How Does the Opioid Withdrawal Scale Influence Treatment?

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The opioid withdrawal scale, also called the Clinical Opioid Withdrawal Scale or COWS, is an “11-item scale” that allows clinicians to determine the severity of a person’s opioid withdrawal reactions (NIDA). Each of the 11 items is measured by the clinician’s observations of the patients or by specific tests, and they all must be measured so that they are directly related to the individual’s opioid withdrawal and no other influences.

The scale is incredibly helpful to doctors who need to determine what treatment needs a patient may have for both their withdrawal and their addiction treatments. But how does the opioid withdrawal scale influence treatment?

How Does the Scale Work?

The opioid withdrawal scale measures the severity of these 11 items which are often experienced during opioid withdrawal on a case-by-case basis.

  1. Resting pulse rate
  2. Sweating
  3. Restlessness
  4. Pupil size
  5. Bone or joint aches
  6. Runny nose or tearing
  7. Gastrointestinal upset (vomiting, nausea, stomach cramps, diarrhea)
  8. Tremor
  9. Yawning
  10. Anxiety or irritability
  11. Gooseflesh skin

In addition, the clinician will also record the date, time, and blood pressure of the patient. A version of the scale can be found at the NIDA. This scale and each of its signs and symptoms must be based solely on the withdrawal the individual is undergoing and not on another condition experienced by the patient. For example, if a person is experiencing allergies, it makes the symptom of a runny nose compromised, insofar as being only related to opioid withdrawal.

When all items have been scored according to the individual’s particular severity of symptoms, all the numbers are added up and their withdrawal can be judged on a scale from mild to moderate and, finally, severe.

  • 5-12 is considered to be mild
  • 13-35 is considered to be moderate
  • 36-48 is considered to be severe

Withdrawal Treatment and the Opioid Withdrawal Scale

According to the NIDA, “Easing withdrawal symptoms can be important in the initiation of treatment” even though treating withdrawal is not the same as treating addiction. Still the individual will need to receive the correct treatment in order to more easily get through withdrawal and to avoid the issue of relapse.

Some of the ways in which the opioid withdrawal scale influences withdrawal treatment, or medically-assisted withdrawal, are:

  • Clinicians can understand just how much pain patients are in which allows them to prescribe stronger medication if necessary.
    • According to SAMHSA, “Even mild levels of opioid use commonly produce uncomfortable levels of withdrawal symptoms,” but severe aches and pains can be extremely problematic as they may lead the individual to relapse. Without the proper treatment (especially medication), this can be very dangerous.
  • Clinicians can give patients a better timeline of their withdrawal symptoms.
    • It can help patients immensely to have more knowledge about what they are facing and how long it will last. By using the opioid withdrawal scale, doctors and nurses can know if a patient is likely to experience withdrawal for a few days or over a week and then be able to communicate that to the patient.
  • Clinicians can “monitor changes in the clinical status [of the patient] over time” (Vermont Buprenorphine Practice Guidelines).
    • The scale is not only used once but may be used multiple times so that the individual can receive the best care possible. In some instances, clinicians can see that the dosage the patient is on is extremely beneficial to them, while other times, they may realize that the patient isn’t making much progress and decide to up their dosage.

Treatment Facility Type

One of the biggest ways the scale influences treatment is by helping to dictate what type of facility the patient may need to attend according to their withdrawal symptoms. If the patient is

opioid addiction treatment.

If a patient is restless, uncomfortable or anxious, inpatient treatment is recommended.

  • Extremely restless, uncomfortable, or miserable, often to the point where they cannot sleep
  • Irritable or difficult to get along with
  • Highly anxious
  • In a great deal of pain
  • Very nauseous or experiencing severe diarrhea or vomiting

it may be necessary for them to be treated in an inpatient facility where they can be looked after 24 hours a day by professional caregivers. If, however, these symptoms are not as severe, the patient may be well suited to attending outpatient treatment. However, the scale can be a large factor in helping to determine if a patient should be in residential treatment, especially during their stabilization process.

Addiction Treatment and the Opioid Withdrawal Scale

The opioid withdrawal scale’s influence does not stop at withdrawal treatment. On the contrary, there are many ways that this assessment can help influence treatment for addiction as well. Some of these factors include

  • The length of time a patient will need to be maintained on medication
    • While withdrawal is a condition that can be treated with a careful tapering of the drug, an individual can also be maintained with the help of medication for a specific amount of time, making them unable to feel the full extent of withdrawal.
    • This is considered to be a treatment for addiction as well because it helps the individual stop abusing illicit or dangerous opioids with the use of stabilizing medications like methadone or buprenorphine.
    • The severity of a person’s opioid withdrawal scale score can help determine whether or not they may need long-term maintenance as opposed to medically-assisted withdrawal, even if they are shifted into the second option sometime later.
  • The likelihood of relapse
    • Understanding the severity of a patient’s withdrawal reaction will help clinicians be aware of the likelihood for relapse and the precautions that may need to be taken during addiction treatment (longer treatment times, more evaluations, etc.), helping them to provide treatment that can better avoid this issue.
  • The possibility of other, co-occurring disorders
    • If all other symptoms seem to subside with treatment except for the psychological ones, it could help the clinician realize that the patient may need additional treatment for a co-occurring mental disorder. For example, lingering anxiety after other symptoms have subsided may point to the possibility of anxiety disorder.

The opioid withdrawal scale actually influences treatment in many ways, and as such, should be performed continuously through medically-assisted withdrawal and into addiction treatment.


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