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Clinical Opioid Withdrawal Scale

The Clinical Opiate Withdrawal Scale (COWS)

COWS is an 11-item scale designed to be administered by a clinician. This tool can be used in both inpatient and outpatient settings to reproducibly rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time. The summed score for the complete scale can be used to help clinicians determine the stage or severity of opiate withdrawal and assess the level of physical dependence on opioids. Practitioners sometimes express concern about the objectivity of the items in the COWS; however, the symptoms of opioid withdrawal have been likened to a severe influenza infection (e.g., nausea, vomiting, sweating, joint aches, agitation, tremor), and patients should not exceed the lowest score in most categories without exhibiting some observable sign or symptom of withdrawal.


Download Clinical Opioid Withdrawal Scale (COWS) form | PDF


Clinical Opiate Withdrawal Scale (COWS)

For each item, circle the number that best describes the patient's signs or symptom. Rate on just the apparent relationship to opiate withdrawal. For example, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score.

Patient's Name: ___________________ Date and Time ____/____ /_____:_______

Reason for this assessment:____________________________________________________

Resting Pulse Rate:_________beats/minute Measured after patient is sitting or lying for one minute

0   pulse rate 80 or below
1   pulse rate 81-100 2 pulse rate 101-120
4   pulse rate greater than 120
GI Upset: over last ½ hour

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

Sweating: over past ½ hour not accounted for by room temperature or patient activity.

0   no report of chills or flushing
1   subjective report of chills or flushing
2   flushed or observable moistness on face
3   beads of sweat on brow or face
  sweat streaming off face

Tremor observation of outstretched hands

  No tremor
1   tremor can be felt, but not observed
2   slight tremor observable
4   gross tremor or muscle twitching

Restlessness Observation during assessment

0   able to sit still
  reports difficulty sitting still, but is able to do so
3   frequent shifting or extraneous movements of legs/arms
5   Unable to sit still for more than a few seconds



Yawning Observation during assessment

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

Pupil size

0   pupils pinned or normal size for room light
  pupils possibly larger than normal for room light
2   pupils moderately dilated
5   pupils so dilated that only the rim of the iris is visible

Anxiety or Irritability

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

Bone or Joint aches If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored

  not present
  mild diffuse discomfort
  patient reports severe diffuse aching of joints/ muscles
4   patient is rubbing joints or muscles and is unable to sit still
      because of discomfort

Gooseflesh skin

  skin is smooth
3   piloerrection of skin can be felt or hairs standing up on arms
5   prominent piloerrection

Runny nose or tearing Not accounted for by cold symptoms or allergies

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

Total Score _________
The total score is the sum of all 11 items

Initials of person completing Assessment: ______________


5-12 = mild
13-24 = moderate
25-36 = moderately severe
>36 = severe withdrawal

Source: Wesson and Ling 2003[326]