Clinical Opioid Withdrawal Scale (COWS)

Clinical Opioid Withdrawal Scale (COWS)

Case #2

The patient is a 24-year-old man brought to your clinic by his family for an evaluation. The patient states that he is struggling with prescription pain pills and wants help. He appears to be in opioid withdrawal; he describes anorexia and diarrhea, he is yawning and sweating upon examination. He scores 15 on the Clinical Opioid Withdrawal Scale (COWS), indicating moderate withdrawal.

·  Initiate office-based buprenorphine/naloxone (Suboxone) with a plan for observation. 

It is recommended that Suboxone be provided 12-14 hours after the last dose of an opioid to manage withdrawals symptoms. The dose should be strong enough to suppress symptoms. This is usually anywhere from 4-16 mg per day, 2-4 mg to start, and increase in 2-4mg increments. The dose will slowly be tapered over as little as 3-5 days, or 30 days or more (ASAM, 2015). The patient will be observed in the office after the initial induction of Suboxone. Individual may need behavioral therapy along with referral to suboxone treatment center, if warranted

·  Include your rationale for each treatment decision

Suboxone has been tried and true, and providers with a DEA license and special training are able to prescribe this medication safely (ASAM, 2015). If a drug like Methadone is prescribed, it requires closer monitoring due to common misuse.

·  Develop a treatment plan for this patient that includes ongoing MAT and psychosocial treatment interventions.

Psychosocial treatment is necessary when combined with MAT, there should be frequent office visits, and frequent blood monitoring to test for drugs (ASAM, 2015).

·  Construct a safe taper schedule for a patient taking alprazolam (Xanax) 2mg TID. Include a brief narrative explaining the evidence for tapering a patient who has been on a benzodiazepine for an extended amount of time.

It takes approximately 8 weeks to wean from Xanax. The dose is typically decreased by 25% every quarter of the determined withdrawal period. In this given case, the dose of Xanax would decrease to 4.5mg in two weeks, then decrease to 3mg for two weeks, then 0.75mg for two weeks, so forth (AAC, 2021).

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