How is the COWS scored?

Each of the 11 items has fixed anchor scores: resting pulse 0–4, sweating 0–4, restlessness 0–5, pupil size 0–5, bone or joint aches 0–4, runny nose or tearing 0–4, GI upset 0–5, tremor 0–4, yawning 0–4, anxiety or irritability 0–4 and gooseflesh 0–5. Add them for a total of 0–48. The published bands are 5–12 mild, 13–24 moderate, 25–36 moderately severe and more than 36 severe.

What is the maximum COWS score?

The maximum possible COWS score is 48. The band describes observed withdrawal severity; it does not select a medication or dose.

What COWS score is needed before giving buprenorphine?

A COWS total alone does not establish medication timing or dose. Published protocols use different thresholds and must also account for the opioid used, time since last use, objective findings, examination and the selected induction approach. Follow the current institutional protocol and the prescribing clinician’s assessment.

How often is the COWS repeated?

Protocols set their own reassessment intervals. Recording each score with its time, as the serial log here does, shows whether withdrawal is rising, stable or settling. Use the interval in your local protocol.

Who administers the COWS?

The COWS is clinician-administered. A trained provider observes and rates each item; a few items, such as bone aches and GI upset, rely on what the patient reports. It is not designed as a self-report questionnaire.

How does COWS differ from SOWS and CIWA?

The Subjective Opiate Withdrawal Scale (SOWS) is a 16-item patient-rated questionnaire scored 0–4 per item (0–64), while COWS is clinician-rated. CIWA-Ar is used for alcohol withdrawal, not opioid withdrawal, and the scales should not be interchanged.

Does this tool store any patient data?

The assessment selections, scores and serial log stay in browser memory and are not stored by this tool or sent to a calculation API. The assessment area is masked from Microsoft Clarity. General page analytics may still receive page-use metadata under the site privacy policy, so do not enter patient identifiers.

COWS Opioid Withdrawal Scale

Rate the 11 COWS signs, which add up to a total of 0–48. The published bands are 5–12 mild, 13–24 moderate, 25–36 moderately severe and more than 36 severe. Add each reassessment to the serial log to follow the trend.

Clinical Assessment Items

1. Resting Pulse Rate (bpm, after sitting or lying 1 minute)

2. Sweating (past ½ hour, not explained by room temperature or activity)

3. Restlessness (observation during assessment)

4. Pupil Size

5. Bone or Joint Aches (score only the part attributed to withdrawal)

6. Runny Nose or Tearing (not accounted for by cold symptoms or allergies)

7. GI Upset (over last ½ hour)

8. Tremor (observation of outstretched hands)

9. Yawning (observation during assessment)

10. Anxiety or Irritability

11. Gooseflesh Skin (piloerection)

Result

—

COWS Total (0 – 48)

—

Item	Pts
Total

Serial scores

Time	Total	Band	Change

The log lives in this tab only and is cleared on reload.

Not medical advice: COWS is clinician-administered and does not replace a full assessment or prescriber decision. Assessment selections and scores are processed only in browser memory and masked from Clarity; do not enter patient identifiers. General page analytics are described in the site privacy policy.

COWS items and scoring

Clinical Opiate Withdrawal Scale, Wesson & Ling (2003). Score each item from the anchor that best matches the observation, then add the 11 item scores.

Item	Anchors	Max
1. Resting Pulse Rate	0 ≤80 · 1 81–100 · 2 101–120 · 4 >120	4
2. Sweating	0 No report of chills or flushing · 1 Subjective report of chills or flushing · 2 Flushed or observable moistness on face · 3 Beads of sweat on brow or face · 4 Sweat streaming off face	4
3. Restlessness	0 Able to sit still · 1 Reports difficulty sitting still, but is able to do so · 3 Frequent shifting or extraneous movements of legs/arms · 5 Unable to sit still for more than a few seconds	5
4. Pupil Size	0 Pupils pinned or normal size for room light · 1 Pupils possibly larger than normal for room light · 2 Pupils moderately dilated · 5 Pupils so dilated that only the rim of the iris is visible	5
5. Bone or Joint Aches	0 Not present · 1 Mild diffuse discomfort · 2 Patient reports severe diffuse aching of joints/muscles · 4 Patient is rubbing joints or muscles and unable to sit still because of discomfort	4
6. Runny Nose or Tearing	0 Not present · 1 Nasal stuffiness or unusually moist eyes · 2 Nose running or tearing · 4 Nose constantly running or tears streaming down cheeks	4
7. GI Upset	0 No GI symptoms · 1 Stomach cramps · 2 Nausea or loose stool · 3 Vomiting or diarrhea · 5 Multiple episodes of diarrhea or vomiting	5
8. Tremor	0 No tremor · 1 Tremor can be felt, but not observed · 2 Slight tremor observable · 4 Gross tremor or muscle twitching	4
9. Yawning	0 No yawning · 1 Yawning once or twice during assessment · 2 Yawning three or more times during assessment · 4 Yawning several times per minute	4
10. Anxiety or Irritability	0 None · 1 Patient reports increasing irritability or anxiousness · 2 Patient obviously irritable or anxious · 4 Patient so irritable or anxious that participation in the assessment is difficult	4
11. Gooseflesh Skin	0 Skin is smooth · 3 Piloerection of skin can be felt or hairs standing up on arms · 5 Prominent piloerection	5
Maximum total		48

Severity bands

0–4	Below the mild band (the form gives no label)
5–12	Mild
13–24	Moderate
25–36	Moderately severe
>36	Severe

Worked example

Pulse 96 bpm (1), subjective chills (1), frequent shifting of legs (3), moderately dilated pupils (2), mild diffuse aches (1), nose running (2), nausea (2), slight observable tremor (2), three yawns during the assessment (2), obviously irritable (2), smooth skin (0). Total = 1 + 1 + 3 + 2 + 1 + 2 + 2 + 2 + 2 + 2 + 0 = 18, which is in the moderate band (13–24). A reassessment an hour later that scores 11 is recorded as a change of −7 and falls in the mild band.

For education and documentation support only. Not medical advice; follow the applicable protocol and clinician judgment.

Summary

The Clinical Opiate Withdrawal Scale (COWS; Wesson & Ling, 2003) is an 11-item clinician-administered instrument for documenting opioid-withdrawal severity. Each item has fixed anchor points and the total ranges from 0 to 48. Enter the resting pulse in bpm to score item 1 automatically, add each reassessment to the in-page serial log, and copy a plain-text summary for the record. Medication timing and dosing depend on the opioid used, the protocol, the examination and prescriber judgment, and cannot be inferred from this score alone. This page is not medical advice.

How it works

Rate each of the 11 COWS items from the dropdowns. For item 1 you can type the resting pulse in bpm instead: ≤80 scores 0, 81–100 scores 1, 101–120 scores 2 and above 120 scores 4.
The total is the sum of the item scores, from 0 to 48. It updates as you change any item.
The band follows the published scale: 5–12 mild, 13–24 moderate, 25–36 moderately severe, above 36 severe. Totals below 5 are below the mild band.
Click "Add to serial log" after each reassessment to record the time and score. The log shows the change from the previous and the first score. It stays in this browser tab and is cleared on reload.
Copy the summary to paste the total, band, positive items and serial scores into a note.

Use cases

Document opioid withdrawal severity with a standard 11-item scale.
Track repeated COWS scores over time during observation or induction under an institutional protocol.
Check which items drive a high total before a clinician reviews the patient.
Teach residents, nurses and students the COWS anchors and scoring.
Cross-check a paper COWS form total.

Frequently Asked Questions

Last updated: 2026-10-10 · Reviewed by Nham Vu