Clinical Withdrawal from Opioids

Whenever a disease or any other type of medical challenge exists in large numbers, has varying levels of severity, and a clear progression or deterioration based on either time or failure to participate in treatment, a scale must exist to rate patients.

Variations of these scales are present across the medical and mental health industries. Conditions like cancer, multiple sclerosis, and other chronic conditions are some of the more common disorders that require the use of a score or scale.

Unfortunately, one of the most frequently used types of scores in existence today is the COWS score, which is associated with opiate abuse disorder. What is a COWS score, and how is it effective in the treatment of opiate abuse disorder?

What Is a COWS Score?

The Clinical Opiate Withdrawal Scale is a mode developed with 11 items based on withdrawal symptoms and side effects. This scale helps physicians determine the level of a client’s physical dependence on opiates or opioids.

Individuals with the goal of entering medically-assisted detox and treatment are the primary subjects of these models. The primary focus is on assessing the dangers a client might face by going through the detox process and understanding withdrawal symptoms’ potential severity.

Currently, COWS is the most heavily used scale for determining the potential severity of withdrawals. However, over the last 80 years, multiple different models have been used, focusing on different criteria and scoring methods. The following section highlights some of the more common scales employed in the past.

A History of Opiate Withdrawal Scales

The following list contains all the most commonly used systems of measurement used over the last 80 years to determine the severity of opiate withdrawals. The first model was formulated in 1939, and the latest is the COWS system. This list highlights these two and everything in between with the scale items and rating criteria.

COWS Score for Opiate Withdrawal

Kolb and Himmelsbach Scale

  • 14 items
  • Point-based

Himmelsbach Scale

  • 14 items
  • Point-based

SDQ1 or Fraser Scale

  • 6 clinician items, 4 patient items
  • Weighted 5-point scale


  • 550 items
  • True or False


  • 29 Items
  • 5-point scale


  • 84 items
  • True or False


  • 80 items
  • True or False

Short Form ARCI

  • 49 items
  • True or False

Wang Scale

  • 10 items
  • Points-based

Judson Scale

  • 10 clinician-administered items, 7 patient-reported items
  • 4-point scale


  • 32 items
  • 4-point scale


  • 16 items (Patient-reported)
  • 5-point scale
COWS Score for Opiate Withdrawal


  • 13 items (Clinician-administered
  • Present/Absent


  • 16 items (Patient-reported)
  • 10-point scale


  • 13 items (Clinician-administered)
  • Point-based


  • 10 (Patient-reported)
  • 4-point scale


  • 20 items (Patient-reported)
  • Anchored 100 mm analog scale


  • 11 items (Clinician- administered)
  • Weighted scale


The primary difference between these methods is whether they are clinician-administered or patient-reported. When these scales are patient-reported, users must answer a set of questions, including true or false, and points-based systems. The questions center around the presence of withdrawal symptoms and their potential severity.

Instead of answering past and present opiate abuse questions, clinician-administered scales include physicians performing one of several physical checks up. During these physicals, the practitioner is looking for visible signs of withdrawal. Once the physician is satisfied, each item is totaled using a numerical value.

A higher value correlates with more severe withdrawal symptoms possible challenges during detox. Even though these scales specifically mention opiates, they are appropriate for measuring opiate or opioid withdrawal. Although they are two separate terms with different substances falling under these classifications, they’re very similar in the way they act on the body before and during withdrawal.

Opiates vs. Opioids

Many people have views on opiates and opioids that aren’t completely accurate and being educated about these two drug classifications is important for the COWS score and detox.


Opiates fall under the category of opioids. Every opiate is an opioid, but not every opioid is an opiate.

The term opiate is used to describe natural opioids such as heroin, morphine, and codeine. These substances are created strictly from plant matter from the opium poppy.


An opioid is an umbrella term for any natural, synthetic, and semi-synthetic opioid. For example, semi-synthetics are oxycodone, hydrocodone, and hydromorphone. These substances have a natural base but have been altered synthetically to create the final formulation. Complete synthetics include drugs like fentanyl and methadone. These substances are completely lab-made and have no plant derivatives.

Whether a client has a history of opiate or opioid abuse, the end results are the same. Intense withdrawal symptoms that are similar in each case accompany any of these drugs.

What are Common Withdrawal Symptoms?

Although withdrawal symptoms may vary slightly from person to person and range in severity depending on the substance and length of abuse, several symptoms are expected during detox.

  • Frequent, intense yawning
  • Watery eyes
  • Feeling generally uncomfortable
  • Hot and cold spells
  • Frequent sweating
  • Shivering/shaking
  • Goosebumps
  • Irritability
  • Anxiety
  • Depression
  • Nausea
  • Vomiting
  • Muscle aches
  • Fatigue
  • Insomnia
  • Intense, vivid nightmares
  • Intense cravings
  • Rapid heart rate
  • High blood pressure

You don’t have to abuse an illegal opioid to experience the symptoms listed above. Many individuals fall into substance abuse disorder because of an overuse of prescription drugs. It’s important that you’re aware of how much pain medication you are taking and how this equates to your chances of dependence and eventually withdrawal symptoms.

How Much Pain Medication are You Taking?

Are you under a specific regimen of pain medication? Are you prescribed multiple types of pain medications? Whenever pain medication is part of your healthcare regimen, these are all critical questions to ask whenever pain medication becomes a part of your healthcare regimen.

You must remain aware of your intake of pain medication and not fall into overuse by not following your physician’s recommended dosage. Once you enter a routine of pain medication, it’s easy to develop a tolerance and eventually return for additional prescriptions.

If you’re taking more than the recommended dosage amounts or running out of your medication early, these could be warning signs of physical dependence. This is especially true if these signs are accompanied by the urge to become intoxicated on your medication. However, these aren’t even the most severe risks associated with overusing pain medication.

The growing risks of opioid overdose doesn’t encompass heroin and fentanyl only. Individuals who overuse their medication, or even worse, look to the streets for pills, are a large portion of the growing risks of opioid overdose.

The Growing Risks of Opioid Overdose

As more people begin to fall into the cycles of opiate use disorders, the risk of overdose will continue to grow. In 2021, the United States experienced the highest number of deaths associated with opioid overdose in a single year.

Fentanyl was responsible for a number of those deaths. However, a large portion of this fentanyl was consumed in forms that might surprise you.

There were, of course, a fair share of deaths associated with street fentanyl or fentanyl marketed as heroin that IV heroin users inject. Another large portion was caused by pills marketed as medications like hydrocodone and oxycodone but instead contained deadly amounts of fentanyl.

This is proof that nobody is safe from the looming dangers of opioids, regardless of the form they come in. If you’re concerned with your potential condition entering detox or coping with the symptoms of withdrawal, you may want to be assessed using the COWS method.

It’s critical that you understand how COWS works so you can consider this assessment as a stepping stone to medication-assisted treatment.

How Does COWS Work?

Authorities on substance abuse disorder recommend that any patients experiencing withdrawal be monitored several times daily for symptoms and ensure no complications arise. A great majority of physicians use the Clinical Opioid Withdrawal Scale for monitoring clients because of the efficiency, accuracy, and effectiveness of this particular model.

COWS assigns numbers to 11 different withdrawal symptoms and then adds them together to determine their severity. This scale will give physicians a good idea of how far into the detox process a client has advanced.

After a client’s situation is more clearly understood, physicians and counselors can determine the next step of the recovery plan. The 11 items used on the scale are as follows:

  • Resting Pulse Rate
  • Gastrointestinal Upset
  • Sweating
  • Tremors
  • Restlessness
  • Yawning
  • Pupil Size
  • Anxiety and Irritability
  • Bone and Joint Aches
  • Goosebumps
  • Runny Nose or Watery Eyes

After understanding the severity of each of these items, physicians can recommend the most appropriate options for the rest of the detox and the initial phases of treatment. Medication-assisted treatment can be incredibly effective when used in conjunction with the COWS model.

COWS Score for Opiate Withdrawal

The MAT and COWS Combo

Once the COWS model has been implemented, physicians have a more accurate picture of exactly where a client lies when it comes to the detox process. Medication-assisted treatment becomes an option when a client makes it far enough into detox.

Medication-assisted treatment has been successful in promoting long-term recovery. However, many of these treatments have specific requirements regarding abstinence from opioids before starting a regimen. Listed below are some common examples.


Methadone maintenance is effective in helping clients avoid the intense symptoms of withdrawal. This medication can be taken much earlier than other MAT options, but a window of abstinence is still required. Most physicians recommend a period of at least 12-24 hours, and the individual must be in full-blown withdrawal.


Suboxone is similar to methadone in the way it helps avoid withdrawal symptoms. However, because Suboxone is a partial agonist, it acts on the receptors differently. Because of this, a long period of abstinence is required before starting this treatment. COWS can be very helpful in determining when to begin Suboxone treatment.

It’s recommended that clients are in the most intense stages of withdrawal before beginning Suboxone (36-48 hours since last opioid use). Failure to follow this requirement will lead to precipitated withdrawal.

Both of these options are available as standalone treatments and as a part of medically-supervised detox. Consider the benefits of medically-supervised detox before making your final decision on recovery and MAT options.

The Benefits of Medically-Supervised Detox

Client chances for successful recovery increase significantly when medically-supervised detox is included in the recovery process. There are multiple benefits to choosing this specific form of detox instead of the cold-turkey version.

  • Guided detox from a team of medical professionals and mental health workers gives you the support and assistance you need to make it through the most intense periods of withdrawal.
  • Additionally, besides MAT options, physicians may also prescribe temporary relief in the form of benzodiazepines, muscle relaxers, mood stabilizers, promethazine, and clonidine for blood pressure and heart rate.
  • Access to group recovery and counseling sessions can be beneficial. Engaging with other clients going through treatment can be inspiring and adds a social element needed for keeping a positive attitude.

Easing Into Long-term Recovery

After completing treatment, it’s critical that clients take their time easing into long-term recovery. The process of recovery takes building, and it’s vital that no important elements are skipped. Having the proper avenues for therapy will help clients prepare for coping with real-life situations after treatment.

At Pathfinders Recovery Centers, we specialize in treating clients for opiate abuse disorder and the underlying mental health challenges associated with this condition. We also use the COWS model to constantly monitor clients, ensuring a safe detox leads to efficient treatment.

If you’re ready to start your journey to recovery, contact one of our admissions specialists today.


  • 7580 E Gray Rd Suite 201 Scottsdale, AZ 85260
  • (877) 224-0761
  • Mon-Sun: 24x7


  • 2953 S Peoria St. Suite 230 Aurora, CO 80014
  • (877) 224-0761
  • Mon-Sun: 24x7

Our Newsletter

See how much of your treatment is covered by insurance

(877) 224-0761

Addiction Counselor Available 24/7

Skip to content