The Clinical Opiate Withdrawal Scale (COWS)
TL;DR: The history of opiate withdrawal scales is reviewed and a template version of the COWS that can be copied and used clinically is appended.
Abstract: The clinical opiate withdrawal scale (COWS) is a clinician-administered, pen and paper instrument that rates eleven common opiate withdrawal signs or symptoms. The summed score of the eleven items can be used to assess a patient's level of opiate withdrawal and to make inferences about their level of physical dependence on opioids. With increasing use of opioids for treatment of pain and the availability of sublingual buprenorphine in the United States for treatment of opioid dependence, clinical assessment of opiate withdrawal intensity has received renewed interest. Buprenorphine, a partial opiate agonist at the mu receptor, can precipitate opiate withdrawal in patients with a high level of opioid dependence who are not experiencing opioid withdrawal. Since development of the first opiate withdrawal scale in the mid-1930s, many different opioid withdrawal scales have been used in clinical and research settings. This article reviews the history of opiate withdrawal scales and the context of their initial use. A template version of the COWS that can be copied and used clinically is appended. PDF formatted versions of the COWS are also available from the websites of the American Society of Addiction Medicine, the California Society of Addiction Medicine, the UCLA Integrated Substance Abuse Programs, and AlcoholMD.com.
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TL;DR: Among opioid-dependent patients, ED-initiated buprenorphine treatment vs brief intervention and referral significantly increased engagement in addiction treatment, reduced self-reported illicit opioid use, and decreased use of inpatient addiction treatment services but did not significantly decrease the rates of urine samples that tested positive for opioids or of HIV risk.
Abstract: RESULTS Seventy-eight percent of patients in the buprenorphine group (89 of 114 [95% CI, 70%-85%]) vs 37% in the referral group (38 of 102 [95% CI, 28%-47%]) and 45% in the brief intervention group (50 of 111 [95% CI, 36%-54%]) were engaged in addiction treatment on the 30th day after randomization (P < .001). The buprenorphine group reduced the number of days of illicit opioid use per week from 5.4 days (95% CI, 5.1-5.7) to 0.9 days (95% CI, 0.5-1.3) vs a reduction from 5.4 days (95% CI, 5.1-5.7) to 2.3 days (95% CI, 1.7-3.0) in the referral group and from 5.6 days (95% CI, 5.3-5.9) to 2.4 days (95% CI, 1.8-3.0) in the brief intervention group (P < .001 for both time and intervention effects; P = .02 for the interaction effect). The rates of urine samples that tested negative for opioids did not differ statistically across groups, with 53.8% (95% CI, 42%-65%) in the referral group, 42.9% (95% CI, 31%-55%) in the brief intervention group, and 57.6% (95% CI, 47%-68%) in the buprenorphine group (P = .17). There were no statistically significant differences in HIV risk across groups (P = .66). Eleven percent of patients in the buprenorphine group (95% CI, 6%-19%) used inpatient addiction treatment services, whereas 37% in the referral group (95% CI, 27%-48%) and 35% in the brief intervention group (95% CI, 25%-37%) used inpatient addiction treatment services (P < .001).
613 citations
TL;DR: This Practice Guideline was developed using the RAND Corporation (RAND)/University of California, Los Angeles (UCLA) Appropriateness Method – a process that combines scientific evidence and clinical knowledge to determine the appropriateness of a set of clinical procedures.
Abstract: The Centers for Disease Control have recently described opioid use and resultant deaths as an epidemic. At this point in time, treating this disease well with medication requires skill and time that are not generally available to primary care doctors in most practice models. Suboptimal treatment has likely contributed to expansion of the epidemic and concerns for unethical practices. At the same time, access to competent treatment is profoundly restricted because few physicians are willing and able to provide it. This "Practice Guideline" was developed to assist in the evaluation and treatment of opioid use disorder, and in the hope that, using this tool, more physicians will be able to provide effective treatment. Although there are existing guidelines for the treatment of opioid use disorder, none have included all of the medications used at present for its treatment. Moreover, few of the existing guidelines address the needs of special populations such as pregnant women, individuals with co-occurring psychiatric disorders, individuals with pain, adolescents, or individuals involved in the criminal justice system. This Practice Guideline was developed using the RAND Corporation (RAND)/University of California, Los Angeles (UCLA) Appropriateness Method (RAM) - a process that combines scientific evidence and clinical knowledge to determine the appropriateness of a set of clinical procedures. The RAM is a deliberate approach encompassing review of existing guidelines, literature reviews, appropriateness ratings, necessity reviews, and document development. For this project, American Society of Addiction Medicine selected an independent committee to oversee guideline development and to assist in writing. American Society of Addiction Medicine's Quality Improvement Council oversaw the selection process for the independent development committee. Recommendations included in the guideline encompass a broad range of topics, starting with the initial evaluation of the patient, the selection of medications, the use of all the approved medications for opioid use disorder, combining psychosocial treatment with medications, the treatment of special populations, and the use of naloxone for the treatment of opioid overdose. Topics needing further research were noted.
519 citations
Cites background or methods from "The Clinical Opiate Withdrawal Scal..."
...Moderate withdrawal would equate to a score greater than 12 on the COWS.(64) An initial dose of 2–4 mg of buprenorphine should be given and the patient should be observed for 1 hour....
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...Clinical Opioid Withdrawal Scale (COWS) is a clinical assessment for 11 medical signs and symptoms of opioid withdrawal (eg, gastrointestinal distress).(64) Subjective Opioid Withdrawal Scale (SOWS) is a measure of 16 subjective symptoms of withdrawal, in which the patient rates their experience on a 5-point scale (eg, ‘‘I feel restless’’)....
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...The use of the COWS can be helpful in determining if patients are experiencing mild to moderate withdrawal.(64) A COWS score of 11–12 or more (mild to moderate withdrawal) is indicative of sufficient withdrawal to allow a safe and comfortable induction onto buprenorphine....
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TL;DR: It is concluded that "food addiction" is a misnomer because of the ambiguous connotation of a substance-related phenomenon, and is proposed the term "eating addiction" to underscore the behavioral addiction to eating.
402 citations
Cites background from "The Clinical Opiate Withdrawal Scal..."
...Opiate dependence is manifested by a withdrawal syndrome that can also be triggered by administration of the opiate antagonist naloxone (Wesson and Ling, 2003)....
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DOI•
01 Jan 2009
TL;DR: The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Abstract: The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. 1.Opioid-related disorders-drug therapy. 2.Opioid-related disorders-psychology. 3.Substance abuse-prevention and control. 4.
397 citations
TL;DR: A general approach to identifying and treating opioid-use disorders is outlined.
Abstract: Opioid-use disorders are common, but most physicians are not trained to recognize and treat them. This review outlines a general approach to identifying and treating these disorders.
376 citations
Cites background from "The Clinical Opiate Withdrawal Scal..."
...Data are from Wesson and Ling.(18) † Only pain that is directly linked to withdrawal from opiates should be scored....
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...Data are from Wesson and Ling.18 † Only pain that is directly linked to withdrawal from opiates should be scored....
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References
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TL;DR: A shortened 10-item scale for clinical quantitation of the severity of the alcohol withdrawal syndrome has been developed and can be incorporated into the usual clinical care of patients undergoing alcohol withdrawal and into clinical drug trials of alcohol withdrawal.
Abstract: A shortened 10-item scale for clinical quantitation of the severity of the alcohol withdrawal syndrome has been developed. This scale offers an increase in efficiency while at the same time retaining clinical usefulness, validity and reliability. It can be incorporated into the usual clinical care of patients undergoing alcohol withdrawal and into clinical drug trials of alcohol withdrawal.
1,578 citations
TL;DR: In this paper, two rating scales for measuring the signs and symptoms of opiate withdrawal are presented: Subjective Opiate Withdrawal Scale (SOWS) contains 16 symptoms whose intensity the patient rates on a scale of 0 (not at all) to 4 (extremely).
Abstract: Two new rating scales for measuring the signs and symptoms of opiate withdrawal are presented. The Subjective Opiate Withdrawal Scale (SOWS) contains 16 symptoms whose intensity the patient rates on a scale of 0 (not at all) to 4 (extremely). The Objective Opiate Withdrawal Scale (OOWS) contains 13 physically observable signs, rated present or absent, based on a timed period of observation of the patient by a rater. Opiate abusers admitted to a detoxification ward had significantly higher scores on the SOWS and OOWS before receiving methadone as compared to after receiving methadone for 2 days. Opiate abusers seeking treatment were challenged either with placebo or with 0.4 mg naloxone. Postchallenge SOWS and OOWS scores were significantly higher than prechallenge scores in the naloxone but not the placebo group. We have demonstrated good interrater reliability for the OOWS and good intrasubject reliability over time for both scales in controls and in patients on a methadone maintenance program. These scales are demonstrated to be valid and reliable indicators of the severity of the opiate withdrawal syndrome over a wide range of common signs and symptoms.
467 citations
01 Jan 1987
TL;DR: Good interrater reliability for the OOWS and good intrasubject reliability over time for both scales are demonstrated to be valid and reliable indicators of the severity of the opiate withdrawal syndrome over a wide range of common signs and symptoms.
Abstract: Two new rating scales for measuring the signs and symptoms of opiate withdrawal are presented. The Subjective Opiate Withdrawal Scale (SOWS) contains 16 symptoms whose intensity the patient rates on a scale of 0 (not at all) to 4 (extremely). The Objective Opiate Withdrawal Scale (OOWS) contains 13 physically observable signs, rated present or absent, based on a timed period of observation of the patient by a rater. Opiate abusers admitted to a detoxification ward had significantly higher scores on the SOWS and OOWS before receiving methadone as compared to after receiving methadone for 2 days. Opiate abusers seeking treatment were challenged either with placebo or with 0.4 mg naloxone. Postchallenge SOWS and OOWS scores were significantly higher than prechallenge scores in the naloxone but not the placebo group. We have demonstrated good interrater reliability for the OOWS and good intrasubject reliability over time for both scales in controls and in patients on a methadone maintenance program. These scales are demonstrated to be valid and reliable indicators of the severity of the opiate withdrawal syndrome over a wide range of common signs and symptoms.
413 citations
"The Clinical Opiate Withdrawal Scal..." refers background in this paper
...Objective Opiate Withdrawal Scale (OOWS) The Objective Opiate Withdrawal Scale (OOWS) is a 13 -item scale on which each sign is rated as absent or present during a time period during which the patient is observed (see Table 3)....
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...Volume 35 (2), April - June 2003 TABLE 3 The Objective Opiate Withdrawal Scale (Handelsman et al. 1987) Item I ....
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TL;DR: The processes whereby a shorter 10-item version of the Opiate Withdrawal Scale was developed are described, suggesting that the SOWS provide a useful instrument which can be used both in research and clinical practice with opiate addicts.
236 citations
"The Clinical Opiate Withdrawal Scal..." refers background in this paper
...TABLE 4 The Short Opiate Withdrawal Scale (Gossop 1990) Item Feeling sick Stomach cramps Muscle spasms/twitching Feelings of coldness Heart pounding Muscular tension Aches and pains Yawning Runny eyes Insomnia/problems sleeping 0 None 1 Mild 2 Moderate 3 Severe Patients were asked to put a check in the column if they had suffered from any of the following conditions within the past 24 hours....
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...The total score was the sum of analogue scores for all 20 items. methadone, the 32-item scale and the 10-item scale showed a 0.97 correlation (Gossop 1990)....
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...TABLE 4 The Short Opiate Withdrawal Scale (Gossop 1990)...
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...TABLE 4 The Short Opiate Withdrawal Scale (Gossop 1990) Item Feeling sick Stomach cramps Muscle spasms/twitching Feelings of coldness Heart pounding Muscular tension Aches and pains Yawning Runny eyes Insomnia/problems sleeping 0 None 1 Mild 2 Moderate 3 Severe Patients were asked to put a check in…...
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210 citations
"The Clinical Opiate Withdrawal Scal..." refers background in this paper
...Their paper was subsequently published in the Journal of Clinical Psychiatry (Kolb & Himmelsbach 1938)....
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