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Clinical Opiate Withdrawal Scale: Everything You Need to Know

Peter Manza, PhD profile image
Reviewed By Peter Manza, PhD • Updated Aug 21, 2023 • 6 cited sources

The Clinical Opiate Withdrawal Scale (COWS) is a tool used by healthcare professionals to assess the severity of opioid withdrawal symptoms in people who are physically dependent on opioids and attempting to stop taking the drugs. 

It is a standardized tool that helps healthcare providers to track a person’s progress through detox, so they can create a unique treatment plan that serves them where they are in the recovery process. 

COWS Basics

The COWS scale is essentially a list of 11 common symptoms of opioid withdrawal, including restlessness, sweating, dilated pupils, gastrointestinal upset, and insomnia.[1] The patient is scored on each symptom according to the severity that they experience, usually on a scale of 0 to 4. Then, those scores are added up to determine the overall severity of their detox experience.

Scores for the overall test can be anywhere between 0 and 48, with higher scores indicating more severe symptoms. The scores are generally classified as follows:

  • No withdrawal symptoms: 4 or less
  • Mild withdrawal: 5–12
  • Moderate withdrawal: 13–24
  • Moderately severe withdrawal: 25–36
  • Severe withdrawal: Higher than 36

Healthcare professionals may use COWS to guide treatment decisions, determining whether or not the use of Medication for Addiction Treatment (MAT) like methadone or buprenorphine would help manage withdrawal symptoms. COWS can also be used to monitor patients as they go through the detoxification process, to make sure that the chosen treatments are working well. 

It’s important to note that while COWS is a useful tool, it is not a substitute for a thorough medical evaluation and treatment plan overseen by healthcare professionals. It is recommended that people experiencing opioid withdrawal symptoms seek professional treatment and support. 

How & When Was the Clinical Opiate Withdrawal Scale Developed? 

The Clinical Opiate Withdrawal Scale (COWS) was developed in 2003 by addition medicine specialists Wesson and Ling as a way to regiment the assessment of opioid withdrawal symptoms to provide a uniform standard that could be applied across the industry.[2]

Prior to the development of COWS, there was no standardized tool for measuring the severity of opioid withdrawal. This made it difficult for healthcare providers to assess and manage withdrawal symptoms and truly understand what patients had experienced in the past in order to create a proper treatment plan going forward. 

The development of COWS was based on existing literature on opioid withdrawal symptoms and documented clinical experience. The goal was to create a design that was easy to use and read that would become a reliable measure of opioid withdrawal symptoms that could be understood industry-wide. 

Who Uses the Clinical Opiate Withdrawal Scale? 

The Clinical Opiate Withdrawal Scale is primarily used by healthcare professionals in any case in which the patient may be dealing with opioid withdrawal symptoms acutely or chronically. 

COWS is a widely used tool in addiction medicine across venues, with research studies demonstrating its effectiveness in assessing opioid withdrawal and guiding treatment decisions. The scale has also been adapted for use in various clinical settings, including emergency departments and primary care clinics, to help healthcare providers identify and manage opioid withdrawal in patients.[3]

The COWS scale is typically used by the following:

  • Addiction medicine specialists
  • Primary care providers
  • Emergency department personnel
  • Any healthcare providers who may encounter patients with opioid use disorder.

The COWS scale is especially important in settings where patients are actively undergoing opioid detox, as it provides a standardized method for assessing and managing withdrawal symptoms.

For example, if a patient presents in the emergency room with symptoms that include nausea and vomiting, agitation, aches and pains, and irritability, the staff may implement the COWS instrument to determine whether or not opioid withdrawal symptoms may be the cause and if so, to what degree. 

The COWS sheet with the patients assessment scores can go with them and be given to the next provider. This can help them come up with a treatment plan that will allow them to safely execute detox from opioids. 

Since its implementation, COWS has been instrumental in improving the care of people with opioid use disorder, improving the consistency and quality of care.

When Is the COWS Scale Used?

The Clinical Opiate Withdrawal Scale (COWS) is used whenever a healthcare provider is dealing with a patient who may be in the throes of opioid detox or experiencing ongoing or chronic opioid withdrawal symptoms. 

These cases might include the following:

  • Initial diagnosis of medical cause in an emergency room setting
  • Baseline assessment when beginning treatment for opioid use disorder
  • Ongoing check-ins during opioid detox and OUD treatment, especially when determining dosage changes during MAT 
  • Check-in treatment and care after relapse
  • Medical assessment in medical setting when opioid detox symptoms may be present

Especially when using medications like Suboxone to manage someone’s withdrawal symptoms, it is very useful to have a way to track ongoing experience of symptoms. This helps providers to determine whether or not a medication is working, if it may be safe to decrease the dosage somewhat, or if it may be possible to stop using medications completely. In fact, it is recommended specifically for use during buprenorphine induction and treatment.[4]

What Are the 11 Withdrawal Symptoms on the Scale? 

There are 11 withdrawal symptoms on the Clinical Opiate Withdrawal Scale the used to determine state of wellness for people struggling with OUD and going through the detox process.[5]

These 11 withdrawal symptoms include the following: 

  1. Resting pulse rate: The heart rate of the individual is measured while the person is at rest. Elevated heart rate at rest can indicate opioid withdrawal. 
  2. Sweating: Profuse and heavy sweating when at rest is often indicative of opioid withdrawal.
  3. Restlessness: Agitation and restlessness are common opioid withdrawal symptoms. 
  4. Pupil size: The size of the individual’s pupils is measured, because “pinned” pupils can indicate opioids in the system.
  5. Gastrointestinal upset: The presence and severity of gastrointestinal symptoms, such as nausea, vomiting, and diarrhea, in combination with other factors can indicate opioid detox.
  6. Tremors: Tremors and shakiness are assessed as well, as they are common opioid withdrawal symptoms.
  7. Yawning: Yawning is common during opioid detox, so the frequency and intensity are evaluated.
  8. Anxiety or irritability: The person’s level of anxiety or irritability is assessed. Higher levels in conjunction with other symptoms can indicate opioid withdrawal. 
  9. Gooseflesh skin: The presence and severity of goosebumps or “gooseflesh” on the skin are assessed as well. 
  10. Bone or joint aches: The presence and severity of bone or joint aches are included, as these will increase and decrease with severity of opioid withdrawal.
  11. Runny nose or tearing: A runny nose and tearing eyes are common during detox, so the intensity level will be noted as part of the evaluation process. 

These symptoms are scored on a scale of 0 to 4 or in some cases 5, with 0 indicating the absence of the symptom and 4 or 5 indicating severe symptoms. Once completed, the scores for each individual symptom are added up, and the total score is then used to guide treatment decisions.

How Do You Read the COWS Score?

Each of the 11 symptoms on the Clinical Opiate Withdrawal Scale is scored, and the total of those scores are added up to determine the overall score. This score is then used to determine the best course forward for treatment. 

Here’s how it works: 

  • Score each symptom. The healthcare provider assesses each of the 11 withdrawal symptoms and assigns a score from 0 to 4 or 5 based on the severity of the symptom.
  • Add up the scores. The scores for each symptom are added together to get a total score, which can range from 0 to 48.
  • Interpret the score. The total score is used to guide treatment decisions.[6] A score of less than 5 indicates that the individual is experiencing no or few withdrawal symptoms, while a score of 5 to 12 indicates mild symptoms. A score of 13 to 24 is assessed as moderate, while a score of 25 to 36 is considered moderately severe. Anything over 37 is severe. 
  • Adjust treatment accordingly. The healthcare provider may use the COWS score to determine the appropriate treatment plan for the person, such as Medication for Addiction Treatment, non-pharmacological interventions, or a combination of treatment approaches. The COWS score can also be used to monitor the individual’s progress through detox, so treatment can be adjusted as needed.

Get Treatment for Opioid Use Disorder 

If opioid withdrawal symptoms are a common occurrence for you or your loved one, it indicates a physical dependence. These symptoms are both physical and mental in nature, and they can range in severity greatly, depending on the severity of OUD. In order to avoid relapse and starting the cycle all over again, MAT is recommended. 

If the dependence is also characterized by cravings for more of the drug, a symptom that is not indicated on the COWS scale, it is essential to undertake nonpharmacological treatment interventions at the same time: therapy, support groups, and lifestyle changes. 
To get started on the path to freedom from opioid use disorder, contact Bicycle Health today. We are ready to help you get on the path to a better tomorrow.

Reviewed By Peter Manza, PhD

Peter Manza, PhD received his BA in Psychology and Biology from the University of Rochester and his PhD in Integrative Neuroscience at Stony Brook University. He is currently working as a research scientist in Washington, DC. His research focuses on the role ... Read More

  1. Clinical Opiate Withdrawal Scale. National Institute on Drug Addiction. April–June 2003. Accessed March 2023.
  2. The Clinical Opiate Withdrawal Scale (COWS). Journal of Psychoactive Drugs. April–June 2003. Accessed March 2023.
  3. Interobserver Agreement Between Emergency Clinicians and Nurses for Clinical Opiate Withdrawal Scale. Journal of the American College of Emergency Physicians Open. June 2021. Accessed March 2023.
  4. COWS Score for Opiate Withdrawal. MD+ Calc. Accessed March 2023.
  5. COWS Algorithm. Vanderbilt University Medical Center. Accessed March 2023.
  6. Clinical Opiate Withdrawal Scale. University of Washington. Accessed March 2023.

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