What is the recommended Clinical Opiate Withdrawal Scale (COWS) score for Suboxone (buprenorphine/naloxone) initiation?

COWS Score for Suboxone (Buprenorphine/Naloxone) Initiation

A COWS score of at least 8, indicating moderate withdrawal, is recommended before initiating Suboxone (buprenorphine/naloxone) to prevent precipitated withdrawal. 1

Understanding the Clinical Opiate Withdrawal Scale (COWS)

The COWS is a validated tool used to objectively quantify opioid withdrawal symptoms before initiating buprenorphine therapy. It assesses 11 different parameters:

1. Resting pulse rate
2. Sweating
3. Restlessness
4. Pupil size
5. Bone or joint aches
6. Runny nose or tearing
7. GI upset
8. Tremor
9. Yawning
10. Anxiety or irritability
11. Gooseflesh skin

Each parameter is scored, and the total score determines the severity of withdrawal:

• 5-12 = mild withdrawal
• 13-24 = moderate withdrawal
• 25-36 = moderately severe withdrawal

• 36 = severe withdrawal 2

Timing of Suboxone Administration

Proper timing of Suboxone administration is critical to prevent precipitated withdrawal. Patients should be in active withdrawal from opioids before receiving buprenorphine:

• Short-acting opioids: Wait >12 hours since last use
• Extended-release formulations: Wait >24 hours
• Methadone maintenance: Wait >72 hours 1

Recommended Protocol for Suboxone Initiation

1. Confirm objective signs of withdrawal: COWS score >8 (moderate withdrawal) 1
2. Initial dosing: Start with 4-8 mg sublingually based on withdrawal severity
3. Reassessment: Check patient after 30-60 minutes
4. Additional dosing: Administer additional doses at 2-hour intervals if withdrawal symptoms persist
5. Target dose: Aim for a stabilization dose of 16 mg daily for most patients 1

Clinical Considerations

• Agreement between providers: Studies show substantial agreement between emergency physicians and nurses when using the COWS tool, with a concordance of 82.5% when using COWS ≥5 as a cutoff 3

• Low-dose induction option: For patients with pain who are currently on full agonist opioids, low-dose buprenorphine induction protocols may be considered to avoid withdrawal symptoms 4

• Extended-release options: Recent research shows that extended-release injectable buprenorphine may be feasible in patients with minimal to mild withdrawal (COWS <8), though this approach is most successful in those with COWS scores of 4-7 5

Common Pitfalls to Avoid

1. Administering buprenorphine too early: This is the most common error and can precipitate severe withdrawal due to buprenorphine's high affinity but partial agonist properties

2. Inadequate dosing: Insufficient initial dosing may fail to control withdrawal symptoms

3. Failing to recognize that pain itself may be a withdrawal symptom

4. Not addressing drug interactions, particularly with benzodiazepines, which can increase risk of respiratory depression 1

Monitoring After Initiation

• Monitor vital signs regularly, especially blood pressure and heart rate
• Check for signs of precipitated withdrawal
• Provide overdose prevention education and consider dispensing take-home naloxone
• Arrange appropriate follow-up for continued treatment 1

By following these guidelines and ensuring a COWS score of at least 8 before initiating Suboxone, clinicians can minimize the risk of precipitated withdrawal and improve treatment outcomes for patients with opioid use disorder.