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COWS Calculator (Clinical Opiate Withdrawal Scale)

Score the Clinical Opiate Withdrawal Scale (COWS) — pulse, sweating, restlessness, pupils, aches, rhinorrhea, GI upset, tremor, yawning, anxiety and gooseflesh — with mild to severe withdrawal bands.

Resting pulse rate (after sitting or lying for 1 minute)

Sweating (past ½ hour, not due to room temperature or activity)

Restlessness (observed during assessment)

Pupil size

Bone or joint aches (only the part due to withdrawal)

Runny nose or tearing (not due to a cold or allergies)

GI upset (past ½ hour)

Tremor (outstretched hands)

Yawning (observed during assessment)

Anxiety or irritability

Gooseflesh skin

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How it works

COWS = sum of 11 observed signs (each item has its own point values); maximum 48. Bands (Wesson & Ling 2003): 5–12 mild · 13–24 moderate · 25–36 moderately severe · more than 36 severe withdrawal.

The Clinical Opiate Withdrawal Scale (Wesson and Ling, 2003) is an 11-item clinician-rated scale that measures opioid withdrawal from observable signs and a few reported symptoms. It is used to decide when to start buprenorphine — which can precipitate withdrawal if given too early — and to monitor withdrawal management. Pulse is measured after the patient has been sitting or lying for a minute, and aches, runny nose and GI symptoms are scored only for the part attributable to opioid withdrawal.

Worked example

Pulse 92 (1), reported chills (1), difficulty sitting still (1), slightly large pupils (1), mild aches (1), stuffy nose (1), nausea (2), a palpable tremor (1), yawning three times (2), obvious irritability (2) and smooth skin (0) give a COWS score of 13 / 48 — moderate withdrawal.

Sources: Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs 2003

Frequently asked questions

What COWS score is needed to start buprenorphine?

Protocols differ, but many wait for at least mild-to-moderate withdrawal — often a COWS of about 8 to 12 — before the first dose, and for a higher score after long-acting opioids such as methadone or illicit fentanyl.

How is COWS different from the CIWA-Ar?

COWS measures opioid withdrawal and relies mostly on observed signs such as pupil size, yawning and gooseflesh. The CIWA-Ar measures alcohol withdrawal and relies more on reported symptoms.

What is the maximum COWS score?

48. Scores above 36 indicate severe withdrawal.

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Clinical decision tool for education and for use by trained clinicians alongside clinical judgement — not a diagnosis and not a substitute for medical assessment. Scores validated in specific populations may not apply to every patient.