How to Use the COWS Scale: Facility Guide and FAQ
The opioid crisis continues to be a pressing public health challenge, accounting for roughly 75% of drug-related deaths nationwide. In the past few decades, several initiatives, programs, and tools have been created to help address this ongoing issue in the healthcare sphere. When it comes to the direct treatment of opioid use disorder (OUD), the Clinical Opioid Withdrawal Scale, or COWS scale, has become a popular instrument used for withdrawal management.
If you’re looking for ways to improve care and outcomes at your facility, you may be considering adoption of the COWS opioid withdrawal scale. To help you with this process, we’ll answer some of the most frequently asked questions about COWS and outline three essential tips for implementation.
What Is the COWS Scale?
The Clinical Opioid Withdrawal Scale (COWS) is an 11-item instrument that healthcare providers use to assess signs and symptoms of opioid withdrawal in patients. The total COWS score infers how severe a patient’s symptoms are and their opioid dependency level. By conducting regular assessments, providers are able to monitor a patient’s withdrawal symptoms over time and evaluate how they’re responding to treatments.
What’s On the COWS Withdrawal Scale?
There are 11 total items on the Clinical Opioid Withdrawal Scale, each measuring a different sign or symptom of opioid withdrawal. These signs and symptoms include:
- Resting pulse rate
- Sweating
- Restlessness
- Pupil size
- Bone or joint aches
- Runny nose or tearing
- GI upset
- Tremor
- Yawning
- Anxiety or irritability
- Gooseflesh skin
Healthcare providers are asked to rate how visible or apparent each sign or symptom is in a patient. Each item has a different rating system, and the exact definitions and rating systems for each item can be found on the full COWS assessment scale.
How Is the COWS Scale Administered?
The COWS assessment can be used in both inpatient and outpatient settings and is designed to be administered by licensed healthcare providers. When conducting a COWS assessment, the provider will typically observe the patient and ask them questions to measure the severity of the 11 symptoms on the scale. They will then circle the number rating that most closely describes each individual symptom.
How Do You Calculate a COWS Score? Example
To calculate a COWS score, providers simply need to add up the number that is circled for each respective item. To provide a more detailed example, we’ll walk through a hypothetical assessment below.
Example scenario: You walk into a patient’s room to conduct a COWS assessment. Upon entering, you notice that the patient is restlessly tapping their foot and walking around. Their face looks pink and their eyes seem to be more watery than usual. Upon closer assessment, you feel that the patient has slight tremors in their hands, but their skin feels smooth. Their pupils appear slightly dilated under room light. The patient also reports nausea, mild joint pain, and is irritated during the assessment. They’re wide awake with a resting heart rate of 110.
Example scenario scoring:
Based on the assessment above and referencing the full COWS instrument, we’ll rate each sign and symptom as follows:
|
|
|
|---|---|
| COWS Item | Rating |
| Resting Pulse Rate | 2 (pulse rate 101-120) |
| Sweating | 2 (flushed or observable moistness on face) |
| Restlessness | 3 (frequent shifting or extraneous movements of legs/arms) |
| Pupil Size | 1 (pupils possibly larger than normal for room light) |
| Bone or Joint Aches | 1 (mild diffuse discomfort) |
| Runny Nose or Tearing | 2 (nose running or tearing) |
| GI Upset | 2 (nausea or loose stool) |
| Tremor | 1 (tremor can be felt, but not observed) |
| Yawning | 0 (no yawning) |
| Anxiety or Irritability | 2 (patient obviously irritable anxious) |
| Gooseflesh Skin | 0 (skin is smooth) |
If we add up the points for each item, we get a total COWS score of 16. Now, let’s take a look at the COWS scale scoring guidelines provided on the instrument:
- 5-12 = mild withdrawal
- 13-24 = moderate withdrawal
- 25-36 = moderately severe withdrawal
- > 36 = severe withdrawal
Based on this scoring system, we can conclude that the patient in this example has moderate withdrawal, since their score (16) falls between 13 and 24.
The exact treatment protocol informed by this score will depend on the substance that a patient is being weaned off of and can also vary by facility. However, patients with more severe withdrawal typically require a more intensive treatment plan.
What Is the Difference Between COWS and CIWA?
The COWS opioid withdrawal scale is derived from an older tool called the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA). The main difference between these two instruments is that COWS is used to assess symptoms of opioid withdrawal, while CIWA is used to assess symptoms of alcohol withdrawal. Both follow a similar method of administration.
Using the COWS Scale: 3 Tips for Facilities
The COWS withdrawal scale should be used to supplement thoughtful, clinical decision-making, as part of a more comprehensive treatment protocol. These three tips will help you effectively implement this tool at your facility.
1. Train Staff on Uses and Implications
The COWS assessment scale requires healthcare providers to make subjective clinical observations. As such, experts recommend providing thorough education and training so that staff understand how to rate each item on the scale. This will also ensure that staff are able to feel more confident in educating patients about their withdrawal symptoms. At baseline, your training should include:
- Instructions on what the tool is and how it’s used.
- Hypothetical scenarios that allow staff to practice rating and scoring items.
- Education on COWS score interpretation and implications for care.
2. Make Staff Aware of the Instrument’s Limitations
While the utility of the COWS scale has been well-validated by research, two common critiques of this tool are its subjectivity and lack of focus on psychological symptoms. It’s important to make staff aware of these limitations so that they’re reminded to exercise their best clinical judgment.
For example, there may be other reasons why a patient is experiencing some of the symptoms listed on the COWS tool at any given moment. This is why staff should consider the patient’s conditions and medical history in a holistic manner when using the tool to inform care decisions.
3. Streamline Use by Implementing Clear Protocols
Remember, the COWS assessment should be used to monitor a patient’s withdrawal symptoms and inform ongoing treatment decisions. As such, it’s important to outline clear protocols that describe how and when the tool should be used at your facility. These protocols should include:
- How often assessments should be conducted.
- Which staff are responsible for conducting and documenting assessments.
- What care steps should be taken for each score range.
As an example of what implementation of this tool can look like, you can refer to Vanderbilt University Medical Center’s COWS protocol. Treatment steps for each score range are clearly outlined, in addition to how often the assessments should be administered.
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As a facility leader, adopting the COWS scale is likely one of many tasks on your to-do list. We understand that you’re busy, and we’re here to give you the information you need, when you need it. Discover dozens of other helpful facility management tips and insights through IntelyCare’s free newsletter.