The COWS scale: how helpful is it?

COWS stands for Clinical Opioid Withdrawal Scale, and it’s probably the most commonly used tool to determine the degree of opioid withdrawal experienced by the patient. The scale has eleven items related to opioid withdrawal. Some are subjective, like the question about the degree of anxiety or irritability the patient is feeling. Some items are strictly objective, such as pupil size and pulse rate. And some are sort of a combination of objective and subjective, like the question asking about both nausea and vomiting. The patient may report nausea and score points on the scale, and if the patient vomits, this scores more points.

I’ve worked in clinics that used the COWS for each dose increase, and I’ve worked in clinics that didn’t use the COWS at all.

I think it’s a good tool, but has some drawbacks. I use it during dose induction, particularly on a patient new to medication-assisted treatment. Sometimes patients aren’t sure how they’re “supposed” to feel on replacement medication, and a COWS score gives me a better idea of how much withdrawal they are in.

For example, I had a patient who felt much fatigue in the evenings. He’s been on the program about a month, and had been dosing at 70mg for about a week. He worked at a strenuous job, and got off work around 5pm. One day, he told the nurses that he needed an increase, since it felt like his methadone “gave out” as soon as he got home, and he had to take a nap before his evening meal because he was so sleepy. When the nurses heard him say   “sleepy,” they correctly became worried he was on too much methadone, and sent him to see me. When I checked him just before dosing the next morning, his pupils were a wide 8 mm and reacted briskly to the bright light I shone in his eyes. He was in withdrawal and he felt better after a few dose increases. His use of the word sleepy was confusing, since to us, we worry “sleepy” means “headed towards a methadone overdose.”

Sometimes, a patient reports severe withdrawal but doesn’t score very high on the COWS. I don’t assume the patient is lying, because some patients don’t tolerate withdrawal symptoms easily. More commonly, I see patients, mostly long-term users, who are in what I would consider to be moderate or severe withdrawal by their COWS score, but they experience it as “not so bad, I’ve felt worse”

In another example, I had a patient on 110mg who reported terrible withdrawal, to the point she couldn’t function during the day. She was restless, anxious, jittery, and felt like her heart was racing. She wasn’t sleeping well. This was puzzling, since a month ago she’d been fine on that same dose. There were no new medications, no change in activities, and she wasn’t drinking alcohol (a common reason for drop in methadone blood level). On the COWS, she scored an 8, but when I looked at the actual COWS, she scored very high on the more subjective items, yet her pupils were pinpoint and her pulse rate in the 60’s

The more we talked, the more I suspected anxiety as the cause of her symptoms. She had a terribly stressful living situation. She was saving money to move out on her own, but felt like she had to endure the circumstances in the short term. In this case, she appeared to be blaming opioid withdrawal for her symptoms of anxiety, and anxiety was a normal response for what she was experiencing. She didn’t need a higher dose of methadone; she needed someone to help her think of better immediate options for safe housing.

I do not think a COWS score is helpful for fine-tuning a patient’s dose of methadone. Many times the COWS score doesn’t pick up subtle withdrawal, so I don’t tend to use it for higher dose changes.

COWS scores are helpful when defending one’s self from regulatory bodies. About five years ago, a state investigator took me to task for authorizing dose increases. “You just believe them when they say they’re in withdrawal?” she asked sarcastically. The investigator didn’t think I should increase the doses of those patients, and yet the studies clearly show methadone patients have better outcomes if they are on an adequate dose. By doing a COWS score, the patient’s signs and symptoms are recorded in the chart for an investigator to see.

In summary, the COWS scale is a useful tool, though probably more useful at lower doses. Like all tools, it’s helpful in some situations, but it’s not perfect. It should be used alongside our other tools, like talking and listening to our patients both before and after dosing, using blood levels in rare cases, and always asking about other medications or new medical problems.

2 responses to this post.

  1. Posted by Courtney Parsons on June 4, 2012 at 8:36 pm

    Dr. Burson,

    i think this is the scale that our doctor uses for us, but like you, she doesn’t seem to decide whether or not to grant a patient an increase based on this.

    As I told you before, I’m in TN, and once a client reaches 120 mg the final decision whether or not a client gets an increase lies with the state. Usually they grant it, I understand, or at least, they did with me.

    I’m at 140 mg now, and honestly, my score on this “COWS” scale, I will admit, would be pretty low now. However, I am still experiencing a strong level of free-floating anxiety, and though I can sleep, I wake up very quickly with a sense of impending doom.

    Now, I have panic disorder and clinical depression with psychotic features, and this is exacerbated by a persistent case of PTSD so because of this diagnosis, the clinic doctor believes I would better be served by psych meds than a further increase in my dose. Besides, she says- and I know state guidelines support this argument- the state isn’t likely to allow it based on my peak and trough analysis.

    Okay, but I’ve tried every anxiety med out there. The only drugs that work are benzos. Take my word for this- I don’t want to use up all my space here telling you every medication I’ve tried, on label and off, including antidepressant increases and decreases, cuz it would take up several pages probably. However, TN has a strong anti-benzo/methadone/suboxone combo policy, and I have been strongly discouraged from taking this path. This, despite of the fact that there is now, and has been since the late 90s, an entire class of benzos that are created to resist abuse the way buprenorphine does, and work, educated people (such as our esteemed Dr.) that should know about these won’t even discuss the subject.

    Okay, so option no. 2, when I was on methadone in the late 90s, even though I suffered from this problem then, and if anything, it was worse at that time, methadone COMPLETELY controlled it. But my tolerance was much, much lower then.

    If they would raise my dose high enough so that I feel like I felt before, which can be done, it just would take more, my anxiety would be completely under control. They can’t seriously expect, after what I’ve been through, that I should stay sober and seriously try to re-enter society as a functioning member unless I can get a handle- a MEDICAL handle, since it is a *medical* problem- on this anxiety issue. Right now, I feel thin and stretched, and fragile, the first major crisis that comes my way and I’m terrified I will shatter like ice.

    I can do without benzos if they’ll give me enough methadone, though, and I’m only asking for one or the other. Does anyone have any suggestions?



  2. Drive to NC where you can take benzo’s with a script and be on methadone (a dose within reason when on benzo’s) or…you can pretty much get a doctor to give you the methadone dose you need to not want to get high or suffer withdrawals despite peak and trough’s which can not really for sure say what active or inactive isomers are doing or not doing in ones SML levels because of the racemic isomers.. .


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