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Clinical Opiate Withdrawal Scale (COWS)

Also called COWS, opioid withdrawal scale, buprenorphine induction score

Eleven clinician-rated signs of opioid withdrawal; used to grade withdrawal and time buprenorphine induction.

Resting pulse (beats/min)
Sweating (past ½ hour)

Allowed scores only; rate with the anchor wording on the official form.

Restlessness

Allowed scores only; rate with the anchor wording on the official form.

Pupil size

Allowed scores only; rate with the anchor wording on the official form.

Bone or joint aches

Allowed scores only; rate with the anchor wording on the official form.

Runny nose or tearing

Allowed scores only; rate with the anchor wording on the official form.

GI upset (past ½ hour)
Tremor

Allowed scores only; rate with the anchor wording on the official form.

Yawning

Allowed scores only; rate with the anchor wording on the official form.

Anxiety or irritability

Allowed scores only; rate with the anchor wording on the official form.

Gooseflesh skin

Allowed scores only; rate with the anchor wording on the official form.

Fill 11 more fields to see the result.

Formula and scoring

Sum of 11 items (maximum 48). 5–12 mild, 13–24 moderate, 25–36 moderately severe, >36 severe.

Exam and ward pearls

  • Buprenorphine, a partial µ-agonist, can precipitate withdrawal in a highly dependent patient who is not yet in withdrawal; COWS documents that withdrawal has begun (Wesson and Ling 2003).
  • Only some items allow every number: e.g. restlessness scores 0, 1, 3 or 5 and gooseflesh 0, 3 or 5.

When not to rely on it

  • Rate each item with the anchor wording on the official form. Fever, anxiety, stimulant use or other illness can raise pulse, sweating and restlessness.
  • The score needed before a first buprenorphine dose is set by local protocol, not by the scale.

Source

  1. Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253-9. doi:10.1080/02791072.2003.10400007 · PMID 12924748
  2. National Institute on Drug Abuse. Clinical Opiate Withdrawal Scale (form reproduced from Wesson and Ling 2003). Link

Formula and cut-offs checked against these sources on 8 Nov 2026. Educational tool for clinicians; it does not replace clinical judgement.

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