For patients in medically assisted opioid treatment, assessing withdrawal severity is essential. Developed in the 1930s, the Clinical Opiate Withdrawal Scale (COWS) guides the withdrawal treatment process by helping clinicians evaluate symptoms and adjust care plans accordingly.
COWS assigns a score to 11 symptoms.

The 11 assessments of the clinical opiate withdrawal scale

Resting pulse rate

Clinicians measure the patient’s pulse while at rest. A pulse under 80 beats per minute is assigned a score of 0. For every additional 20 beats, clinicians assign one additional point.

Sweating

Clinicians observe the patient for sweating without physical exertion. No visible sweating is assigned a score of 0. Facial sweat is assigned a score of 4. Intermediate levels receive scores between 1 and 3.

Restlessness

Clinicians evaluate how well the patient stays calm and still. If the patient remains calm, the score is 0. If they cannot stay seated for more than a few seconds, the score increases to 5.

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Pupil size

Under normal lighting, clinicians evaluate pupil dilation. Normal pupil size is assigned a score of 0. In contrast, severely dilated pupils with minimal visible iris are assigned a score of 5.

Gastrointestinal upset

Clinicians check for nausea, vomiting, or diarrhea. If none are present, the score is 0. If the patient vomits or has diarrhea within the past 30 minutes, the score is 5.

Bone and joint ache

Clinicians ask whether the patient feels aches. If there is no pain, the score is 0. Severe aches exclusive to withdrawal are assigned a score of 5. They do not count pain that existed before withdrawal.

Tears and running noses

Clinicians observe for either symptom. If neither is present, the score is 0. Obvious symptoms not linked to allergies or colds are assigned a score of 4. Mild symptoms are scored between 1 and 3.

Tremors

Clinicians ask the patient to extend their arms. If there are no tremors, the score is 0. Severe shaking caused by anxiety can be assigned up to a score of 4.

Goosebumps

This symptom uses a fixed scale. No goosebumps is assigned a score of 0. Hair standing up on arms or neck is assigned a score of 3. Visible skin changes are assigned a score of 5.

Anxiety or irritability

Clinicians ask the patient to describe their mood. If the patient shows no signs, the score is 0. If irritability disrupts their ability to participate, the score is 4.

Yawning

Clinicians count yawns during the assessment. No yawns are assigned a score of 0. Yawning more than once per minute is assigned a score of 4.

To access the Clinical Opiate Withdrawal Scale, visit the American Society of Addiction Medicine

Scoring interpretation

  • 0–4: little to no withdrawal
  • 5–12: mild withdrawal
  • 13–24: moderate withdrawal
  • 25–36: moderately severe withdrawal
  • 36+: severe withdrawal

Final thoughts

COWS is a key tool in withdrawal management. A clear assessment helps ensure that treatment plans meet each patient’s needs. Recognizing moderate to severe withdrawal early can prevent unnecessary suffering and guide better outcomes in detox and recovery.

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