Clinical Opiate Withdrawal Scale (COWS) Question

[scrubulator]

Situation:

MVA pt with heroin on board/hx of drug abuse, pt had surgery, MDs prescribed morphine/tramadol/tylenol for pain. I suggested we do COWS every few hours, my coworker didn't think we need to since he was prescribed mainly opioids for pain ("he wouldn't be in withdrawal since we are giving him opioids").

Question:

But COWS is for opiates (not opioids), so he could still withdraw from the opiate (heroin) right?? Thoughts? 

 

[JBMmom, MSN, NP]

It's my understanding that morphine and heroin both fall in the category of opiates because they are derived from naturally occurring substances. I also think that both opiates and opioids hit the same receptors so one should theoretically impact the potential withdrawal from the other. However, depending on the quantity of drug use, the patient could still experience withdrawal symptoms. Sometimes hard to distinguish withdrawal symptoms from post surgical course with tachycardia, restlessness, and pain but diaphoresis and GI symptoms would not be typical post surgery symptoms so it should theoretically become more obvious if true withdrawal sets in. I think you were right to think it could be a complicating factor for the patient and certainly adding a screen every 4 hours or so shouldn't be a problem. 

[Davey Do]

Off the top of my head:

Withdrawal symptoms are basically the result of synaptic receptor sites not receiving certain neurotransmitters which previously had been stimulated by a specific drug. 

If a similar drug stimulates the release of those neurotransmitters, the synaptic receptor site is filled, and no withdrawal symptoms result.

For example, benzodiazepines will stimulate neurotransmitters previously stimulated by alcohol. Benzos are not alcohol, merely similar in chemical composition, and are routinely prescribed for possible alcohol withdrawal.

Utilizing this premise, it is highly unlikely that a heroin user will go into withdrawal when administered a drug of similar chemical composition.

But I cannot stress this enough: Patients with the potential to go into withdrawal ALWAYS need to be monitored.

[UrbanHealthRN, BSN, RN]

I do outpatient substance use nursing and we use COWS. We used to use the word "opiate", but technically that's only for naturally derived substances like opium and heroin. Nowadays there's also synthetically made opiates such as Fentanyl, so we use "opioid" to cover everything out there. 

The best way I'll address risk of withdrawal is by saying, if your patient was in a car accident to the point where he needed surgery, then he should not be in withdrawal while he's in the hospital. Full stop. He needs adequate pain meds to address his post op needs, and if those needs are being met then he should not be showing any withdrawal symptoms. If he's post op and in withdrawal, then my heart aches for how much post op pain he must be experiencing. 

If the plan is to discharge him with non-opioid pain meds, then that's another story and yes he could experience withdrawal if opioid pain meds are suddenly stopped. That's where COWS scoring could become useful.