Clinical Opiate Withdrawal Scale (COWS)

Interactive COWS Scale

Clinical Opiate Withdrawal Scale (COWS)

For each item, select the number that best describes the patient’s signs or symptoms based *only* on their apparent relationship to opiate withdrawal. Scores update automatically.

Patient’s Name:

Date:

Resting Pulse Rate

(Record beats per minute, measured after patient sitting/lying for one minute)

80 or below 0

81-100 1

101-120 2

Greater than 120 4

Sweating

(Over past ½ hour, not accounted for by room temperature or activity)

No report of chills or flushing 0

Subjective report of chills or flushing 1

Flushed or observable moistness on face 2

Beads of sweat on brow or face 3

Sweat streaming off face 4

Restlessness

(Observation during assessment)

Able to sit still 0

Reports difficulty sitting still, but able to do so 1

Frequent shifting or extraneous movements of legs/arms 3

Unable to sit still for more than a few seconds 5

Pupil Size

Pupils pinned or normal size for room light 0

Pupils possibly larger than normal for room light 1

Pupils moderately dilated 2

Pupils so dilated that only the rim of the iris is visible 5

Bone or Joint Aches

(If patient had prior pain, only score additional component attributed to withdrawal)

Not present 0

Mild diffuse discomfort 1

Patient reports severe diffuse aching of joints/muscles 2

Patient is rubbing joints or muscles; unable to sit still due to discomfort 4

Runny Nose or Tearing

(Not accounted for by cold symptoms or allergies)

Not present 0

Nasal stuffiness or unusually moist eyes 1

Nose running or tearing 2

Nose constantly running or tears streaming down cheeks 4

GI Upset

(Over last ½ hour)

No GI symptoms 0

Stomach cramps 1

Nausea or loose stool 2

Vomiting or diarrhea 3

Multiple episodes of diarrhea or vomiting 5

Tremor

(Observation of outstretched hands)

No tremor 0

Tremor can be felt, but not observed 1

Slight tremor observable 2

Gross tremor or muscle twitching 4

Yawning

(Observation during assessment)

No yawning 0

Yawning once or twice during assessment 1

Yawning three or more times during assessment 2

Yawning several times/minute 4

Anxiety or Irritability

None 0

Patient reports increasing irritability or anxiousness 1

Patient obviously irritable or anxious 2

Patient so irritable/anxious that assessment is difficult 4

Gooseflesh Skin (Piloerection)

Skin is smooth 0

Piloerection can be felt or hairs standing up on arms 3

Prominent piloerection 5

Total Withdrawal Score

No Withdrawal Detected

All Scales