What Is the Clinical Opiate Withdrawal Scale (COWS)

The Clinical Opiate Withdrawal Scale, or COWS, is a numbered scale designed to help clinicians tailor opioid withdrawal treatment to individual people. It is used in both inpatient and outpatient rehabilitation settings to determine the severity of opioid withdrawal and monitor how symptoms change over time during treatment.

The scale uses 11 common symptoms of opioid withdrawal and measures their severity. Typically, symptoms of opioid withdrawal feel like a cold or the flu, but other measures like pulse or blood pressure can help a clinician monitor the severity of the experience.

The 11 Withdrawal Symptoms on the Scale

The 11 withdrawal symptoms measured as part of COWS are:

1. Resting pulse rate: 80 or below, 81-100, 101-120, or greater than 120 beats per minute
2. Gastrointestinal upset: based on symptoms from the past 30 minutes and rated as no symptoms, stomach cramps, nausea or loose stool, vomiting or diarrhea, and multiple episodes of vomiting or diarrhea
3. Sweating: not taking physical activity or room temperature into account and measured over the past 30 minutes; scale includes no chills or flushing, some self-reported chills and flushing, flushed face with observable sweat, beads of sweat on brow or face, and sweat streaming off of face
4. Tremor: based on the clinician’s observation of the patient’s outstretched hands; measures no tremor, felt but not observed, slight observable tremor, or gross tremor or muscle twitching
5. Restlessness: measurable through observation, like tremor, and described with able to sit still, difficulty sitting still, frequent shifting of legs or arms, unable to sit still
6. Yawning: measured as none, once or twice during assessment, three or more times during assessment, and several times per minute
7. Pupil size: measured based on visual exam, through descriptions pinned or normal size for light, larger than normal for light in room, moderately dilated, and extremely dilated
8. Anxiety and irritability: predominantly self-reported by the patient, but can be a very useful measure of how the individual experiences withdrawal symptoms; scale rates as none, increasing irritability/anxiousness, obvious irritability/anxiousness, and participation in assessment is difficult due to irritability/anxiety
9. Bone or joint aches: only related to sensations attributable to opiate withdrawal; measures as none, mild and diffuse discomfort, patient-reported severe aches, and patient visibly rubbing sore joints or muscles during assessment
10. Goosebumps: measured with descriptions skin is smooth, piloerection (hairs standing up) can be felt but not seen, and piloerection is prominent
11. Runny nose and watering eyes: measurement only for withdrawal-related symptoms; descriptions for measurement: none present, nasal stuffiness and unusually moist eyes, and nose constantly running with tears streaming down the cheeks

In some clinics, COWS also includes the introduction of buprenorphine during the assessment: whether none was given, or when it was supplied during the assessment and how often.

Each description in the 11-symptom scale has a numerical value, which is tallied to help the clinician understand the severity of withdrawal. Scores of 5-12, for example, indicate mild withdrawal, while a score of 36 or more indicates severe withdrawal.

History of the Clinical Opiate Withdrawal Scale

As heroin addiction became a greater problem in the US and Europe, the COWS scale was developed to measure the severity of the addiction and withdrawal syndrome. COWS is based on the CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised), used to measure alcohol withdrawal after a person struggles with alcoholism. The opioid scale was developed in the 1930s, and since then, many other scales have been developed for opioid withdrawal and other substances of addiction.

COWS is in contrast with another scale, called the Subjective Opiate Withdrawal Scale (SOWS), according to the World Health Organization. This is a self-reported scale in which a clinician interviews a person experiencing opioid withdrawal symptoms to understand the person’s experience of symptoms, including:

• Sweating
• Watering of the eyes
• Runny nose
• Yawning
• Hot and cold flashes
• Anorexia, or loss of appetite
• Abdominal cramps
• Nausea
• Vomiting and diarrhea
• Shaking or tremor
• Insomnia
• Restlessness
• General aches and pains
• Tachycardia
• Hypertension
• Goosebumps
• Dilated pupils
• Bowel sounds

Typically, when using SOWS, a clinician will also measure specific items like hypertension to verify the report. Using a combination of scales can help the clinician to not only understand the experience of withdrawal symptoms but also how their patient experiences them, which could be an indication of cravings, psychological withdrawal, and potential for relapse. Understanding all of these experiences gives rehabilitation professionals a good understanding of how to best help each client individually.

Administration of Medically Managed Detox

COWS, and other scales, exist to aid a clinical in learning, during assessment, whether the person needs medication like buprenorphine to help them overcome opioid addiction. Severe withdrawal can turn into protracted withdrawal without this kind of management and lead to suffering for several weeks or months. Instead, using medications like buprenorphine to ease the body off physical dependence on the drug can help the person feel good about their choice to end their addiction and help them focus during therapy and counseling sessions.

An associated buprenorphine administration scale works with COWS to help doctors appropriately dose people who need this type of medication management. The scale distinguishes between pregnant and non-pregnant patients, and lowers the dose over a period of three days. However, the clinician should feel able to adjust treatment so the person ends the taper earlier or later, depending on their needs, as recovery is an individual process.

The medication scale also has notes regarding other medications that can be used during detox. These include:

• Clonidine, a benzodiazepine to ease anxiety
• Dicyclomine, which helps relieve abdominal discomfort
• Loperamide, for improved bowel movements
• Zofran, to address nausea and vomiting
• Doxepin or trazodone, for insomnia in male or female patients, respectively
• Ibuprofen and Tylenol, in prescription doses, for aches and pains

COWS and similar scales are extremely important in rehabilitation because they help the medical professionals involved in recovery to understand their clients. These scales use both self-reporting, and medical measurements, so the person can get highly personalized treatment and work toward sobriety. Detox is just one part of overcoming addiction, but it is important to manage it properly so the person can progress into comprehensive therapy.

Desert Hope, American Addiction Centers’ drug detox center in Las Vegas, is ready to help you achieve a life of sobriety and long-term recovery. Call us today at to learn more about our specialized addiction treatment programs near you.