COWS Scale

Tiny Tips: The COWS Scale

In Tiny Tips, TipsForEMExams by Isabelle GrayLeave a Comment

As the opiate crisis continues to escalate, emergency departments are seeing higher numbers of patients with complaints and complications related to opiate use disorder. There is strong evidence for opiate agonist treatment in preventing opiate related deaths. Additionally, Suboxone (buprenorphine-naloxone) is the recommended first line treatment.​1​

Suboxone Treatment

For a full Suboxone start, a patient is required to be in moderate withdrawal, meaning a Clinical Opiate Withdrawal Scale (COWS) score of greater than 12.​2​ A “full start” initiation of Suboxone is straightforward, with few contraindications, and starts at 4 mg orally, followed by 4 mg orally every 2 hours until symptoms resolve, up to a Day 1 maximum of 12 mg.​3​ To remember this, simply recall the number 12 (COWS >12 and max dose on day 1 of 12 mg).

COWS Scale Mnemonic

If you are at the bedside without the COWS scale (or if you’re cramming knowledge for an exam), here is an easy mnemonic to remember the components of the scale: “STOP TRYING Joints”

S – Sweating

T – Tremor

O – pupil size (O looks like a pupil)

P – Piloerection

T – Tachycardia 

R – Restlessness

Y – Yawning

I – Irritability or anxiety

N – Nose running or eyes tearing

G – GI upset (vomiting / diarrhea)

Joints – joint pain or bone pain

In addition to opiate agonist treatment, don’t forget other adjuncts for opiate withdrawal (including clonidine and loperamide). For more information on Suboxone induction, check out this great quick reference guide.

This post was copyedited by Nicholas Swanson.

  1. 1.
    Bruneau J, Ahamad K, Goyer M, et al. Management of opioid use disorders: a national clinical practice guideline. CMAJ. 2018;190(9):E247-E257. doi:10.1503/cmaj.170958
  2. 2.
    Provincial Opioid Use Disorder Treatment Guideline Committee. Guidelines for the Clinical Management of Opioid Use Disorder. British Columbia Centre on Substance Use. Published June 5, 2017.
  3. 3.
    Wesson D, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253-259. doi:10.1080/02791072.2003.10400007

Isabelle Gray

Izzy is an Assistant Professor in Emergency Medicine at Queen's University in Kingston. Her interests include medical education, evidence-based medicine and research. When not working, studying or running after her children, she can be found adventuring in the mountains. No conflicts of interest.

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