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Diagnosis and Treatment of Opioid Use Disorders
Published in James M. Rippe, Lifestyle Medicine, 2019
Managing opioid withdrawal symptoms is aided by using two scales that measure the severity of withdrawal symptoms. The Subjective Opiate Withdrawal Scale (SOWS) is an 18-item scale designed to be self-administered to rate common signs and symptoms of opioid withdrawal and monitor these symptoms over time (Figure 93.3).13 The Clinical Opiate Withdrawal Scale (COWS), shown in Figure 93.4, is an 11-item self-report scale that measures the severity of opioid withdrawal symptoms from the clinician’s perspective.14 The integration of clinical observations from the COWS and subjective observations from the patient’s perspective gives a fair overall assessment of the severity of withdrawal.
Diagnostics
Published in R. Andrew Chambers, The 2 × 4 Model, 2017
COWS: The Clinical Opiate Withdrawal Scale, is a rapid rating tool that quantifies the severity of opioid withdrawal. It is a multi-item scale that uses a combination of objective observations and self-reports, with a max score of 49 (severe withdrawal). The scale is a good adjunct to the vital sign data in assessing withdrawal and is rapidly repeatable, being sensitive to changes in symptoms on the order of minutes (e.g., with office dosing of buprenorphine). It is a handy way for the clinician to keep in mind the many features of opioid withdrawal. The major drawback of the scale is it lacks specificity; positive scores can be obtained by other conditions (e.g., flu or alcohol withdrawal).
Pharmacological Treatment Approaches
Published in Andrea Kohn Maikovich-Fong, Handbook of Psychosocial Interventions for Chronic Pain, 2019
Catherine G. Derington, David K. Choi, Katy E. Trinkley
When opioid therapy is no longer warranted, patients are aberrant, or hyperalgesia or adverse effects arise, then tapering or discontinuation is appropriate (see Figure 8.4) Many guidelines promote the reduction of opioid doses; however, there is little consensus, evidence, or guidance for the most appropriate opioid reduction strategy, often called an opioid “taper.” An opioid taper includes both dose reduction and complete opioid discontinuation. Goals of opioid tapering include reduction of reliance on opioids for pain management, reduction of opioid burden, minimization of adverse effects of opioid use and tapering, and addressing the risks of opioid treatment.Patients may experience opioid withdrawal symptoms while tapering or discontinuing. Although uncomfortable, these symptoms are short-lived and not life-threatening. The Clinical Opiate Withdrawal Scale (COWS) assesses the severity of withdrawal symptoms and level of physical dependence on opioid therapy. It can be used in inpatient or outpatient settings (Wesson & Ling, 2003). The spectrum and severity of withdrawal symptoms seen on clinical presentation is influenced by the duration of opioid exposure, amount of daily opioid burden, speed of tapering, concomitant medications, and other psychosocial factors. The range of withdrawal symptoms includes anxiety, restlessness, dizziness, hot flashes, sweating, shivering, tremors, hyperalgesia, myalgias, arthralgias, nausea, diarrhea, abdominal cramping, anorexia, hypertension, tachycardia, tear production, mucus production, itching, insomnia, and yawning. The symptom timeline is relative to the last dose of the opioid. Symptoms appear within 2 to 3 half-lives, peak within 4 to 5 half-lives, and resolve within 7 to 14 days (Berna, Kulich, & Rathmell, 2015; Mattick & Hall, 1996).
A week-long outpatient induction onto XR-naltrexone in patients with opioid use disorder
Published in The American Journal of Drug and Alcohol Abuse, 2020
Mohammad Sibai, Kaitlyn Mishlen, Edward V. Nunes, Frances R. Levin, John J. Mariani, Adam Bisaga
Opioid withdrawal symptoms were assessed before and after administration of medications during the study Days 1–5, and at each clinic visit afterward, using the self-reported Subjective Opiate Withdrawal Scale (SOWS) (11) and the Clinical Opiate Withdrawal Scale (COWS) (10) rated by a physician or nurse. The SOWS includes 16 common symptoms of withdrawal rated on a severity scale from 0 = not at all to 4 = extremely with a possible score ranging from 0 to 64. The COWS is an 11-item scale completed by a trained observer including several signs of opioid withdrawal with a possible score of 0–48. An additional opioid withdrawal item used the same Likert scale as the SOWS (range 0–4) to evaluate difficulty with sleep. Opioid craving was assessed using the visual analog scale (VAS) of heroin/opioid desire intensity since the previous visit (0–100). Drug use was determined on-site using a urine toxicology panel that included tests for opioids, methadone, oxycodone, buprenorphine, cocaine, amphetamines, tetrahydrocannabinol, benzodiazepines, and barbiturates. Also, self-reports of drug use were collected using the Timeline Followback method (12).
Fentanyl use disorder characterized by unprescribed use of transdermal patches: a case report
Published in Journal of Addictive Diseases, 2022
Cavid Guliyev, Zehra Olcay Tuna, Kültegin Ögel
According to DSM-5, the patient was diagnosed with severe opioid (fentanyl) use disorder as seven of the opioid use disorder criteria were fulfilled. The Clinical Opiate Withdrawal Scale (COWS) value was 22 on the first day of the hospitalization. The patient was started on diazepam 40 mg/day, naproxen/codeine phosphate 1650/240 mg/day and thiocolchicoside 24 mg/day for arthralgia and myalgia, trimethobenzamide HCl 600 mg/day for nausea and quetiapine 300 mg/day for insomnia. He participated in psycho-education sessions, and personal therapeutic interviews were conducted. As the withdrawal symptoms subsided on the third day of hospitalization (COWS score was 17), the medications were tapered off. On the fourth day, when the patient stated that he was ready, the used patches that he had previously been reluctant to take off were removed. As the withdrawal symptoms were resolved completely on the 12th day of hospitalization, diazepam, naproxen + codeine phosphate, thiocolchicoside, and trimethobenzamide HCl were discontinued and oral naltrexone 25 mg/day was initiated as maintenance treatment. Upon the completion of the detoxification treatment on the 16th day of hospitalization, the patient was discharged by prescribing quetiapine 300 mg/day and naltrexone 50 mg/day, and an outpatient control visit was scheduled. Since the patient did not come for two consecutive follow-up visits, he was reached via a phone interview. He stated that he could not attend to follow-ups because of his busy work schedule. As learned from the phone interview, he stopped using naltrexone after two weeks, did not use opioids but consumed 500 ml/day of hard drinks. He was informed about his heavy drinking and encouraged for a hospital visit.
An open-label randomized trial of intramuscular olanzapine versus oral clonidine for symptomatic treatment of opioid withdrawal in the emergency department*
Published in Clinical Toxicology, 2019
Lauren R. Klein, Jon B. Cole, Brian E. Driver, James R. Miner, JoAn R. Laes, Erik Fagerstrom, Marc L. Martel
For all enrolled patients, baseline data were obtained including demographics and opioid use history. Baseline severity of symptoms was scored using the Clinical Opiate Withdrawal Scale (COWS). Baseline level of alertness was scored using the Observer’s Assessment of Alertness/Sedation Scale (OAA/S). Additional assessments occurred at 60 min post-medication administration, 120 min post-medication administration, and at the time of disposition. These assessments were conducted by the RAs, and included calculation of the COWS score, calculation of the OAA/S score, and recording of any medications given during the previous interval.