COWS Cannot Be Used for Methamphetamine Withdrawal
The Clinical Opiate Withdrawal Scale (COWS) is specifically designed and validated only for opioid withdrawal and should not be used to assess methamphetamine withdrawal, as these are fundamentally different clinical syndromes with distinct symptom profiles and pathophysiology.
Why COWS Is Inappropriate for Methamphetamine
Different Withdrawal Syndromes
COWS measures opioid-specific symptoms including pupil size, piloerection (gooseflesh), gastrointestinal upset, yawning, and lacrimation—symptoms that are characteristic of opioid withdrawal but not methamphetamine withdrawal 1.
Methamphetamine withdrawal presents with a completely different symptom profile dominated by psychiatric symptoms (depression, anhedonia, psychosis), hypersomnia, increased appetite, and fatigue—none of which are captured by COWS 2.
The COWS scoring system (pulse rate, sweating, tremor, GI symptoms, anxiety) was developed and validated specifically for opioid withdrawal with severity ranges of 5-12 (mild), 13-24 (moderate), 25-36 (moderately severe), and >36 (severe) 3, 4.
Distinct Pathophysiology
Opioid withdrawal results from mu-opioid receptor downregulation causing hyperadrenergic symptoms that peak at 48-72 hours and resolve within 7-14 days 5.
Methamphetamine withdrawal stems from dopaminergic and noradrenergic depletion, producing a withdrawal syndrome characterized by psychiatric symptoms rather than autonomic hyperactivity 2.
What to Use Instead for Methamphetamine
No Validated Assessment Tool Exists
There is currently no FDA-approved or widely validated withdrawal scale specifically for methamphetamine withdrawal 2.
A novel inpatient protocol for methamphetamine withdrawal has been developed that includes both behavioral and pharmacological components (ascorbic acid, antipsychotics, sedatives), but this requires further validation 2.
Clinical Assessment Should Focus On
Psychiatric symptoms: Depression, anhedonia, psychosis, agitation, paranoia 2.
Sleep disturbances: Hypersomnia is common in methamphetamine withdrawal, opposite to the insomnia seen in opioid withdrawal 2.
Cardiovascular monitoring: Up to 70% of methamphetamine users have abnormal ECGs, most commonly tachycardia, and may have hypertension or cardiomyopathy 1.
Behavioral manifestations: Craving intensity, irritability, and functional impairment 2.
Critical Pitfall to Avoid
Do not attempt to adapt or modify COWS for methamphetamine withdrawal. Using COWS in this context would miss the predominant psychiatric symptoms of methamphetamine withdrawal while falsely emphasizing autonomic symptoms that are not the primary clinical concern 2. This could lead to inappropriate treatment decisions and inadequate symptom management.
Treatment Implications
Behavioral interventions are first-line treatment for methamphetamine use disorder, including cognitive behavioral therapy (CBT) and contingency management (CM), which show the strongest evidence for promoting abstinence 6.
No pharmacotherapy is currently FDA-approved for methamphetamine use disorder, though methylphenidate shows low-strength evidence of potential benefit 7.
Psychosocial interventions remain the mainstay of treatment, as pharmacological options have inconsistent evidence 8, 7.