Clinical Opiate Withdrawal Scale (COWS)
Opioid withdrawal severity, used to time buprenorphine induction.
Inputs
CompleteResting pulse
Sweating
Restlessness
Pupil size
Bone or joint aches
Runny nose or tearing
GI upset
Tremor
Yawning
Anxiety or irritability
Gooseflesh skin
Worked calculation
Your values are highlighted.
- Points
When to use
- Before and during buprenorphine induction or withdrawal management.
Pearls and pitfalls
- Buprenorphine induction usually starts at COWS 8–12 or higher (moderate withdrawal) to avoid precipitated withdrawal.
Why use
The standard scale for buprenorphine timing.
| Criterion | Points |
|---|---|
| Resting pulse: 80 or below | 0 |
| 81–100 | +1 |
| 101–120 | +2 |
| Above 120 | +4 |
| Sweating: None | 0 |
| Barely, flushing or moist | +1 |
| Beads on brow or face | +2 |
| Streaming | +4 |
| Restlessness: Sits still | 0 |
| Reports difficulty sitting still | +1 |
| Frequent shifting | +3 |
| Unable to sit still | +5 |
| Pupil size: Normal or pinned | 0 |
| Possibly larger than normal | +1 |
| Moderately dilated | +2 |
| Only the rim of the iris visible | +5 |
| Bone or joint aches: None | 0 |
| Mild diffuse discomfort | +1 |
| Severe diffuse aching | +2 |
| Rubbing joints, unable to sit still | +4 |
| Runny nose or tearing: None | 0 |
| Nasal stuffiness or moist eyes | +1 |
| Nose running or tearing | +2 |
| Constant running or tears streaming | +4 |
| GI upset: None | 0 |
| Stomach cramps | +1 |
| Nausea or loose stool | +2 |
| Vomiting or diarrhea | +3 |
| Multiple episodes of vomiting or diarrhea | +5 |
| Tremor: None | 0 |
| Felt, not observed | +1 |
| Slight tremor observable | +2 |
| Gross tremor or muscle twitching | +4 |
| Yawning: None | 0 |
| Once or twice | +1 |
| Three or more times | +2 |
| Several times per minute | +4 |
| Anxiety or irritability: None | 0 |
| Reports increasing irritability | +1 |
| Obviously irritable or anxious | +2 |
| So irritable it is hard to assess | +4 |
| Gooseflesh skin: Smooth | 0 |
| Piloerection felt or hairs standing up | +3 |
| Prominent piloerection | +5 |