Skip to main content

COWS

Clinical Opiate Withdrawal Scale

11 items
Score 0–48
current state
All scales

An 11-item clinician-administered scale quantifying severity of opioid withdrawal. Commonly used to time the first dose of buprenorphine during induction.

Your responses are scored in your browser and are never sent to or stored on our servers.

Rate each item based on patient observation. For vitals, use the current measurement. A total ≥ 8–12 is often the threshold before initiating buprenorphine to avoid precipitated withdrawal.

0 / 11 answered
COWS items
1.

1. Resting pulse rate (BPM)

2.

2. Sweating — over past ½ hour, not accounted for by room temperature or activity

3.

3. Restlessness

4.

4. Pupil size

5.

5. Bone or joint aches — if patient was having pain previously, only score additional component attributable to withdrawal

6.

6. Runny nose or tearing — not accounted for by cold symptoms or allergies

7.

7. GI upset — over last ½ hour

8.

8. Tremor — observation of outstretched hands

9.

9. Yawning — observation during assessment

10.

10. Anxiety or irritability

11.

11. Gooseflesh skin

Licensing

Developed by Wesson DR, Ling W (2003). Distributed by SAMHSA / NIDA. Free to use with attribution.

Citation

Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003 Apr-Jun;35(2):253-9.

This tool is for education and clinical decision support — it does not substitute for a full clinical evaluation. Always interpret results in the context of a complete history and exam.