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    Clinical Opiate Withdrawal Scale—Treatment

    Special Populations, Substance Use, Toxicology

    Last Updated Apr 28, 2021
    Read Disclaimer
    By Julian Marsden, Brenna Mackay


    Patients with Opioid Use Disorder (OUD) who are in withdrawal and receptive to treatment. OUD is a chronic relapsing illness associated with increased morbidity and mortality.

    • In 2016, BC declared a state of public health emergency in response to an alarming rise in overdose deaths.
    • 112% increase in drug toxicity-related deaths from September 2019 to September 2020.
    • Signs and symptoms of opioid withdrawal include flu-like symptoms, nausea, vomiting, diarrhea, sweating or chills, rhinorrhea, goosebumps, ab cramps, bone, and muscle aches, yawning, mydriasis, restlessness, anxiety, agitation, shaking or tremors, and a strong desire to use opioids.
    • The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale used to determine the severity of opiate withdrawal and to monitor symptoms over time.
    • Guides withdrawal interventions and is validated in both inpatient and outpatient settings.
      • COWS Scoring:
        • 5-12 = mild
        • 13-24 = moderate
        • 25-36 = moderately severe
        • >36 = severe withdrawal
      • The risk of precipitated withdrawal upon initiation of the first dose of buprenorphine/naloxone (Suboxone) is decreased if the patient is in at least moderate opioid withdrawal (COWS >12).

    Typical Course

    • Time between last opioid dose and the onset of moderate withdrawal (COWS score >12):


    Time since
    last dose


    Short-acting opioids 12-16 hrs Heroin, morphine, hydrocodone, immediate-release oxycodone
    Intermediate-acting opioids 17-24 hrs Slow-release oral morphine (Kadian), controlled-release hydromorphone, sustained-release oxycodone
    Long-acting opioids 30-48 hrs Methadone

    Recommended Treatment

    Withdrawal management in isolation is neither effective nor appropriate for treating OUD and puts patients at increased risk of relapse, overdose and infection (ie. HIV and Hep C).

    • Communicate the risks of withdrawal management as a standalone treatment and suggest initiating opioid agonist therapy (OAT) or a slower (ie. > 3 months) outpatient taper with Buprenorphine/naloxone (Suboxone) or methadone.
    • Consider an informed consent form should the patient choose to proceed with standalone withdrawal management against medical advice.
    • Suboxone is 1st line in most cases.
      • Available as 2mg/0.5mg or 8mg/2mg sublingual tablets—may be combined and halved to reach target dose.

    Approach to induction of Suboxone


    • Assessment:
      • Rule out contraindications for suboxone: allergy, severe respiratory distress, delirium tremens, acute alcohol intoxication, weigh risks and benefits if liver enzymes > 3-5 times normal.
    • Preparation:
        • Explain how suboxone works.
        • Review risks and benefits and obtain informed consent.
        • Complete COWS to assess the severity of withdrawal symptoms.
          • If, COWS score >12 and sufficient time since last opioid use (see in the ‘typical course’ section above), follow emergency department (ED) induction approach.
          • If, COWS score ≤ 12 and/or insufficient time since last opioid use, follow home induction approach.

    ED induction:

    • Ensure patient’s mouth is moist.
    • Administer 1st dose: Two x 2mg/0.5 mg bup/nlx tablets sublingually.
    • Repeat COWS to check for signs of precipitated withdrawal after 30-60 mins.
      • If feeling worse or COWS score increase: Stop—could be precipitated withdrawal.
      • If withdrawal symptoms are adequately relieved within 1-3 hrs, Day 1 of induction is complete—prescribe the same dose for Day 2.
      • If withdrawal symptoms are not adequately relieved give an additional dose to a maximum total of 12mg/3mg bup/nlx.
        • If unsure if an additional dose is required, consider prescribing a take-home dose that the patient can take PRN.
        • If symptoms are relieved after additional doses prescribe the total dose for the following day.
        • If symptoms not relieved with additional doses manage symptoms with non-opioid agents and continue induction the next day:
          • Clonidine tablets: 0.1-0.2 mg q4hrs PRN for <12 hrs
          • Oral anti-emetic, antidiarrheals, acetaminophen, NSAIDs PRN.
        • It is recommended the patient be seen in an addictions clinic the next day. If this isn’t possible prescribe enough suboxone dose(s) to sustain patient until they can be seen in the clinic.
        • Give patient dosing instructions and naloxone kit.

    Home induction:

    • Patient to monitor withdrawal symptoms using the subjective opiate withdrawal scale (SOWS)—wait until score is ³17 to begin.
    • Dispense Eight x 2mg suboxone tablets.
    • Provide take-home instructions on dosing and timing and a naloxone kit.
    • Schedule follow-up by phone or in-office and provide emergency contact information.
        • By the end of the first week:
          • Goal: To achieve stable once-daily dose of suboxone that keeps the patient symptom-free over a 24hr period.
          • Once the stable dose is achieved patients can be prescribed a 1–2-week supply of take-home doses or enrolled in a daily dispensing schedule at a community pharmacy.
          • Methadone treatment is 2nd line and should be considered for patients who have contraindications to suboxone or if the individual is responding poorly to suboxone.

    Criteria For Hospital Admission

    If home induction is not a feasible option, consider admitting the patient until they are at a sufficient level of withdrawal to initiate medication.

    Criteria For Close Observation And/or Consult

    • Repeat COWS every 30-60 mins after suboxone induction and perform routine monitoring.
    • Addiction medicine specialists are available for consult Mon-Fri 8:00 am-5:00 pm via the Rapid Access to Consultative Expertise (RACE) line.
      • Vancouver area: 604-696-2131
      • Toll-Free: 1-877-696-2141

    Criteria For Safe Discharge Home

    • Patient has been provided with a take-home naloxone kit and emergency contact information.
    • Schedule follow-up in the office or over the phone.
    • Ensure patient has enough suboxone to sustain them until their next appointment.

    Quality Of Evidence?


    • Based on National and Provincial clinical practice guidelines.

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