Wesson 2003: the Clinical Opiate Withdrawal Scale (COWS)

What they tested

The authors describe COWS, which a clinician fills in by rating eleven withdrawal signs or symptoms. The summed score is used to judge how much withdrawal a patient is in and to make inferences about how physically dependent on opioids they are.

They also review opioid withdrawal scales since the first one in the mid-1930s and the settings each was first used in. A template of COWS that can be copied is attached.

What they found

The authors say interest in measuring withdrawal had grown with wider use of opioids for pain and with sublingual (under-the-tongue) buprenorphine becoming available in the US for opioid dependence.

Buprenorphine, a drug that partly activates opioid receptors, can bring on withdrawal in people with high opioid dependence who aren't already in withdrawal. That is part of why measuring withdrawal had drawn renewed interest.

Many different withdrawal scales had been used in clinics and research before COWS. Printable versions were made available through addiction medicine societies and other websites.

Limits

• This is a description of a scale and a history of earlier scales. The abstract reports no study testing how accurate or reliable COWS is.
• It is about opioid withdrawal in general and buprenorphine, not naltrexone.

What it means if you're considering naltrexone

For someone on opioids thinking about naltrexone, COWS is the scale clinicians and researchers use to put a number on withdrawal, including in the precipitated withdrawal studies the site's guide describes. The scale itself says nothing about naltrexone; it measures how much withdrawal someone is in.