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    Attention COACH STUDY participants:

    The principal investigators of the study request that you use the official version of the modified score here.

    COWS Score for Opiate Withdrawal

    Quantifies severity of opiate withdrawal.
    When to Use
    Pearls/Pitfalls
    Why Use
    • COWS may be used in both inpatient and outpatient settings:
      • During Detox: for the general monitoring of opiate withdrawal during opioid detoxification.
      • During Pain Treatment: for patients receiving opiates for the treatment of acute or chronic pain who may show subtle signs of opiate withdrawal.
      • In the ED & More: for patients requesting methadone for opiate withdrawal symptoms and their enrollment in methadone maintenance treatment has not been verified.
    • COWS is most commonly used in buprenorphine induction, and is recommended specifically for this use.
    • The Clinical Opiate Withdrawal Score (COWS) limits possibility of feigned responses by combining subjective symptoms with objective signs. (Wesson DR 2003)
    • COWS was first published in a training manual for buprenorphine treatment.
    • While commonly used for buprenorphine or buprenorphine/naloxone induction, it can also be useful in a variety of office, clinic and hospital settings. Examples include the assessment of acute opiate withdrawal during an opiate detoxification program, methadone maintenance treatment, and the treatment of chronic pain.
    • The scale is designed to be used quickly (< 2 minutes) by clinicians.
    • Be aware that the prescribing of buprenorphine and buprenorphine/naloxone in the context of opioid addiction treatment requires additional credentialing by the DEA.
    • As stated above, it combines subjective and objective components, limiting the possibility of feigned responses.
    • It can be serially administered to track changes in the severity of withdrawal symptoms over time or in response to treatment.
    ≤80
    0
    81-100
    +1
    101-120
    +2
    >120
    +4
    No report of chills or flushing
    0
    Subjective report of chills or flushing
    +1
    Flushed or observable moistness on face
    +2
    Beads of sweat on brow or face
    +3
    Sweat streaming off face
    +4
    Able to sit still
    0
    Reports difficulty sitting still, but is able to do so
    +1
    Frequent shifting or extraneous movements of legs/arms
    +3
    Unable to sit still for more than a few seconds
    +5
    Pupils pinned or normal size for room light
    0
    Pupils possibly larger than normal for room light
    +1
    Pupils moderately dilated
    +2
    Pupils so dilated that only the rim of the iris is visible
    +5
    Not present
    0
    Mild diffuse discomfort
    +1
    Patient reports severe diffuse aching of joints/ muscles
    +2
    Patient is rubbing joints or muscles and is unable to sit still because of discomfort
    +4
    Not present
    0
    Nasal stuffiness or unusually moist eyes
    +1
    Nose running or tearing
    +2
    Nose constantly running or tears streaming down cheeks
    +4
    No GI symptoms
    0
    Stomach Cramps
    +1
    Nausea or loose stool
    +2
    Vomiting or diarrhea
    +3
    Multiple episodes of vomiting or diarrhea
    +5
    No tremor
    0
    Tremor can be felt, but not observed
    +1
    Slight tremor observable
    +2
    Gross tremor or muscle twitching
    +4
    No yawning
    0
    Yawning once or twice during assessment
    +1
    Yawning three or more times during assessment
    +2
    Yawning several times/minute
    +4
    None
    0
    Patient reports increasing irritability or anxiousness
    +1
    Patient obviously irritable/anxious
    +2
    Patient so irritable or anxious that participation in the assessment is difficult
    +4
    Skin is smooth
    0
    Piloerection of skin can be felt or hairs standing up on arms
    +3
    Prominent piloerection
    +5

    Result:

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    Next Steps
    Evidence
    Creator Insights
    Dr. Donald R. Wesson

    About the Creator

    Donald R. Wesson, MD, is a board-certified psychiatrist and currently on the executive council of the California Society of Addiction Medicine. He formerly served as chief psychiatrist at the Haight-Ashbury Free Medical Clinic in San Francisco while maintaining a private practice. Dr. Wesson has been the principal investigator for 20+ clinical trials, some sponsored by the National Institute on Drug Abuse (NIDA), and has authored numerous publications.

    To view Dr. Donald R. Wesson's publications, visit PubMed

    Are you Dr. Donald R. Wesson? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
    Content Contributors
    About the Creator
    Dr. Donald R. Wesson
    Are you Dr. Donald R. Wesson?
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