Withdrawing from opioids can be a challenging process for people living with opioid use disorder. Symptoms of opioid withdrawal can be uncomfortable, painful, and emotionally exhausting.

To help evaluate and manage opioid withdrawal symptoms, doctors often use the Clinical Opiate Withdrawal Scale (COWS). The scale is designed to help medical personnel monitor and treat opioid withdrawal as safely and effectively as possible, while controlling unpleasant symptoms.

If you have opioid use disorder and need help overcoming opioid addiction and managing your condition, it’s essential to talk to your healthcare team about treatments that may be appropriate for you. Understanding how tools such as the Clinical Opiate Withdrawal Scale work can help you have a better idea of what to expect if you are undergoing opioid withdrawal under medical supervision.

Importantly, people with opioid use disorder shouldn’t attempt withdrawal on their own — without appropriate medical care and monitoring. This can be ineffective and dangerous.

Here’s more on what COWS measures and why it matters for people with opioid use disorder.

Is COWS Used To Diagnose Opioid Use Disorder?

Doctors don’t use the Clinical Opiate Withdrawal Scale to diagnose opioid use disorder. It also isn’t designed to be used by an individual with opioid use disorder for any type of self-diagnosis or withdrawal without medical supervision.

Signs of opioid use disorder may include withdrawal symptoms as indicated in the Clinical Opiate Withdrawal Scale, but the condition also includes a range of risky behaviors that can seriously affect physical and mental well-being. People with opioid use disorder develop an uncontrollable opioid dependence outside of how these pain medications may have been prescribed by a doctor.

Opioid use disorder is characterized by a strong urge to acquire and use opioids. Opioid use disorder is a mental health condition in which people have problems with improper and addictive use of opioid medications.

If you think you may have opioid use disorder, it’s important to talk to your doctor. Opioid use disorder is a life-threatening condition that can severely impact your quality of life. It’s a chronic (ongoing) health condition that may require lifelong management.

Your doctor can review your medical history and behaviors around the use of opioids for a diagnosis of opioid use disorder. In some cases, a drug test may be recommended.

What Are the Symptoms of Opioid Withdrawal in COWS?

The Clinical Opiate Withdrawal Scale evaluates 11 specific withdrawal signs and symptoms. Each one is scored starting at zero, and the top score depends on the symptom. Symptoms that are evaluated with COWS include:

• Resting pulse rate (heart rate)
• Sweating or chills
• Restlessness or the ability to sit still
• Pupil size
• Bone or joint aches that aren’t caused by another health problem
• Runny nose or tearing that isn’t associated with a cold, flu, or allergies
• Gastrointestinal upset, such as stomach cramps, vomiting, and diarrhea
• Tremor or shaking of outstretched hands or muscle twitching
• Yawning frequency
• Anxiety or irritability and how apparent it is during evaluation
• Gooseflesh skin or goosebumps (temporary bumps on the skin that are associated with conditions such as fear, emotion, or cold)

Based on the total COWS score, opioid withdrawal can be assessed as mild to severe according to the following numbers:

• A score of 5-12 — Mild withdrawal
• A score of 13-24 — Moderate withdrawal
• A score of 25-36 — Moderately severe withdrawal
• A score greater than 36 — Severe withdrawal

The total score provides doctors with an understanding of how severe your symptoms are and helps them choose the safest treatment plan.

How Does COWS Guide Withdrawal Treatment Decisions?

The severity of symptoms helps doctors decide when and how to start medication for withdrawal. Starting medication too early can cause precipitated withdrawal, which means symptoms can suddenly get worse. To lower this risk, clinicians usually wait until a person is in clear withdrawal based on the COWS score and the clinic’s treatment plan.

For example, buprenorphine/naloxone (Suboxone or Zubsolv) can trigger precipitated withdrawal if it’s taken before someone is in enough withdrawal. Different clinics use different COWS targets, but many wait until symptoms are at least moderate before the first dose. Some people may be treated with methadone instead, depending on their situation and what care is available.

This is especially important because today’s opioid supply may include fentanyl, and some people may need a different timing or approach that their clinician will guide.

Monitoring Symptoms During Treatment

COWS scoring is also used to monitor symptoms during treatment. When someone is given a first dose of buprenorphine/naloxone, they will be watched over the next hour, and their symptoms will be scored to see if they are relieved or if they worsen. COWS scoring of symptoms may be repeated as needed.

Within the first week of withdrawal treatment, the goal is to monitor symptoms with COWS as closely as necessary until someone is symptom-free for 24 hours straight. Then a stable withdrawal treatment plan can be implemented.

Monitoring Withdrawal Symptoms at Home

In milder cases of opioid withdrawal, someone may be able to manage their treatment at home with medical supervision and a detailed treatment plan. If your doctor recommends this approach, you may be asked to use the Subjective Opioid Withdrawal Scale (SOWS) to monitor and report your symptoms as needed.

Opioid withdrawal at home is hard. It’s important to have a good support system and to go through withdrawal slowly. It’s essential to talk to your doctor about the risks of detoxification at home and whether this is the right choice for you.

How Can COWS Help Manage Individualized Care?

If you or someone you love is living with opioid use disorder, withdrawal can be intense and overwhelming — both physically and mentally. The Clinical Opiate Withdrawal Scale is an important assessment tool for managing withdrawal in a structured and careful way.

Each case of opioid use disorder is unique, and COWS is designed to help doctors treat each individual according to their particular symptoms and reactions to opioid withdrawal. The Clinical Opiate Withdrawal Scale is designed to manage difficult symptoms as safely as possible and to help ensure that people with opioid use disorder get on a path to long-term treatment and recovery.

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