Opioids are a class of drugs that include heroin, fentanyl, and prescription painkillers like oxycodone, hydrocodone, codeine, and morphine. These drugs are often prescribed to manage pain, but they also carry a high risk of dependence and addiction. When someone uses opioids regularly, their brain and body start to rely on the drug to feel “normal.” Over time, brain chemistry actually adapts to the constant presence of opioids.
So, when the opioids are suddenly reduced or stopped—whether by choice, running out of a prescription, or trying to quit—the body reacts. This reaction is called opioid withdrawal. Withdrawal is not usually life-threatening, but it can be incredibly uncomfortable, with symptoms like anxiety, sweating, nausea, body aches, and chills. Because these symptoms can look a lot like the flu, families may not realize what’s really going on. That’s where COWS comes in.
What is COWS?
COWS stands for the Clinical Opiate Withdrawal Scale, an 11-item tool that healthcare providers use to measure and track how bad a person’s opioid withdrawal is.1 Think of it as a checklist doctors and nurses use to figure out how uncomfortable a person is, how withdrawal is progressing, and when it might be safe to start treatment like buprenorphine/naloxone (Suboxone).
The scale looks at things like:
- Resting pulse rate
- Sweating
- Restlessness
- Pupil size
- Bone or joint aches
- Runny nose or tearing
- Stomach upset (nausea, vomiting, diarrhea)
- Tremors
- Yawning
- Anxiety or irritability
- Gooseflesh skin (goosebumps)
Each symptom gets a score, and the total adds up to show whether withdrawal is mild, moderate, or severe. For example, a score of 5–12 suggests mild withdrawal, while anything above 25 is considered moderately severe to severe.
How COWS Is Used in Healthcare Settings
In clinics, hospitals, and emergency departments, COWS is a trusted guide. Here’s how it’s used:
- Emergency departments: Before starting someone on buprenorphine, providers check the COWS score. If it’s above 12 (moderate withdrawal), that’s usually the safe point to begin.
- Monitoring progress: Doctors and nurses often repeat COWS scoring every 30–60 minutes during withdrawal treatment to make sure symptoms are improving.
- Treatment planning: The score helps determine the right dose of medication and whether a person needs more intensive care.
One of the biggest reasons COWS is so valuable is that it helps prevent something called precipitated withdrawal. This happens when someone takes a medication like buprenorphine (Suboxone) too soon after their last opioid use. This sudden switch triggers rapid and severe withdrawal symptoms, often much worse than regular withdrawal.
By waiting until a person reaches a moderate COWS score, providers can be confident that most opioids are out of the system and the risk of precipitated withdrawal is low. This makes the start of medication treatment safer and more comfortable.
Home Treatment Plans
Sometimes loved ones may begin withdrawal management at home. In these cases, people might use the Subjective Opiate Withdrawal Scale (SOWS) themselves until symptoms necessitate starting medication.2 This is a tool that examines many of the same symptoms that are included in COWS, but instead of relying on a healthcare provider’s observations, SOWS asks a loved one to report on how they feel including their aches, nausea, anxiety, and cravings. Once they start to feel sick from their withdrawal symptoms, they can start taking medication to help like buprenorphine.3 It’s important that any home care like this be done with the support of a healthcare professional. This includes getting medications from a reputable pharmacy and having naloxone (e.g., Narcan) on hand to reverse an overdose in case of an emergency.
When Families Might Mistake Withdrawal for the Flu
Here’s where things get tricky. At home, withdrawal can look a lot like an everyday illness. Families might see:
- Muscle aches, restlessness, yawning → looks like fatigue from a bad cold
- Sweating, chills, nausea, diarrhea → the same as food poisoning or the flu
- Runny nose, watery eyes, sneezing → typical sinus infection signs
- Anxiety, irritability, insomnia → might be chalked up to stress
- Dilated pupils or goosebumps → these are more unique to withdrawal, but easy to miss if you’re not looking for them
Because withdrawal symptoms overlap so much with the flu, it’s easy for families to misinterpret what’s happening. If someone recently reduced or stopped opioid use and suddenly seems “flu-ish,” it might not be a bug—it could be opioid withdrawal. Recognizing the difference can help families get their loved one the right help sooner.
Why This Matters
If you’re reading this because you’re trying to understand opioid withdrawal symptoms at home, you’re doing something incredibly caring. Here’s what to watch for:
- Flu-like symptoms that don’t follow the usual pattern (e.g., sudden onset despite no exposure to virus).
- Uncharacteristic anxiety, extreme restlessness, or unmanageable GI upset.
- A loved one who just recently stopped opioids—whether intentionally or not.
Remind yourself: It could be withdrawal—and COWS isn’t just for clinicians, but knowing about it could prompt you to seek medical help early. If you need help understanding what is happening with your loved one, connect with our helpline specialists. They can help you develop a plan and guide you to additional resources. Their support is free and confidential.