RATING SCALES SERIES – COWS (Clinical Opiate Withdrawal Scale)

INTRODUCTION

- COWS is an acronym for Clinical Opiate Withdrawal Scale

- Numbered scale designed to help clinicians tailor opiate withdrawal treatment to individual
people, by determining severity of opioid withdrawal and monitor how symptoms change
with treatment outcome
- It is an 11 symptom scale

HISTORY

- It was developed in the 1990s by Werson and colleagues, keeping in mind the rising heroin
addiction problem in the USA and Europe
- It is based on the CIWA-Ar scale used for alcohol withdrawal
- It was developed to improve upon the existing scoring systems and the scoring was based on
the author’s clinical expertise

RELIABILITY AND VALIDITY

- Since it is based on observation of common opioid withdrawal symptoms, and due to its
simple questionnaire, its reliability is high.
- It has sufficient sensitivity to detect even mild opiate withdrawal
- Internal consistency of COWS was found to be high
- With regards to validity, studies comparing COWS with CINA (an established validated scale)
found similar results over time.
- Also, the overlap in content of the 2 scales supports content validity and face validity of
COWS.

MATERIAL

- Administration of COWS requires the material in the form of the structured scale and an
observant clinician
- It can be combined with buprenorphine administration scale for appropriate dosing of
patient requiring medical management.

ADMINISTRATION

- COWS can be administered in both inpatient and outpatient settings

- It can be administered by clinicians to determine stage of severity of opiate withdrawal and
assess the level of physical dependence on opioids.
- Approximately 1-2 minutes interview and observation is required for administration.
 - It can be administered

1. During detoxification
2. During pain treatment
3. During buprenorphine induction

It is a 11 item scale with a list of common opioid withdrawal symptoms which require observation by
clinician and symptom description by the patient

SCORING

- Each symptom is rated from minimal/absent as zero and maximum upto 4 or 5

- 7 symptoms are rated from 0-4 and the rest from 0-5
- A minimum score of zero and a maximum score of 48 can be obtained

The severity of opioid withdrawal can be graded as follows

Score 5-12 : Mild

13-24 : Moderate

25-36 : Moderately severe

> 36 : severe

ADVANTAGES

- Simple and easy to administer

- Less time consuming
- Can be applied in all settings
- Useful to grade severity of symptoms as well as monitor treatment
- It combines subjective symptoms with objective signs and hence limits possibility of feigned
responses

DISADVANTAGES

- The withdrawal symptoms described can be confused with exacerbations in concurrent

medical conditions (for eg : nausea, running nose, joint ache, sweating in influenza
infections) and is hence difficult to quantify in such conditions
- Does not have the provision for possibility of comorbid withdrawal conditions (like alcohol,
BZDs or other sedative hypnotics)