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 prescribing clinician’s assessment.

What is the maximum COWS score?

The maximum possible COWS score is 48. The published interpretation is 5–12 mild, 13–24 moderate, 25–36 moderately severe, and more than 36 severe. The band describes observed withdrawal severity; it does not select a medication or dose.

Who administers the COWS?

The COWS is a clinician-administered scale. A trained healthcare provider observes and rates each item. It is not designed for self-reporting by the patient, though some items incorporate patient report for symptoms that cannot be directly observed (e.g., bone aches, GI upset).

How does COWS differ from CIWA?

CIWA (Clinical Institute Withdrawal Assessment) is used for alcohol withdrawal. COWS is specific to opioid withdrawal. They assess different physiological systems and should not be interchanged.

Does this tool store any patient data?

The assessment selections and calculated score 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

Score 11 clinical signs to calculate a COWS total and classify withdrawal as mild, moderate, moderately severe, or severe.

Clinical Assessment Items

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

2. Sweating (past ½ hour; exclude room/activity)

3. Restlessness

4. Pupil Size

5. Bone or Joint Aches

6. Runny Nose or Tearing

7. GI Upset (over last ½ hour)

8. Tremor (observe outstretched hands)

9. Yawning

10. Anxiety or Irritability

11. Gooseflesh Skin (piloerection)

Result

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COWS Total (0 – 48)

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Item	Pts
Total

Disclaimer: 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.

Summary

Score 11 clinical signs to calculate a COWS total and classify withdrawal as mild, moderate, moderately severe, or severe.

How it works

Select the observed value for each of the 11 COWS items using the dropdowns.
Each item has predefined point values reflecting clinical severity.
The total and severity band update as selections change; the Calculate button remains available for keyboard workflows.
The result panel shows the total score, severity band, and a brief clinical note.
Use the reset button to clear all fields for a new assessment.

Use cases

Assess severity of opioid withdrawal before initiating buprenorphine induction.
Monitor changes in withdrawal severity over time during treatment.
Document objective withdrawal findings in clinical notes.
Determine readiness for buprenorphine re-induction after missed doses.
Teach residents and students to recognize and quantify opioid withdrawal signs.
Support triage decisions in emergency and addiction medicine settings.

Frequently Asked Questions

Last updated: 2026-09-19 · Reviewed by Nham Vu