COWS: Clinical Opiate Withdrawal Scale

For each item, choose the description that best fits the patient’s signs or symptoms. Rate only what relates to opioid withdrawal: for example, if the heart rate is raised because the patient was jogging just before the assessment, the higher pulse would not add to the score.

1. 1Resting pulse rateBeats per minute, measured after the patient has been sitting or lying for one minute

   080 or below181–1002101–1204Greater than 120
2. 2SweatingOver the past half hour, not accounted for by room temperature or patient activity

   0No report of chills or flushing1Subjective report of chills or flushing2Flushed or observable moistness on face3Beads of sweat on brow or face4Sweat streaming off face
3. 3RestlessnessObservation during assessment

   0Able to sit still1Reports difficulty sitting still, but is able to do so3Frequent shifting or extraneous movements of legs or arms5Unable to sit still for more than a few seconds
4. 4Pupil size

   0Pupils pinned or normal size for room light1Pupils possibly larger than normal for room light2Pupils moderately dilated5Pupils so dilated that only the rim of the iris is visible
5. 5Bone or joint achesIf the patient was having pain previously, only the additional component attributed to opioid withdrawal is scored

   0Not present1Mild diffuse discomfort2Patient reports severe diffuse aching of joints or muscles4Patient is rubbing joints or muscles and is unable to sit still because of discomfort
6. 6Runny nose or tearingNot accounted for by cold symptoms or allergies

   0Not present1Nasal stuffiness or unusually moist eyes2Nose running or tearing4Nose constantly running or tears streaming down cheeks
7. 7Gastrointestinal upsetOver the last half hour

   0No GI symptoms1Stomach cramps2Nausea or loose stool3Vomiting or diarrhoea5Multiple episodes of diarrhoea or vomiting
8. 8TremorObservation of outstretched hands

   0No tremor1Tremor can be felt, but not observed2Slight tremor observable4Gross tremor or muscle twitching
9. 9YawningObservation during assessment

   0No yawning1Yawning once or twice during assessment2Yawning three or more times during assessment4Yawning several times a minute
10. 10Anxiety or irritability

    0None1Patient reports increasing irritability or anxiousness2Patient obviously irritable or anxious4Patient so irritable or anxious that participation in the assessment is difficult
11. 11Gooseflesh skin

    0Skin is smooth3Piloerection of skin can be felt or hairs standing up on arms5Prominent piloerection