The Clinical Opiate Withdrawal Scale (COWS)

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The Clinical Opiate Withdrawal Scale (COWS)

For patients receiving medically assisted opioid treatment, assessing the withdrawal levels is critical. Developed in the 1930’s, the clinical opiate withdrawal scale has been successfully used in assisting in the progression of opioid withdrawal treatment programs.

The scale, also known as COWS, assigns and sums numerical values for eleven different symptoms. When the scores are added together, the resulting number provides an indication of where the patient is in the withdrawal process. This important information aids medical professionals in tailoring the next step of the withdrawal plan.

An assessment using COWS should only be conducted by trained professionals. Although this assessment most commonly applies to individuals receiving opiate addiction treatment, it may also be used in healthcare facilities when a patient has been given opiates for pain treatment and shows adverse withdrawal symptoms.

The 11 assessments of the clinical opiate withdrawal scale include:

Resting Pulse Rate

While resting, the number of beats-per-minute is recorded. A pulse lower than 80 scores a 0. Above 80 beats-per-minute, the score goes up by 1 for every 20 additional beats.



The level of sweat is observed over a period of thirty minutes in a comfortable setting absent of any physical activity. Patients with visible facial sweat receive a score of 4. Less sweating receives lower scores and when no observed sweating, chills, flushing is observed a score of 0 is awarded.


Using a scale of 0 to 5, administrators determine a level of restlessness in the patient. A score of 0 is given when patients are calm and able to remain still. Patients who are unable to remain calmly seated for more than a few seconds would receive the highest score.



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Pupil Size

Under normal lighting conditions, the size of the patient’s pupils is assessed. Normal pupil size scores a zero while dilated pupils, which leave very little visible iris showing, receive the highest score of 5. The clinician would attach a lower number for less extreme dilation.

Gastrointestinal Upset

During the withdrawal process, patients can experience upset stomachs. When patients show no upset in their gastrointestinal tract, they receive a score of 0. If there have been instances of vomiting or diarrhea within the past 30 minutes, a score of 5 is assessed.

Symptoms of COWS SCALE

Bone and Joint Ache

If the patient is not experiencing any bone or joint pain, a score of 0 is assessed. Those who experience severe pain receive a 5. It is important to note assessment is only made for bone or joint pain experienced only during withdrawal. Pain or aches which were present before the withdrawal process are not contemplated.

Tears and Running Noses

Obvious running nose or tearing not caused by the common cold or allergy conditions are given the highest score of 4. Patients not showing any signs of a runny nose or tearing related to withdrawal receive a 0. Clinicians can assess a middle number for the low to moderate presence of tears or runny nose related to withdrawal.


When the patient is asked to reach out their arms ahead of their torso, the health care provider will look for any signs of shakiness or tremor. If no signs are present, a score of 0 is assessed. The clinician has the ability to score up to 4 for those who are extremely anxious.

COWS Scale Symptoms


Unlike other indicators, only a score of 0, 3, or 5 is available for the assessment of goosebumps. A score 0f zero is given for patients who show no signs of goosebumps. If the hair is standing upright on the patient’s arms or neck, a score of 3 is assessed. The highest score of 5 is reserved for those patients whose goosebumps are clearly visible on the skin of the arms or legs.

Anxiety of Irritability

Using a scale of 0 to 4, patients report their perceived level of anxiousness. The highest score of 4 is assessed to those who are so irritable they have difficulty participating in the assessment. Patients showing no signs of anxiousness or irritability are assessed as 0.


The number of yawns is counted throughout the duration of the overall assessment. If a patient doesn’t yawn, a score of zero is given. When a patient yawns multiple times per minute, a score of 4 is assessed. A number between 0 and 4 is assessed for infrequent yawning.


Using the results based on the clinical opiate withdrawal scale, the final step of the assessment process is adding the scores together. The final tally is used to determine the approximate level of withdrawal symptoms as follows:

• 0 – 4 little to none
• 5 – 12 mild
• 12 – 24 moderate
• 25 – 36 moderately severe
• 36+ severe withdrawal

The clinical opiate withdrawal scale plays an important role in the overall process of the detoxification process and the management of withdrawal symptoms. Patients who experience moderate to severe withdrawal unknowingly can unnecessarily suffer for weeks or months.

However, regular evaluation using COWS assists health care providers in administering the appropriate type and amount of withdrawal assisting medications. Ultimately the clinical opiate withdrawal scale helps medical professionals gain an understanding of their patients, resulting in personalized care and high withdrawal success rates.


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