Free tool · Scored assessment
COWS Calculator.
The Clinical Opiate Withdrawal Scale — the standard bedside score for opioid withdrawal. Rate all eleven clinician-observed items and get the aggregate (max 48), the severity band, and the context for buprenorphine-induction timing. Item wording is transcribed from the original Wesson & Ling 2003 scale; the induction context follows SAMHSA guidance. The score supports your judgment and your facility's protocol — it doesn't replace them.
Score the 11 COWS items
Rate each item on the patient in front of you for symptoms not better explained by another cause (room temperature, allergies, pre-existing pain). The total updates as you go.
Score all eleven items to see the total and severity band.
Severity bands [1]
| COWS total | Severity |
|---|---|
| 5–12 | Mild withdrawal |
| 13–24 | Moderate withdrawal |
| 25–36 | Moderately severe withdrawal |
| > 36 | Severe withdrawal |
A score of 4 or less indicates minimal or no withdrawal. The total ranges 0–48 across the 11 clinician-observed items.[1] COWS is commonly used to time buprenorphine induction: many protocols wait until the patient is in at least moderate objective withdrawal (often a COWS in the low double digits, per your protocol) before the first buprenorphine dose, to reduce the risk of precipitated withdrawal.[3] Your facility's order set defines the exact induction threshold.
The 11 items at a glance [1]
| Item | Possible points |
|---|---|
| Resting pulse rate | 0, 1, 2, 4 |
| GI upset | 0, 1, 2, 3, 5 |
| Sweating | 0, 1, 2, 3, 4 |
| Tremor | 0, 1, 2, 4 |
| Restlessness | 0, 1, 3, 5 |
| Yawning | 0, 1, 2, 4 |
| Pupil size | 0, 1, 2, 5 |
| Anxiety or irritability | 0, 1, 2, 4 |
| Bone or joint aches | 0, 1, 2, 4 |
| Runny nose or tearing | 0, 1, 2, 4 |
| Gooseflesh skin | 0, 3, 5 |
Maximum possible score 48. Items are scored on what the clinician can observe and what the patient reports during the assessment.[1]
References
- Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253–259. PMID: 12924748. (Original 11-item scale; item anchors, point values, maximum 48, and the mild/moderate/moderately-severe/severe bands transcribed from this instrument.)
- Clinical Opiate Withdrawal Scale (COWS). National Institute on Drug Abuse (NIDA), reproduced form. nida.nih.gov. (Standard reproduced version of the Wesson & Ling form used to confirm item wording and scoring.)
- Substance Abuse and Mental Health Services Administration (SAMHSA). TIP 63: Medications for Opioid Use Disorder. Rockville, MD: SAMHSA. samhsa.gov. (Buprenorphine induction is timed to objective opioid withdrawal — commonly assessed with the COWS — to reduce the risk of precipitated withdrawal; the exact threshold is set by local protocol.)
Item wording, point values, and bands were transcribed from the COWS instrument. Your facility may use a locally adapted COWS protocol and induction threshold — those take precedence at the bedside.
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