Clinical Assessment Tool
Clinical Opiate Withdrawal Scale
An 11-item clinician-rated scale that puts a number on how far along someone is in opioid withdrawal. Score it on what you see in front of you and what the patient tells you right now.
Before you start
Rate each item for this moment, not for the whole day. If the patient already had a symptom before withdrawal started, score only the part that got worse.
If you are considering buprenorphine, the patient needs to be far enough into withdrawal before the first dose. Most protocols want a score above 5 or 6, and many prefer 10 or higher, to reduce the risk of precipitated withdrawal.
5 to 12 is mild, 13 to 24 is moderate, 25 to 36 is moderately severe, 37 and up is severe.
This is a scoring aid, not a diagnosis. The COWS supports clinical judgment and does not replace it. Anyone in withdrawal should be evaluated by a licensed medical provider, and treatment decisions belong to the treating clinician.
Instrument: Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). Journal of Psychoactive Drugs. 2003;35(2):253-259.
