COWS (opioid withdrawal)
Clinical Opiate Withdrawal Scale (Wesson & Ling 2003): eleven pre-graded items per the COWS scoring sheet; 5-12 mild, 13-24 moderate, 25-36 moderately severe, > 36 severe.
Open the calculator → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Resting pulse points
- 1
- Sweating points
- 2
- Restlessness points
- 1
- Pupil size points
- 1
- Bone / joint aches points
- 2
- Runny nose / tearing points
- 2
- GI upset points
- 2
- Tremor points
- 1
- Yawning points
- 1
- Anxiety / irritability points
- 2
- Gooseflesh skin points
- 0
Result: COWS 15 (moderate withdrawal).
The tool opens with these values already filled in. Replace them with your own.
What the result means
- 5-12
- Mild opioid withdrawal per source.
- 13-24
- Moderate opioid withdrawal per source.
- 25-36
- Moderately severe opioid withdrawal per source.
- >=37
- Severe opioid withdrawal per source.
What you enter
- Resting pulse points (0/1/2/4)
- Sweating points (0-4)
- Restlessness points (0/1/3/5)
- Pupil size points (0/1/2/5)
- Bone / joint aches points (0/1/2/4)
- Runny nose / tearing points (0-4)
- GI upset points (0/1/2/3/5)
- Tremor points (0-4)
- Yawning points (0-4)
- Anxiety / irritability points (0/1/2/4)
- Gooseflesh skin points (0/3/5)
What this is
Score the Clinical Opiate Withdrawal Scale (Wesson 2003) across its 11 observed and reported items - resting pulse, sweating, restlessness, pupil size, bone or joint aches, runny nose, GI upset, tremor, yawning, anxiety, and gooseflesh skin. Sophie Well sums the items to a 0-48 total and returns the published severity band: mild (5-12), moderate (13-24), moderately severe (25-36), or severe (>=37).
When to use it
Use this at induction onto buprenorphine to confirm objective withdrawal before the first dose (typically COWS >=8-12 per the SAMHSA TIP 63 induction protocol), or to track withdrawal severity during inpatient opioid taper. The score is an aid to clinical judgment, not a substitute for it; precipitated withdrawal can still occur even when COWS is in the expected range.
How this is calculated
Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253-259. Read the source ↗
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.
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