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Calculator: Clinical Opioid Withdrawal Scale (COWS) for adults and adolescents

Calculator: Clinical Opioid Withdrawal Scale (COWS) for adults and adolescents

Resting pulse rate measured after patient is sitting or lying for 1 minute

Pulse rate 80 or below (0 points)

Pulse rate 81 to 100 (1 point)

Pulse rate 101 to 120 (2 points)

Pulse rate greater than 120 (4 points)
Sweating: Over past half-hour, not accounted for by room temperature or patient activity

No report of chills or flushing (0 points)

Subjective report of chills or flushing (1 point)

Flushed or observable moistness on face (2 points)

Beads of sweat on brow or face (3 points)

Sweat streaming off face (4 points)
Restlessness: Observation during assessment

Able to sit still (0 points)

Reports difficulty sitting still but is able to do so (1 point)

Frequent shifting or extraneous movements of legs/arms (3 points)

Unable to sit still for more than a few seconds (5 points)
Pupil size

Pupils constricted or normal size for room light (0 points)

Pupils possibly larger than normal for room light (1 point)

Pupils moderately dilated (2 points)

Pupils so dilated that only the rim of the iris is visible (5 points)
Bone or joint aches (if patient was having pain previously, only the additional component attributed to opioid withdrawal is scored)

Not present (0 points)

Mild diffuse discomfort (1 point)

Patient reports severe diffuse aching of joints/muscles (2 points)

Patient is rubbing joints or muscles and is unable to sit still because of discomfort (4 points)
Runny nose or tearing, not accounted for by cold symptoms or allergies

Not present (0 points)

Nasal stuffiness or unusually moist eyes (1 point)

Nose running or tearing (2 points)

Nose constantly running or tears streaming down cheeks (4 points)
GI upset: Over last half-hour

No GI symptoms (0 points)

Stomach cramps (1 point)

Nausea or loose stool (2 points)

Vomiting or diarrhea (3 points)

Multiple episodes of diarrhea or vomiting (5 points)
Tremor: Observation of outstretched hands

No tremor (0 points)

Tremor can be felt but not observed (1 point)

Slight tremor observable (2 points)

Gross tremor or muscle twitching (4 points)
Yawning: Observation during assessment

No yawning (0 points)

Yawning once or twice during assessment (1 point)

Yawning 3 or more times during assessment (2 points)

Yawning several times/minute (4 points)
Anxiety or irritability

None (0 points)

Patient reports increasing irritability or anxiousness (1 point)

Patient obviously irritable or anxious (2 points)

Patient so irritable or anxious that participation in the assessment is difficult (4 points)
Gooseflesh skin

Skin is smooth (0 points)

Piloerrection of skin can be felt or hairs standing up on arms (3 points)

Prominent piloerrection (5 points)

Important: Inputs must be complete to perform calculation.

Total criteria point count:


COWS score interpretation

5 to 12 points: Mild withdrawal
13 to 24 points: Moderate withdrawal
25 to 36 points: Moderately severe withdrawal
37 to 48 points: Severe withdrawal


  • GI: gastrointestinal.

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