If you’re trying to quit opioids, you’ve probably heard that starting Suboxone too soon can make things worse. Maybe you’ve even read about precipitated withdrawal—that nightmare scenario where taking Suboxone at the wrong time sends you into sudden, severe withdrawal instead of relieving your symptoms.
So, how do you know when it’s safe to start?
Doctors use a tool called the Clinical Opiate Withdrawal Scale (COWS) to measure how severe your withdrawal symptoms are. The COWS scale helps determine if your body is ready for Suboxone or if you need to wait longer before taking your first dose.
If you’re preparing to start Suboxone or another form of medication-assisted treatment (MAT), learning how to use the COWS scale yourself can help you take Suboxone at the right time—so you get relief instead of making withdrawal worse.
In this guide, we’ll explain the COWS scale, how it works, and how to use it to start Suboxone safely.
What Is the COWS Scale?
The Clinical Opiate Withdrawal Scale (COWS) is a standardized test used by doctors to measure how severe opioid withdrawal is. It looks at physical symptoms (like sweating and heart rate) and how you feel (like restlessness and anxiety).
The COWS scale is scored based on your withdrawal symptoms, and the final number helps determine if you’re ready to start Suboxone safely.
| COWS Score | Withdrawal Severity | Is It Safe to Start Suboxone? |
| 5 or below | No or very mild withdrawal | No—too early to start Suboxone |
| 6–12 | Mild withdrawal | No—better to wait |
| 13–24 | Moderate withdrawal | Yes—this is the ideal time to start Suboxone |
| 25+ | Severe withdrawal | Yes—but higher doses of Suboxone may be needed |
To avoid precipitated withdrawal, you should only take Suboxone when you score at least a 13 on the COWS scale.
How to Use the COWS Scale Step-by-Step
The COWS test looks at 11 withdrawal symptoms. Each symptom is scored from 0 to 4 or 5, depending on severity. Add up the scores at the end to get your total COWS score.
Here’s how to check your withdrawal severity:
1. Resting Heart Rate (Pulse per Minute)
- 0 points: 80 beats per minute (bpm) or below
- 1 point: 81-100 bpm
- 2 points: 101-120 bpm
- 4 points: Over 120 bpm
Why it matters: Opioid withdrawal increases your heart rate, so a higher pulse means stronger withdrawal.
2. Sweating (Not Caused by Exercise)
- 0 points: No sweating
- 1 point: Sweating, but no sweat beads
- 2 points: Sweat beads forming on face or skin
- 3 points: Sweating heavily
Why it matters: Withdrawal causes sudden, excessive sweating, even in a cool room.
3. Restlessness or Anxiety
- 0 points: Calm and relaxed
- 1 point: Slightly restless
- 3 points: Frequently moving or fidgeting
- 5 points: Completely restless—unable to stay still
Why it matters: If you feel unable to sit still, your withdrawal is getting stronger.
4. Pupil Size (Check in Normal Light)
- 0 points: Normal size
- 1 point: Slightly larger than normal
- 2 points: Moderately dilated
- 5 points: Very large pupils
Why it matters: Opioid withdrawal causes dilated pupils, which is a key sign of worsening symptoms.
5. Bone or Joint Aches
- 0 points: No pain
- 1 point: Mild discomfort
- 2 points: Moderate aches
- 4 points: Severe pain
Why it matters: Opioid withdrawal often causes flu-like body aches.
6. Runny Nose or Tearing Eyes (Not Due to Allergies)
- 0 points: No symptoms
- 1 point: Mild runny nose or watery eyes
- 2 points: Moderate symptoms
- 4 points: Severe nasal congestion, constant tearing
Why it matters: A runny nose and watery eyes are early signs of withdrawal.
7. Stomach Issues (Nausea, Vomiting, or Diarrhea)
- 0 points: No nausea
- 1 point: Mild nausea
- 2 points: Some dry heaving
- 3 points: Frequent vomiting or diarrhea
Why it matters: Opioid withdrawal can cause stomach cramps, nausea, and diarrhea.
8. Yawning (More Than Normal)
- 0 points: No yawning
- 1 point: Occasional yawning
- 2 points: Frequent yawning
- 4 points: Constant yawning
Why it matters: Frequent yawning is an early withdrawal sign.
9. Goosebumps or Cold Sweats
- 0 points: Normal skin
- 1 point: Slight goosebumps or chills
- 2 points: Moderate chills, visible goosebumps
- 5 points: Severe chills and sweating
Why it matters: Goosebumps (“cold turkey”) are a classic sign of opioid withdrawal.
10. Irritability or Anxiety
- 0 points: No anxiety
- 1 point: Slightly irritable
- 2 points: Moderately anxious
- 4 points: Severe anxiety or panic
Why it matters: Many people in withdrawal feel high anxiety, panic, or agitation.
11. Tremors (Shaking Hands or Muscles)
- 0 points: No shaking
- 1 point: Slight hand tremor
- 2 points: Moderate tremors
- 4 points: Severe shaking
Why it matters: Shaking and muscle spasms can indicate worsening withdrawal.
How to Calculate Your COWS Score
- Add up all your points.
- Check your total score:
✔ Under 12: Too soon for Suboxone.
✔ 13-24: Safe to take Suboxone—this is the ideal range.
✔ 25+: Severe withdrawal—Suboxone can still be taken but may require higher doses.
How QuickMD Can Help You Start Suboxone Safely
If you’re unsure when to take Suboxone or need help starting treatment, QuickMD offers fast, online care from experienced addiction specialists.
Why Choose QuickMD?
- Same-day Suboxone prescriptions sent to your pharmacy.
- Online doctor visits—no in-person clinic required.
- Expert addiction doctors are available 7 days a week.
- Step-by-step guidance to start Suboxone safely.
Final Thoughts
- The COWS scale helps determine when it’s safe to take Suboxone.
- A score of 13+ means you’re in moderate withdrawal and ready to start.
- Taking Suboxone too early can cause precipitated withdrawal.
If you’re ready to start Suboxone but need expert guidance, QuickMD’s online doctors can help you start treatment safely.
