COWS Score for Opiate Withdrawal

The global unit selector only affects unanswered questions
1.Resting pulse rate
3.Restlessness observation during assessment
4.Pupil size
5.Bone or joint aches
6.Rhinorrhea or tearing
7.GI Upset
8.Tremor observation of outstretched hands
9.Yawning observation during assessment
10.Anxiety or irritability
11.Gooseflesh skin
Created by

1. Resting pulse rate

More Information

Measured after patient seated or lying flat for 1 minute

Created by
0/11 completed

About this Calculator

The COWS (Clinical Opiate Withdrawal Scale) Score was developed to assist clinicians in quantifying the degree of opiate withdrawal during their patient assessments.

The COWS derivation study (Wesson and Ling 2003) found a spectrum of severity within 11 historical and physical findings to quantify the degree of withdrawal and infer level of opiate dependence in patients. The study premise was that opioid withdrawal intensity relies on both the severity of physical dependence to opioids along with the relative occupancy of the opioid receptors at the point of assessment. Notably, the parameters were created based on author expertise rather than statistical derivation. However, the COWS score was validated in 2009 (Tompkins et al. 2009) using naloxone challenges on opioid dependent volunteers.

The COWS score measures acute opioid withdrawal and is a useful tool frequently applied to buprenorphine/naloxone starts for opioid dependent patients. COWS scores are useful to prevent precipitated withdrawal whereby buprenorphine/naloxone combination medicines rapidly provoke withdrawal when the opioid receptors are still too occupied.

Variable Assessed

Resting pulse, Sweating, Degree of restlessness, Pupil size, Bone or joint aches, Rhinorrhea or tearing, GI upset, Tremor, Yawning, Anxiety or irritability, Gooseflesh skin.

Interpretation based on answers:

No active opiate withdrawal, mild opiate withdrawal, moderate opiate withdrawal, moderately severe opiate withdrawal, severe opiate withdrawal.


Wesson DR, Ling W.

The clinical opiate withdrawal scale (COWS). Journal of Psychoactive Drugs.

Journal of Psychoactive Drugs 2003, 35 (2): 253-9

Contributed By:
  • Riley Golby, MD
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