Reach for the COWS


    Reach for the COWS

    Your patient in intake is miserable. Doubled over, complaining of pain everywhere, sweating, ill-appearing but not unstable. He tells you that the last time he used heroin was two nights ago, and he is asking for help.

    How do you treat this patient? And how do you determine what medication would be appropriate? There are many non-opioid symptomatic treatments for opioid withdrawal, as well as several opioid-based treatments. Some of these are covered in an excellent prior pearl. The use of buprenorphine has gained popularity recently as an effective means of treating withdrawal in the acute setting and preventing future use. But when is buprenorphine appropriate for us to administer in the ED? Or, perhaps more importantly, when is it inappropriate? Buprenorphine can actually precipitate withdrawal if given to a patient who is not already in withdrawal; as a partial agonist with high affinity, it can boot a lower affinity full agonist from the opioid receptor. Use the Clinical Opiate Withdrawal Scale (COWS) assessment to assist with your decision:

    The algorithm below, in conjunction with the COWS score, can help you navigate this likely unfamiliar territory. For patients who are in mild-severe withdrawal (score of 8 or above), buprenorphine can be used to manage initial symptoms. Note, though, that securing close, reliable follow up for your patient is very important here. Unless your attending is X-waivered to prescribe buprenorphine for a few days (most aren’t), your patient will need immediate follow up. Talk with your social workers about arranging a 24-hour visit to an appropriate clinic. Fortunately, our patient was able to get an appointment with the Mount Sinai REACH clinic the next day, where he did obtain a prescription and further care.

    NIDA. Initiating Buprenorphine Treatment in the Emergency Department. Accessed at

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