Dope sick. The intense fear of this all-consuming affliction drives many users to continue seeking out their opiate of choice long past that initial desire to quit. Many describe the misery of dope sickness by simply saying, “It made me wish for a death button instead.” Precipitated withdrawal from poorly timed antagonists makes the nausea even worse. But thanks to advances in addiction neuroscience and pharmacology, detoxing from opiates doesn’t have to make you dope sick.

Precipitated Withdrawal

Normal Withdrawal vs. Precipitated Withdrawal

What exactly pushes a normal withdrawal into a precipitated withdrawal? First, we need to understand what precipitate actually means.

precipitate   verb

to cast, plunge, or send, especially violently or abruptly

So precipitated withdrawal means that the body throws itself into withdrawal much quicker than normal. Several factors can trigger precipitated withdrawal from opiates. The most common culprits are detox taper drugs administered too quickly, such as:

But pharmacologists designed these drugs to have the opposite effect; that is, they mitigate withdrawal symptoms rather than exacerbate them.

The catch: they only work properly when individuals accurately report their last use. Clinical detox programs systematically monitor withdrawal symptoms to ensure tapers medications are administered at the proper time and at the proper dosage. This circumvents precipitated withdrawal and makes the process as comfortable as possible. So how to detox programs assess taper schedules, exactly?

COWS: Clinical Opiate Withdrawal Scale

Although pain acts as a real physical sensation controlled by neurological pain receptors, there’s no objective way to measure it. But proper detox requires an assessment of symptoms to avoid precipitated withdrawal (which make the pain worse). So psychiatrists developed the Clinical Opiate Withdrawal Scale (COWS) to pinpoint what each individual case requires in terms of detox.

Each addiction treatment center is different, but they follow the same general COWS guidelines. Along with recording vitals every half hour, our detox clinical staff rates the following symptoms on a relative 0-5 scale twice a day:

Clinical Opiate Withdrawal Scale (0-5)

Information Not intended to Treat without Clinical Supervision. If you need help for a substance abuse problem, contact our staff 24/7: 855-737-7363


  • Excessive Sweating
  • Restlessness
  • Pupil Size
  • Bone or Joint Aches (If Client was having pain previously, only the additional component attributed to opiates withdrawal is scored)
  • Runny Nose or Tearing (Not Accounted for by Cold Symptoms or Allergies)
  • Tremor Observation of Outstretched Hands
  • Yawning Observation During Assessment
  • Anxiety or Irritability
  • Gooseflesh Skin
  • Gastrointestinal upset

Total COWS Score

  • 0 to 5 – Absent or Minimal Withdrawal
  • 5 to 12 – Mild Withdrawal
  • 13 to 24 – Moderate Withdrawal
  • 25 to 36 – Moderately Severe Withdrawal
  • 36 & Above – Severe Withdrawal

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Hippocampus Overdrive: Chaotic Thoughts

When it comes to detoxing off addictive substances, opiates inspire the most fearful anxiety of all the withdrawals. Although it’s not as dangerous as alcohol and benzo withdrawal (which can actually kill you), dope sickness presents the most miserable physical symptoms. So it’s understandable that many prescription opiate and heroin addicts divert back to using despite the best intentions. Why is this, exactly?

Precipitated Withdrawal

We look to the hippocampus for answers. As the brain’s center of memory and emotion, the hippocampus goes into overdrive when dope sickness sets in. Chaotic thoughts envelop our best intentions to get clean.

Dr. Alyssa Cohen, Psy.D.

New Start Executive Director

“We see it all the time. People desperately want to get off the Oxy, Vicodin, heroin, or whatever it is, but they are so scared of the withdrawals that they don’t even try. Understandably so. Opiate withdrawals are some of the worst. It takes a lot of courage to face that fear and decide that the benefits of recovery outweigh the initial discomfort of withdrawals. Most people don’t understand that in detox, withdrawals aren’t nearly as bad as they are if you try to quit cold turkey. That’s why we use the COWS scale. It determines what strength of detox meds clients need, when they should be administered. We never really see precipitated withdrawals in detox because we don’t give clients detox meds while they’re still high.”

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It takes trained and licensed clinicians to identify that sweet spot; that is, when they are sober enough for an antagonist, but aren’t yet in the pains of withdrawal. If you’d like to learn more about detox antagonists and precipitated withdrawal, our addiction counselors are available 24/7 to discuss treatment options: 855-737-7363