SOWS & COWS Guide

The single most important thing about Suboxone induction is timing it by your withdrawal score, not by the clock. Two scoring tools exist for this. SOWS (Subjective Opiate Withdrawal Scale) is the one you score yourself, and it’s the right tool if you’re inducting at home alone, which most people in this community are. COWS (Clinical Opiate Withdrawal Scale) is the clinician version, scored by a prescriber or nurse, often on a video call. Both measure the same underlying thing: are you in enough withdrawal that bupe won’t precipitate worse withdrawal?

The rule: don’t induct until SOWS ≥ 17 (or COWS ≥ 12), regardless of how many hours it’s been. If you hit 24 hours and your SOWS is still at 10, you’re not ready. If you hit 14 hours and your SOWS is solidly past 17, you probably are. The score decides.

One exception: the Bernese method (micro-induction) doesn’t use the withdrawal-score gate. It starts tiny doses of bup while you keep taking your opioid, gradually shifting receptor occupancy over 5–10 days. If you’re considering that pathway, especially for long-acting synthetics like MGM-15 or pseudo, or after a prior precipitated-withdrawal attempt, read the Bernese page; the scoring on this page is for the standard wait-then-induct approach.

SOWS vs COWS: which one you’ll use

SOWS is the one to use if you’re inducting solo at home (common with telehealth-only providers). It’s purely subjective: you rate how strongly you’re feeling each of 16 symptoms (anxiety, yawning, sweating, runny eyes/nose, goosebumps, shakiness, hot/cold flashes, bone/muscle aches, restlessness, nausea, vomiting urge, muscle twitching, stomach cramps, craving). Each item is 0–4. No external observation needed, so you can’t accidentally mis-score the observable signs you have no way to measure alone. Score yourself, write it down with a timestamp, and re-score every hour. The WHO Annex 10 SOWS form (PDF) and the SAMHSA TIP 40 SOWS table are the canonical published versions.

COWS is the clinical tool a prescriber or nurse will score if you’re on a video call. It mixes things you can self-report (yawning, anxiety, GI upset) with observable signs someone else should ideally measure: resting pulse, pupil size, blood pressure trends, gooseflesh on visual inspection. Some are doable solo with a pulse oximeter or wearable; some aren’t. Know what they’re looking at. The NIDA COWS form (PDF) is the official version.

The two are correlated but not identical. Sometimes SOWS catches the subjective awfulness before COWS reaches the threshold, sometimes the reverse. If you’re scoring both, most prescribers will accept either when you bring numbers and timestamps.

Thresholds for inducting:

• SOWS ≥ 17 (mild-to-moderate range), the at-home induction floor
• COWS ≥ 12 (moderate withdrawal), roughly equivalent, the clinical standard
• Some prescribers want COWS ≥ 13 or higher for the long-acting compounds; ask yours

Self-scoring SOWS (by hand)

The calculator at the top of the page does the math for you. If you’d rather score by hand, the items are listed below. The official forms are the WHO Annex 10 PDF (clean printable version) and the SAMHSA TIP 40 HTML table.

The items:

1. I feel anxious
2. I feel like yawning
3. I’m perspiring / sweating
4. My eyes are tearing
5. My nose is running
6. I have goosebumps
7. I am shaking
8. I have hot flashes
9. I have cold flashes
10. My bones and muscles ache
11. I feel restless (can’t sit still)
12. I feel nauseous
13. I feel like vomiting
14. My muscles twitch
15. I have cramps in my stomach
16. I feel like using right now / strong cravings

Scoring each item:

• 0 = not at all
• 1 = a little
• 2 = moderately
• 3 = quite a bit
• 4 = extremely

Interpreting your SOWS total

Induct at SOWS ≥ 17. That’s roughly equivalent to COWS ≥ 12, moderate, induction-ready withdrawal. If your SOWS is in the 21+ range, you’re past induction-ready and probably shouldn’t wait longer than necessary.

If you’re scoring both SOWS and COWS and they disagree (e.g., SOWS at 22 but COWS at 9), trust the higher one and re-score in an hour. The two scales emphasize different things, long-acting compounds sometimes produce strong subjective misery before the observable signs catch up.

Self-scoring COWS

If a prescriber or nurse is on the call, this is the scale they’ll use. You’re scoring 11 items, each on a 0 to 4 or 0 to 5 scale. Add them up for your total. The official NIDA COWS form (PDF) has the full scoring rubric and is what you should use. Below is a quick-reference so you know what each item is asking.

Interpreting your COWS total

Induct at COWS ≥ 12. Some people prefer to wait until 13 to 17 for extra safety margin, particularly if you’ve been on long-acting compounds. If you induct below 12, you risk precipitated withdrawal. If you wait much past the moderate range, you’re suffering longer than you need to.

Half-lives as context (not as the gate)

Half-life tells you roughly when your withdrawal score is likely to climb to induction-ready, not whether you should induct.

• 7-OH alone: short half-life (community-observed effect duration roughly 90 minutes to a couple of hours; no direct human PK published, see 7-OH compound page). Most users reach induction-ready withdrawal in the 12 to 18 hour range.
• MGM-15 (also sold as MIT-A or DHM): community-reported effective duration roughly 9–15 hours per dose (no published human PK; see MGM-15 page). Often takes 36 to 72 hours to reach induction-ready scores.
• Pseudo (MP): binds tighter than buprenorphine itself (Varadi 2016 reports MP Kᵢ ≈ 0.8 nM vs bupe ~1.5 nM). Receptor occupancy can outlast plasma levels. Closer to fentanyl-induction territory than standard kratom-induction.

If you’ve been on the long-acting compounds and your score isn’t climbing past 24 hours, that’s the half-life. Wait it out. The clock isn’t the gate, but the half-life is why some people wait longer than others.

Practical tips

• Score yourself every couple of hours once you’re past 12 hours since last dose. Watch the trajectory.
• Wait about an hour after waking up before scoring. A first-thing-in-the-morning score is unreliable, pulse hasn’t settled, you’ve been still for hours so restlessness reads low, and the mental fog of just waking up makes the subjective items inconsistent. Get up, drink water, walk around, then score.
• Be honest about each item. Don’t talk yourself into a higher score because you want to dose. Don’t talk yourself into a lower score because you’re scared.
• Pulse and pupils are the hardest to fake either direction. If those are climbing, you’re getting close.
• Pulse needs a real resting reading. Sit or lie down for at least a minute first. Anxiety alone can spike pulse and inflate your score.
• Goosebumps and yawning showing up together is a classic signal you’re solidly in withdrawal.
• If your score climbs well into the 20s, you’re past the threshold. You don’t need to wait longer.

Sources

• NIDA Clinical Opiate Withdrawal Scale (PDF, full scoring rubric)
• Medscape COWS calculator (online tool)
• Emergency Care BC: COWS-based induction protocol
• SAMHSA induction guidance

Reminder: Suboxone induction is a medical event. Your withdrawal score is the tool that times it, but interpreting it and acting on it is best done with a prescriber who’s on board with what you’re trying to do. If you’re inducting at home, ideally your prescriber knows that and is reachable.