Interobserver agreement between emergency clinicians and nurses for Clinical Opiate Withdrawal Scale

Area of Science:

• Emergency Medicine
• Pharmacology
• Addiction Medicine

Background:

• The Clinical Opiate Withdrawal Scale (COWS) is a standard tool for quantifying opioid withdrawal severity.
• Buprenorphine is a common treatment for opioid use disorder, often initiated in the emergency department (ED).
• Accurate and timely assessment of withdrawal is crucial for effective buprenorphine induction.

Purpose of the Study:

• To evaluate the agreement between emergency department (ED) nurses and physicians in scoring opioid withdrawal using the COWS.
• To assess the safety of initiating buprenorphine treatment in the ED setting.

Main Methods:

• 120 patients presenting to the ED for opioid withdrawal treatment were independently scored by ED clinicians and nurses using the COWS.
• Agreement was calculated using overall concordance and weighted kappa, with analysis at various cutoffs (overall severity, COWS ≥ 5, individual measures).
• Patient records were reviewed for complications related to buprenorphine induction.

Main Results:

• Overall concordance between ED clinicians and nurses for COWS scoring was 67.5% (weighted kappa = 0.55, moderate agreement).
• When dichotomized by a COWS score ≥ 5, concordance increased to 82.5% (weighted kappa = 0.65, substantial agreement).
• No adverse effects or worsening withdrawal symptoms were reported during buprenorphine induction in 58% of patients.

Conclusions:

• There is substantial agreement between ED nurses and physicians in utilizing the COWS for patients with opioid withdrawal.
• ED nurse-led COWS scoring can potentially streamline the initiation of buprenorphine treatment.
• Buprenorphine induction appears safe in the ED setting.