[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Nursing](https://durgical.com/en/nursing/) › [Mental health and psychiatric nursing](https://durgical.com/en/nursing/areas/mental-health/) › Opioid withdrawal and overdose risk: COWS monitoring, naloxone and safe discharge # Opioid withdrawal and overdose risk: COWS monitoring, naloxone and safe discharge - Assessment Rate withdrawal with the COWS, keep the person hydrated and calm, know how to respond to an overdose with naloxone and discharge with overdose education. Updated Nov 13, 2026 ## Key points - Withdrawal signs: craving, anxiety, restlessness, gastrointestinal upset (vomiting, diarrhoea, cramps), sweating, tachycardia. - The COWS rates eleven signs and symptoms; repeat it on the protocol's schedule. Use the cut-offs in your protocol. - Buprenorphine can worsen withdrawal if given too early: the prescriber starts it once the COWS shows objective withdrawal, per protocol. - Overdose: pinpoint pupils, slow or no breathing, unresponsiveness; call for help, support breathing, give naloxone per protocol. - Naloxone wears off sooner than many opioids: keep watching for at least four hours after the last dose, longer for long-acting opioids. - After withdrawal, tolerance is low: teach overdose risk and link to opioid agonist treatment and follow-up. ## What it is Opioid withdrawal is very unpleasant, and the period around it carries a serious danger: overdose. The COWS (Clinical Opiate Withdrawal Scale) rates eleven signs and symptoms of withdrawal and is repeated to follow the trend and guide treatment, including the timing of buprenorphine, within the institution's protocol. The nurse keeps the environment calm, treats dehydration, gives the prescribed medicines, recognises an overdose and responds with airway support and naloxone per protocol, and prepares a discharge that covers lowered tolerance and access to treatment. ## Reference values - COWS: eleven items; the institutional protocol sets the intervals and the scores for each action. - Overdose triad: pinpoint pupils, respiratory depression, reduced consciousness. - Most people breathe again within 2–3 minutes of naloxone; repeat per protocol if they do not. - Monitoring after naloxone: at least four hours after the last dose. ## What you need - The COWS form used by the institution and the withdrawal protocol. - Pulse oximeter, blood pressure monitor, thermometer. - Naloxone, a bag-valve-mask or barrier device, oxygen and suction available. - A calm, quiet room and oral or intravenous fluids as ordered. ## How to measure it (and why) - Ask which opioids are used, the route, the amount and the time of last use — short- and long-acting opioids give different withdrawal timing and overdose risk. - Score the COWS and take vital signs on the protocol's schedule — the trend shows the severity and the response to treatment. - Report the score before the first buprenorphine dose and give the prescribed medicines per protocol — starting it too early can precipitate withdrawal. - Offer fluids and monitor intake and output when there is vomiting, diarrhoea or sweating — these cause dehydration. - Keep the room calm and quiet and offer reassurance, warm baths and gentle stretching — a supportive setting reduces symptoms and the need for medicine. - Watch sedation and breathing, especially if methadone, buprenorphine and sedatives are combined — oversedation and respiratory depression can follow. - Suspected overdose: try to rouse, call for help, open the airway, support breathing and give naloxone per protocol — timely naloxone and ventilation save lives. - Before discharge, teach about lowered tolerance, mixing substances and naloxone, and arrange follow-up — overdose is the main risk after withdrawal. ## How to read it - Naloxone can cause sudden withdrawal: the person may wake confused, agitated or aggressive; explain and keep everyone safe. - The goal of naloxone is adequate spontaneous breathing, not full arousal. - Benzodiazepines or sleep medicines with methadone or buprenorphine need close supervision because of oversedation. - Methadone has a long half-life: overdose can occur if the dose rises too fast and can cause arrhythmia or respiratory depression. ## Next step: when to call for help - Call a rapid response at once for slow or absent breathing, unresponsiveness or cyanosis. - Call if breathing slows or drowsiness returns after naloxone. - Call if vomiting or diarrhoea prevents oral fluids or vital signs show dehydration. - Call if the COWS score rises despite treatment or the person wants to leave in withdrawal. ## Test yourself Think of the answer, then tap the question to see it. ## What does the COWS assess? The severity of opioid withdrawal by rating eleven signs and symptoms, repeated over time to follow the trend and response to treatment. ## Why must a person be watched after they respond to naloxone? Naloxone acts for a shorter time than many opioids, so overdose signs can return; monitor for at least four hours after the last dose. ## Why is buprenorphine not started too early in withdrawal? Given too early it can worsen opioid withdrawal; it is started once objective withdrawal is present, per protocol. [Add to my cards (3)](https://durgical.app/estudiar/?add=/en/nursing/opioid-withdrawal-and-overdose-risk-cows-monitoring-naloxone-and-safe-discharge/) ## Connections ## Related 2 - [Substance use from the nursing side: screening, intoxication, harm reduction and recovery](https://durgical.com/en/nursing/substance-use-from-the-nursing-side-screening-intoxication-harm-reduction-and-re/) - [Recognising deterioration and calling the rapid response team](https://durgical.com/en/nursing/recognising-deterioration-and-calling-the-rapid-response-team/) ## Related conditions 2 - [Opioid use disorder, overdose and withdrawal](https://durgical.com/en/conditions/opioid-use-disorder-overdose-and-withdrawal/) - [Opioid overdose](https://durgical.com/en/conditions/opioid-overdose/) ## In Pharmacology 3 - [Naloxone](https://durgical.com/en/pharmacology/naloxone/) - [Methadone](https://durgical.com/en/pharmacology/methadone/) - [Buprenorphine](https://durgical.com/en/pharmacology/buprenorphine/) [← All of nursing](https://durgical.com/en/nursing/) Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order. Sources: [Nursing: Mental Health and Community Concepts, 14.5: Withdrawal management / detoxification](https://med.libretexts.org/Bookshelves/Nursing/Nursing%3A_Mental_Health_and_Community_Concepts_(OpenRN)/14%3A_Substance_Use_Disorders/14.05%3A_Withdrawal_Management_Detoxification) (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts, 2022); [Nursing: Mental Health and Community Concepts, 14.4: Substances: use, intoxication and overdose](https://med.libretexts.org/Bookshelves/Nursing/Nursing%3A_Mental_Health_and_Community_Concepts_(OpenRN)/14%3A_Substance_Use_Disorders/14.04%3A_Substances-_Use_Intoxication_and_Overdose) (Open RN, Wisconsin Technical College System (CC BY 4.0), LibreTexts, 2022); [Opioid overdose (fact sheet)](https://www.who.int/news-room/fact-sheets/detail/opioid-overdose) (World Health Organization (WHO), 2025). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/nursing/opioid-withdrawal-and-overdose-risk-cows-monitoring-naloxone-and-safe-discharge/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/nursing/opioid-withdrawal-and-overdose-risk-cows-monitoring-naloxone-and-safe-discharge/