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
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Clinical Opiate Withdrawal Scale (COWS) |
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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. |
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Patient's Name: ___________________ Date and Time ____/____ /_____:_______ Reason for this assessment:____________________________________________________ |
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Resting Pulse Rate:_________beats/minute Measured after patient is sitting or lying for one minute 0 pulse rate 80 or below1 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 |
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Sweating: over past ½ hour not accounted for by room temperature or patient activity. 0 no report of chills or flushing1 subjective report of chills or flushing 2 flushed or observable moistness on face 3 beads of sweat on brow or face 4 sweat streaming off face |
Tremor observation of outstretched hands 0 No tremor1 tremor can be felt, but not observed 2 slight tremor observable 4 gross tremor or muscle twitching |
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Restlessness Observation during assessment 0 able to sit still1 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
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Yawning Observation during assessment 0 no yawning |
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Pupil size 0 pupils pinned or normal size for room light1 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 |
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Bone or Joint aches If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored 0 not present1 mild diffuse discomfort 2 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 0 skin is smooth |
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Runny nose or tearing Not accounted for by cold symptoms or allergies 0 not present1 nasal stuffiness or unusually moist eyes 2 nose running or tearing 4 nose constantly running or tears streaming down cheeks |
Total Score _________
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Score: 5-12 = mild13-24 = moderate 25-36 = moderately severe >36 = severe withdrawal
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