COWS

Monitors severity of opioid withdrawal to guide buprenorphine induction timing

Indication

Monitors severity of opioid withdrawal to guide buprenorphine induction timing

Criteria

id: pulse; label: Resting pulse rate; type: options; options: label: ≤ 80; value: 0; label: 81-100; value: 1; label: 101-120; value: 2; label: > 120; value: 4
id: sweating; label: Sweating (past 30 min); type: options; options: label: No chills or flushing; value: 0; label: Subjective chills or flushing; value: 1; label: Flushed or observable moisture; value: 2; label: Beads of sweat on brow; value: 3; label: Sweat streaming off face; value: 4
id: restlessness; label: Restlessness; type: options; options: label: Able to sit still; value: 0; label: Reports difficulty sitting still; value: 1; label: Frequent shifting or leg movements; value: 3; label: Unable to sit still for more than a few seconds; value: 5
id: pupils; label: Pupil size; type: options; options: label: Pinned or normal; value: 0; label: Possibly larger than normal; value: 1; label: Moderately dilated; value: 2; label: So dilated only rim of iris visible; value: 5
id: bone_joint; label: Bone or joint aches; type: options; options: label: Not present; value: 0; label: Mild diffuse discomfort; value: 1; label: Patient reports severe diffuse aching; value: 2; label: Rubbing joints/muscles, unable to sit still from discomfort; value: 4
id: rhinorrhea; label: Runny nose or tearing; type: options; options: label: Not present; value: 0; label: Nasal stuffiness or unusually moist eyes; value: 1; label: Nose running or tearing; value: 2; label: Nose constantly running or tears streaming; value: 4
id: gi; label: GI upset; type: options; options: label: No GI symptoms; value: 0; label: Stomach cramps; value: 1; label: Nausea or loose stool; value: 2; label: Vomiting or diarrhea; value: 3; label: Multiple episodes of vomiting or diarrhea; value: 5
id: tremor; label: Tremor; type: options; options: label: No tremor; value: 0; label: Tremor can be felt but not observed; value: 1; label: Slight tremor observable; value: 2; label: Gross tremor or muscle twitching; value: 4
id: yawning; label: Yawning; type: options; options: label: No yawning; value: 0; label: Yawning 1-2 times during assessment; value: 1; label: Yawning 3+ times during assessment; value: 2; label: Yawning several times per minute; value: 4
id: anxiety; label: Anxiety or irritability; type: options; options: label: None; value: 0; label: Patient reports increasing anxiety/irritability; value: 1; label: Visibly anxious or irritable; value: 2; label: So anxious/irritable admission requested; value: 4
id: gooseflesh; label: Gooseflesh skin; type: options; options: label: Skin is smooth; value: 0; label: Piloerection can be felt; value: 3; label: Prominent piloerection; value: 5

Interpretation

function(score) { if (score <= 4) return { risk: score + '/48', tier: 'No/Minimal Withdrawal', action: 'Not yet in sufficient withdrawal for buprenorphine induction. Recheck in 1-2 hours.', color: 'green' }; if (score <= 12) return { risk: score + '/48', tier: 'Mild Withdrawal', action: 'Early withdrawal. Consider initiating buprenorphine if score \u22658 and rising. Low-dose buprenorphine induction protocol available at COWS \u22654.', color: 'yellow' }; if (score <= 24) return { risk: score + '/48', tier: 'Moderate Withdrawal', action: 'Adequate withdrawal for standard buprenorphine induction. Buprenorphine 4mg SL; may re-dose 4mg in 1-2 hours.', color: 'yellow' }; if (score <= 36) return { risk: score + '/48', tier: 'Moderately Severe', action: 'Significant withdrawal. Buprenorphine induction recommended. Symptom management: clonidine, loperamide, ondansetron.', color: 'red' }; return { risk: score + '/48', tier: 'Severe Withdrawal', action: 'Severe withdrawal. Immediate buprenorphine induction. Aggressive symptom management. Consider admission if unable to tolerate oral meds.', color: 'red' }; }

Clinical pearls

Traditional induction: wait for COWS ≥12 before starting buprenorphine
Low-dose (micro-dosing) induction protocols can start at lower COWS scores
Precipitated withdrawal occurs if buprenorphine given while significant opioid agonist still at receptors
Pupil dilation is the most objective COWS finding

Source and review

Wesson and Ling, J Psychoactive Drugs 2003. Last reviewed: 2024-11-01