COWS & SOWS Guide

⚠️ Community information, not medical advice. Use this alongside guidance from a qualified provider.

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 — COWS and SOWS. Both measure the same underlying thing (are you in enough withdrawal that bupe won’t precipitate worse withdrawal?), just with different methods and different scales.

The rule: don’t induct until COWS ≥ 12 (or SOWS ≥ 17), regardless of how many hours it’s been. If you hit 24 hours and your COWS is still at 8, you’re not ready. If you hit 14 hours and your COWS is solidly at 14, you probably are. Trust the score over the timer.

COWS vs SOWS — which to use

COWS is the standard clinical tool. It mixes things you can self-report (yawning, anxiety, GI upset) with observable signs that someone else should ideally measure: resting pulse, pupil size, blood pressure trends, gooseflesh on visual inspection. Some of these are doable solo with a pulse oximeter or wearable; some aren’t. The NIDA COWS form (PDF) is the official version.

SOWS is 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.

In practice:

• If you have a prescriber or nurse on a video call, they’re going to score COWS. Know what they’re looking at.
• If you’re inducting solo at home (common with telehealth-only providers like QuickMD), SOWS is more honest because you’re not faking the observable items you can’t actually measure. Score yourself, write it down with a timestamp, and re-score every hour.
• Both are useful at the same time. They’re correlated but not identical — sometimes SOWS catches the subjective awfulness before COWS reaches the threshold (or vice versa). Most prescribers will accept either if you bring numbers and timestamps.

Thresholds for inducting:

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

How to score yourself — COWS

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 actually use. Below is a summary so you know what each item is asking.

1. Resting pulse rate (after sitting/lying for 1 minute)

• 0 = pulse 80 or below
• 1 = 81 to 100
• 2 = 101 to 120
• 4 = above 120

2. Sweating (over the past 30 min, not from heat or activity)

• 0 = no chills or flushing
• 1 = subjective chills/flushing
• 2 = flushed or visible moisture on face
• 3 = beads of sweat on brow or face
• 4 = sweat streaming off face

3. Restlessness (during observation)

• 0 = able to sit still
• 1 = reports difficulty sitting still but is able to
• 3 = frequent shifting or extraneous movements of legs/arms
• 5 = unable to sit still for more than a few seconds

4. Pupil size

• 0 = pinned or normal for room light
• 1 = possibly larger than normal
• 2 = moderately dilated
• 5 = so dilated only the rim of the iris is visible

5. Bone or joint aches (only if attributable to withdrawal)

• 0 = not present
• 1 = mild diffuse discomfort
• 2 = patient reports severe diffuse aching of joints/muscles
• 4 = patient is rubbing joints/muscles, unable to sit still

6. Runny nose or tearing (not from cold/allergies)

• 0 = not present
• 1 = nasal stuffiness or unusually moist eyes
• 2 = nose running or tearing
• 4 = nose constantly running or tears streaming down cheeks

7. GI upset (over the last 30 min)

• 0 = no GI symptoms
• 1 = stomach cramps
• 2 = nausea or loose stool
• 3 = vomiting or diarrhea
• 5 = multiple episodes of diarrhea or vomiting

8. Tremor (observation of outstretched hands)

• 0 = no tremor
• 1 = tremor can be felt but not observed
• 2 = slight tremor observable
• 4 = gross tremor or muscle twitching

9. Yawning (during observation)

• 0 = no yawning
• 1 = yawning once or twice during assessment
• 2 = yawning three or more times during assessment
• 4 = yawning several times per minute

10. Anxiety or irritability

• 0 = none
• 1 = patient reports increasing irritability or anxiousness
• 2 = patient obviously irritable or anxious
• 4 = so irritable/anxious that participation in assessment is difficult

11. Gooseflesh skin

• 0 = skin is smooth
• 3 = piloerection of skin can be felt or hairs standing up on arms
• 5 = prominent piloerection

What your total COWS score means

Score      Severity
─────────  ──────────────────
5 to 12    Mild withdrawal
13 to 24   Moderate withdrawal
25 to 36   Moderately severe
Over 36    Severe withdrawal

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.

How to score yourself — SOWS

SOWS is 16 items, each scored 0 (not at all) to 4 (extremely). Add them up for your total (range 0–64). Re-score every 60–90 minutes during induction so you can see the trajectory, not just a single snapshot.

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

What your total SOWS score means

Score      Severity
─────────  ──────────────────
0 to 10    Mild withdrawal
11 to 20   Moderate withdrawal
21 to 30   Severe withdrawal
Over 30    Very severe

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 COWS and SOWS and they disagree (e.g., COWS at 9 but SOWS at 22), 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.

Half-lives as context (not as the gate)

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

• 7-OH alone: plasma half-life ~100 minutes. Most users hit COWS ≥ 12 in the 12 to 18 hour range.
• MGM-15: ~15 hour half-life. Often takes 36 to 72 hours to reach induction-ready COWS.
• MIT-A/DHM: also long-acting. Similar timeline to MGM-15.
• Pseudo (MP): binds tighter than buprenorphine itself. 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 COWS 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.
• 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 COWS climbs to the high teens or 20s, you’re well 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. The COWS score is the standard tool, 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.