Menu Close

Clinical Opiate Withdrawal Scale (C.O.W.S.): Measuring the Agony

Clinical Opiate Withdrawal Scale (C.O.W.S.): Measuring the Agony

Measuring the actual severity of withdrawal from opioid drugs during medically-assisted detoxification, either in a rehab center or in an ER or other hospital setting, has obviously become paramount in recent years during the nation’s ongoing opioid crisis. However, the trusted standard used today by rehab doctors and nurses, and other trained medical staff – the Clinical Opiate Withdrawal Scale (C.O.W.S., for short) – was actually first developed way back in the 1930s.

“How much pain medication are you taking?” That was the very routine question that changed my life.” – Travis Rieder, TEDTalk Speaker: “The Agony of Opioid Withdrawal

Assessing the exact nature and severity of a detoxing patient’s opioid withdrawal is critical for physicians and clinicians to accurately determine the risks involved in the detox process as it progresses. This is where the use of the C.O.W.S. system has become so vital in the field of addiction treatment, and absolutely essential in determining a patient’s ongoing physical well-being during opioid withdrawal management programs. Not only will this article be addressing the topics related to the C.O.W.S. system, but we’ll also provide you with the story of Travis Rieder, a TEDTalk Speaker (“The Agony of Opioid Withdrawal”) and his addiction to opioid meds – one man’s harrowing ordeal at both the mercy of the opioid prescription medication he was given, and, seemingly, the medical world entrusted with the safe and sound use of such powerful and addictive drugs. The honest and, frankly, disturbing account of Travis’s opioid withdrawal will sadly strike a chord with many of you reading this.

The Opioid Crisis: What’s The Latest?

At the time of writing this, the entire world is currently dealing with the unparalleled coronavirus (Covid-19) pandemic, which has seen unprecedented complete country and city lockdowns, physical border closures, hospitals at maximum capacity, a major disruption to daily life, such as shops, bars, and restaurants being forced to close entirely, and the entire sports calendars being decimated, and, for many of us, it has yet to even peak. To use “man-on-the-street” terminology, it will get a whole lot worse before it even starts to get a little bit better. Unsurprisingly then, coronavirus may well be overshadowing the U.S. opioid crisis at present, but that does nothing to alter the fact that the opioid crisis is still there, and it is still continuing, utterly regardless of where the public’s mind is now focused. According to government figures, approximately 10.3 million U.S. citizens aged 12 and older still misused opioids in 2018, including 9.9 million prescription painkiller abusers, and a further 808,000 heroin users – some of these users resorted to heroin after their opioid prescriptions ran out, because it’s cheaper and more easily available. This 2018 National Institute on Drug Abuse (NIDA) data also shows that 128 people in the U.S. are still dying every single day after overdosing on opioids. The National Institutes of Health (NIH) is the U.S.’s leading medical research agency helping solve the opioid crisis. In April 2018, the agency’s Director – Francis S. Collins, M.D., Ph.D. – announced the launch of the HEAL (Helping to End Addiction Long-term) Initiative  – a trans-agency effort to accelerate scientific solutions to stem the opioid crisis. However, as yet, there is no clear evidence that this initiative is achieving its primary aim in any form. In fact, in his very own blog post published in January 2020, Collins reported on an issue that his research agency had uncovered – the lack of opioid addiction treatment in young people after they had overdosed. The study of recently opioid-overdosing 13-22-year-olds found that only one third had received any kind of follow-up treatment. Even worse, “less than 2% received the gold standard approach* of medication treatment.” *The “gold standard approach” is opioid addiction treatment that “should include behavioral therapy, and treatment with one of three drugs: buprenorphine, naltrexone, or methadone.” Furthermore, and quite disturbingly:

  • Less than 20% received a diagnosis of opioid use disorder
  • 68.9% did not receive addiction treatment of any kind
  • 29.3% received only the behavioral therapy element, and 
  • Only 1.9% received 1 of the 3 approved medications for opioid use disorder

opioid withdrawal symptoms

Opioid Withdrawal: Symptoms & Timeline

The COWS assessment, which is explained fully below, was designed to accurately measure a patient’s ongoing detox and withdrawal from opioids, enabling attending clinicians to respond to changes in a patient’s symptoms with appropriate medication if required. This is the fundamental requirement of any professional opioid withdrawal management strategy. The severity of any opioid withdrawal, and the risks inherent with that severity, are predominantly governed by:

  • The patient’s previous daily amount of opioids used
  • The patient’s historical length of use, and
  • The patient’s genetics

It is important to remember that opioid withdrawal, if left unmanaged, can prove to be fatal – the patient’s death normally results from heart failure.

Opioid Withdrawal Symptoms

The predominant symptoms of opioid withdrawal include (but are not limited to):

  • Nausea
  • Diarrhea
  • Vomiting
  • Anxiety
  • Insomnia
  • Hot and cold flushes
  • Sweating
  • Muscle cramps
  • Lacrimation (uncontrollable tear flow)
  • Rhinorrhea (runny nose)

Opioid Withdrawal Timelines

Opioid withdrawal from using short-acting opioids, such as heroin, usually begins 8-24 hours after last using the drug, and the symptoms described above will last between 4-10 days. Long-acting opioids, like methadone, usually present opioid withdrawal symptoms within 12-48 hours after the last use and will last for approximately 10-20 days.

Clinical Opiate Withdrawal Scale

How Does the Clinical Opiate Withdrawal Scale (C.O.W.S.) Work?

It is recommended by the relevant medical authorities that any patient who is experiencing opioid withdrawal, either within an emergency room or detoxification setting, should be monitored regularly 3-4 times daily (at least) for symptoms and possible complications that may arise. Clinicians and physicians use the Clinical Opioid Withdrawal Scale for the continued monitoring of the severity of a patient’s withdrawal, although a number of opioid withdrawal scales now exist, as described in the World Health Organization’s publication “Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence.”

What Exactly Does It Measure?

The C.O.W.S.scale works by assigning, and then adding, numerical values for 11 different symptoms of opioid withdrawal, providing an individual measure of their severity. When these 11 values are added together, the resulting number provides an indication of where the patient actually is in the opioid withdrawal process. This indicative yet important information assists clinicians and other medical professionals in tailoring the next step of the withdrawal plan to fit the patient’s condition. The 11 designated opioid withdrawal symptoms are as follows (and are also shown afterward within an example assessment form):

  • Resting Pulse Rate
  • Gastrointestinal (GI) Upset, ie. nausea, vomiting or diarrhea
  • Sweating
  • Tremor
  • Restlessness
  • Yawning
  • Pupil Size
  • Anxiety or Irritability
  • Bone or Joint Aches
  • Gooseflesh Skin
  • Runny Nose or Tearing

Clinical Opiate Withdrawal Scale: Example Assessment Form

Patient Name: ______________________________  Assessment Date: ________________________ Reason for Assessment: _______________________________________________________________


Resting Pulse Rate:       _________ beats/minute (Measured after patient is sitting / lying for one minute) 0 pulse rate 80 or below 1 pulse rate 81 – 100 2 pulse rate 101 – 120 4 pulse rate greater than 120 GI Upset: over last ½ hour 0 no GI symptoms 1 stomach cramps 2 nausea or loose stool 3 vomiting or diarrhea  5 multiple episodes of diarrhea or vomiting
Sweating: over last ½ hour not accounted for by           temperature or patient activity 0 no report of chills or flushing 1 subjective report of chills or flushing 2 flushed or observable moisture on face 3 beads of sweat on brow or face 4 sweat streaming off face Tremors: observation of outstretched hands 0 no tremor 1 tremor can be felt, but not observed 2 slight tremor observable 4 gross tremor or muscle twitching
Restlessness: observation during assessment 0 able to sit still 1 reports difficulty sitting still, but is able to do so 2 frequent shifting or extraneous movement of legs/arms 5 unable to sit still for more than a few seconds Yawning: observation during assessment 0 no yawning 1 yawning once or twice during assessment 2 yawning three or more times during assessment 4 yawning several times/minute
Pupil size 0 pupils pinned or normal size for room light 1 pupils possibly larger than normal for room light 2 pupils moderately dilated 5 pupils so dilated that only the rim of the iris is visible Anxiety or Irritability 0 none 1 patient reports increasing irritability or anxiousness 2 patient obviously irritable or anxious 4 patient so irritable or anxious that participation in the assessment is difficult
Bone or Joint aches: If patient was having pain previously, only the additional component attributable to opioid withdrawal is scored 0 not present 1 mild diffuse discomfort 2 patient reports severe diffuse aching of joints/muscles 4 patient is rubbing joints or muscles and is unable to sit still because of discomfort Gooseflesh skin 0 skin is smooth 3 piloerection of skin can be felt or hairs standing up on arms 5 prominent piloerection
Runny nose or tearing: Not accounted for by cold symptoms or allergies 0 not present 1 nasal stuffiness or unusually moist eyes 2 nose running or tearing 4 nose constantly running or tears streaming down cheeks

Total score: _________

The total score is the sum of all 11 items

Initials of person completing assessment:    __________________

Score: 5-12 = Mild; 13-24 = Moderate; 25-36 = Moderately severe; more than 36 = Severe withdrawal

Who Can Perform a C.O.W.S. Assessment?

C.O.W.S. assessments, which are obviously either conducted within a rehab facility during a medically-assisted detox, or within an ER or other hospital setting, can only be performed by trained professionals, eg. medical clinicians, physicians, doctors, nurses, or other professionally qualified medical staff. Although the majority of assessments are carried out as part of opioid addiction treatment, they are also used in healthcare facilities when a patient has been given opioids for pain treatment, and the patient experiences adverse withdrawal symptoms.

How Quickly Can a C.O.W.S. Assessment Change?

As these assessments are performed during the process of opioid withdrawal, they should be administered as and when any change in the patient’s medical condition is observed, and at least 3-4 times daily, as a matter of course. It should be noted that a C.O.W.S. assessment will only depict changes when they are recordable changes in the patient’s medical condition during opioid withdrawal.

Medically Assisted Drug Detox

The Clinical Management of Medically-Assisted Detox

During a medically-assisted detox for opioid withdrawal, the C.O.W.S. assessments (and other similar assessments) are vital in enabling the clinicians and medical staff present to manage the process safely, and with the use of medications, eg. buprenorphine and naloxone, as and when required. With opioid withdrawal, if medicinal help is not given or provided, the process of detoxification can take considerably longer, with the patient suffering withdrawal symptoms for many weeks, even months. Using medication, like those described below, helps the patient physically be eased off their opioid dependence. This, in turn, leads the patient to feel positive about their decision to end their opioid addiction and helps them to focus during their opioid addiction treatment therapy and counseling sessions.

Medications Used to Assist Opioid Withdrawal During Detox 

Before we look at the medications themselves, an explanatory word about how opioids affect certain receptors in the brain – it’s why users can feel a sense of euphoria when taking their opioid-based prescriptions, and exactly why people can become addicted.

Brain Receptors, Dopamine & Opioid Agonists and Antagonists

Opioids affect us by attaching to certain receptors in our brains. Once they attach fully, they send signals which block any pain, slows our breathing, and makes us feel calm and at ease. They do this by flooding our brain’s reward system with dopamine, a chemical neurotransmitter that evokes a feeling of happiness. Drugs such as opioids are known as agonists – they activate particular receptors in our brains. A full agonist will activate the opioid receptors fully, resulting in the full opioid effect. Full opioid agonists include:

  • Heroin
  • Oxycodone
  • Methadone
  • Morphine
  • Hydrocodone, and
  • Opium

Drugs called opioid antagonists will also attach themselves to these same receptors, but with the completely opposite outcome. They bind to the receptors more strongly than agonists are able to do, but they do not activate those receptors, preventing the body from responding to opioids and endorphins. Naloxone, used in cases of opioid overdose, and naltrexone, used in the long-term treatment of opioid addiction, are primary examples of opioid antagonists. When opioid withdrawal symptoms are present, the pharmacological management of opioid withdrawal is done by using one of the following medications, as and when required:

  • Methadone: Gradual cessation of a full opioid agonist
  • Buprenorphine: Short-term use of a partial mu-opioid agonist ( the mu-opioid receptor is pivotal in the development of an addiction), or
  • Naloxone / Naltrexone: Detoxification using opioid antagonists (either of these antagonists will quicken the detox process, resulting in a precipitated or abrupt withdrawal. Even though it is quicker, it is far more uncomfortable for the patient)
  • Lofexidine: Recently FDA-approved non-opioid medication

In addition to these agonists and antagonists, other medications may be given to alleviate particular opioid withdrawal symptoms (known as symptomatic treatment), including:

  • Clonidine: for reducing anxiety and blood pressure
  • Loperamide: for diarrhea
  • Dicyclomine: for abdominal discomfort
  • Promethazine / Zofran: for nausea/vomiting
  • Ibuprofen / Tylenol: for myalgia (muscle pain), and
  • Doxepin or Trazodone: for insomnia in male or female patients, respectively

IMPORTANT: All detoxed opioid-dependent patients should be advised that, if they return to opioid use or abuse, they are at an increased risk of overdose, due to their newly reduced opioid tolerance.

Travis Rieder’s Story: “The Agony of Opioid Withdrawal”

Travis Rieder’s TEDTalk – “The Agony of Opioid Withdrawal,” an extremely personal story, is not only harrowing in respect of his various firsthand descriptions of undergoing the uncertainty and severe discomfort of opioid withdrawal at home, but it’s a frightening reminder of how we, as the dependent patients of a normal family physician, are at the mercy of our family doctors, and how our continued health (or lack of it, in the case of opioid withdrawal)) can be as fragile as our physician’s grasp of the latest opioid-related information. In Travis Rieder’s case (and this becomes plainly and painfully apparent during his talk), the acute opioid withdrawal that he experienced was the simple but direct fault of a far too aggressive medication-tapering program advised by his doctor. At no point, sadly, was Travis’s advised tapering program supervised in any way. Please watch the video.

This story is important precisely because I’m not special… My dependence on opioids was entirely predictable given the amount that I was prescribed and the duration for which I was prescribed it… I would need a supervised, well-formed tapering plan, but our health care system seemingly hasn’t decided who’s responsible for patients like me.” – Travis Rieder, from the transcript of “The Agony of Opioid Withdrawal”