Clinical Opioid Withdrawal Score (COWS)

Resting ...
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Description

Clinical Opioid Withdrawal Score (COWS)



Resting Pulse Rate: Record beats per minute after patient is sitting or lying down for one minute

• 0 - pulse rate 80 or below

• 1 - pulse rate 81–100

• 2 - pulse rate 101–120

• 4 - pulse rate greater than 120

Sweating: Over past ½ hour not accounted for by room temperature or activity

• 0 - no chills or flushing

• 1 - subjective chills or flushing

• 2 - flushed or observable moistness on face

• 3 - beads of sweat on brow or face

• 4 - sweat streaming off face

Restlessness: Observation during assessment

• 0 - able to sit still

• 1 - reports difficulty sitting still, but is able to do so 

• 3 - frequent shifting or extraneous movement of legs/arms

• 5 - unable to sit still for more than a few seconds

Pupil size

• 0 - pupils pinned or normal size for light

• 1 - pupils possibly larger than normal for light

• 2 - pupils moderately dilated

• 5 - pupils dilated that only rim of the iris is visible

Bone or joint aches: If patient was having pain previously, only the additional component attributed to opiate withdrawal is scored

• 0 - not present

• 1 - mild/diffuse discomfort

• 2 - patient reports severe diffuse aching of joints/muscles

• 4 - patient is rubbing joints or muscles and is unable to sit still because of discomfort

Runny nose or tearing: Not accounted for by cold symptoms or allergy

• 0 - none present

• 1 - nasal stuffiness or unusually moist eyes

• 2 - nose running or tearing

• 4 - nose constantly running or tears streaming down cheeks

GI upset: Over last ½ hour • 2 - nausea or loose stool

• 0 - no GI symptoms

• 1 - stomach cramps

• 3 - vomiting or diarrhea

• 5 - multiple episodes of diarrhea or vomiting

Tremor: Observation of outstretched hands

• 0 - no tremor

• 1 - tremor can be felt, but not observed

• 2 - slight tremor observable

• 4 - gross tremor or muscle twitching

Yawning: Observation during assessment

• 0 - no yawning

• 1 - yawning once or twice during assessment

• 2 - yawning three or more times during assessment

• 4 - yawning several times/minute

Anxiety or irritability 

• 0 - none

• 1 - patient reports increasing irritability or anxiousness

• 2 - patient obviously irritable or anxious

• 4 - patient so irritable or anxious that participation in the assessment is difficult

Gooseflesh skin 

• 0 - skin is smooth 

• 3 - piloerrection of skin can be felt or hairs standing up on arms

• 5 - prominent piloerrection



5—12 = mild;

13—24 = moderate;

25—36 = moderately severe;

> 36 = severe withdrawal



Support for Hospital Opioid Use Treatment (SHOUT)



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Contributed by

Dr. Gerald Diaz
@GeraldMD
Board Certified Internal Medicine Hospitalist, GrepMed Editor in Chief 🇵🇭 🇺🇸 - Sign up for an account to like, bookmark and upload images to contribute to our community platform. Follow us on IG:  https://www.instagram.com/grepmed/ | Twitter: https://twitter.com/grepmeded/
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