of assessing withdrawal severity, their use is specialized to the substance in question – alcohol for CIWA and opiates for COWS – making them indispensable in their respective areas for ensuring safe and effective withdrawal management.
Sources
Pubmed – The Clinical Opiate Withdrawal Scale (COWS)
