What COWS score is needed before giving buprenorphine?

Most protocols require a COWS score of 8 or higher before initiating buprenorphine. This ensures sufficient receptor displacement so buprenorphine does not precipitate acute withdrawal. Always follow your institutional protocol and clinical judgment.

What is the maximum COWS score?

The maximum possible COWS score is 48, though scores above 36 are uncommon. Scores above 36 indicate severe withdrawal requiring close monitoring and possibly higher initial buprenorphine doses under supervision.

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?

No. All calculations run in your browser. Nothing is sent to any server or stored anywhere.

COWS Opioid Withdrawal Scale

Name: COWS Opioid Withdrawal Scale
Availability: InStock
Author: Nham Vu

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)

2. Sweating

3. Restlessness

4. Pupil Size

5. Bone or Joint Aches

6. Runny Nose or Tearing

7. GI Upset

8. Tremor

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 used clinically to titrate buprenorphine induction — clinical judgment is required. This tool does not replace a full clinical assessment or prescriber decision-making. No patient data is sent to any server.

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.
Click "Calculate COWS Score" to sum all items and display the total.
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: 2026-07-22 · Reviewed by Nham Vu