From the Guidelines
To effectively utilize the COWS score, clinicians should assess patients across 11 parameters, assign point values based on symptom severity, and use the total score to guide treatment decisions, such as initiating buprenorphine when scores reach 8-12 or higher, as recommended by the most recent evidence 1. The COWS score is a clinical tool designed to assess the severity of opioid withdrawal symptoms. The assessment includes evaluating the patient across parameters such as:
- Resting pulse rate
- Sweating
- Restlessness
- Pupil size
- Bone/joint aches
- Runny nose/tearing
- GI upset
- Tremor
- Yawning
- Anxiety/irritability
- Gooseflesh skin For each parameter, assign the appropriate point value based on the severity of symptoms observed, as outlined in the COWS scale 1. After completing the assessment, add up the total score to determine the withdrawal severity:
- 5-12 points indicates mild withdrawal
- 13-24 points moderate withdrawal
- 25-36 points moderately severe withdrawal
- More than 36 points severe withdrawal The COWS score should be used to guide treatment decisions, such as when to initiate medication-assisted treatment with buprenorphine, with initial dosing of 4-8 mg SL based on severity of withdrawal 1. Reassess the patient regularly using the COWS to monitor treatment effectiveness and adjust interventions accordingly, with reassessment recommended in 1-2 hours for mild withdrawal and 30-60 minutes for moderate to severe withdrawal 1. This standardized approach helps clinicians objectively quantify withdrawal severity, ensuring appropriate treatment intensity and reducing the risk of precipitated withdrawal when initiating replacement therapy, as supported by recent evidence 1.
From the Research
Utilizing the COWS Score
The Clinical Opiate Withdrawal Scale (COWS) is used to assess the severity of opioid withdrawal symptoms. To utilize the COWS score, healthcare providers can follow these steps:
- Assess the patient's withdrawal symptoms using the COWS scale, which evaluates factors such as restlessness, yawning, sweating, and nausea 2
- Use the COWS score to determine the severity of withdrawal and guide treatment decisions, such as the initiation of buprenorphine or methadone therapy 3
- Monitor the patient's COWS score over time to assess the effectiveness of treatment and adjust the treatment plan as needed 4
Buprenorphine Treatment
Buprenorphine is a medication used to treat opioid use disorder, and its effectiveness can be evaluated using the COWS score. Key points to consider when utilizing buprenorphine treatment include:
- Buprenorphine has been shown to be effective in reducing withdrawal symptoms and improving treatment outcomes compared to other medications, such as clonidine or lofexidine 2
- The COWS score can be used to guide the initiation and titration of buprenorphine therapy, with the goal of reducing withdrawal symptoms and improving patient comfort 5
- Buprenorphine can be used in combination with other medications, such as naloxone, to improve treatment outcomes and reduce the risk of diversion 6
Methadone Treatment
Methadone is another medication used to treat opioid use disorder, and its effectiveness can also be evaluated using the COWS score. Key points to consider when utilizing methadone treatment include:
- Methadone has been shown to be effective in reducing withdrawal symptoms and improving treatment outcomes, although its use may be limited by regulatory restrictions and availability 2
- The COWS score can be used to guide the initiation and titration of methadone therapy, with the goal of reducing withdrawal symptoms and improving patient comfort 3
- Methadone can be used in combination with other medications, such as lofexidine, to improve treatment outcomes and reduce the risk of withdrawal symptoms 3