How COWS Can Help Assess Opiate Withdrawals

Clinical Opiate Withdrawals Scale (COWS)

The clinical opiate withdrawals scale (COWS) is a pen and paper instrument that rates eleven common opiate withdrawals symptoms.  Once the score for all of the opiate withdrawals symptoms are summed up, the counselor or physician can determine the level of physical dependence on opioids as well as determine what stage of opiate withdrawals the client is in.  For each of the symptoms that are assessed, the rating is based solely on the relationship to the opiate withdrawals.  For instance, if the client was jogging prior to the test then their heart rate must be given a chance to return to normal prior to the test.

Clinical Test For Rating Withdrawal Intensity

Here is a brief summary of the COWS test for opiate withdrawal:

1. Resting Pulse Rate: a score of 0 is given for a heart rate 80 or below while a score of 4 is given for a heart rate above 120.  There are various scores for heart rates in between these readings which can indicate the severity of the opiate withdrawals.
2. GI Upset: a score of 0 is given if there have been no symptoms of GI upset over the last ½ hour while a score of 5 is given if there have been  multiple episodes of diarrhea and vomiting over the last ½ hour.  Again there are scores provided for GI symptoms in between these.
3. Sweating (over the last ½ hour not caused by room temperature or patient activity): a zero is given is there is no reports of chills or flushing while a 4 is given if the opiate withdrawals are causing sweat to stream off of the face.  Other scores for symptoms in between these are also provided.
4. Tremor: with outstretched hands if the client shows no indication of tremors or shakes then a score of 0 is given.  If the opiate withdrawals are causing gross tremors or muscle twitching then a score of 4 is given.  Other scores are given for symptoms in between.
5. Restlessness: if during the assessment the client is able to sit still, then a score of 0 is give.  On the other hand, if the client is unable to sit still for more than a few seconds then they are given a score of 5 with other scores in between these based on their level of opiate withdrawals.
6. Yawning: if during the assessment the patient doesn’t yawn, then a score of 0 is appropriate.  If, however they are yawning several times per minute then a score of 4 is given with other scores for symptoms in between.
7. Pupil Size: 0 is given if the client’s pupils are pinned or normal for the ambient light.  A score of 5 is given if the opiate withdrawals are causing the client’s pupils to be so dilated that only the rim of the iris is visible.
8. Anxiety or Irritability: 0 for none and 4 if the patient is so irritable or anxious that participation in the opiate withdrawals assessment is difficult.
9. Bone or Joint Aches: if there is additional pain which wasn’t present prior to the onset of opiate withdrawals, the client is given a score of 4 if they are rubbing joints or muscles and unable to sit still because of the additional discomfort.  A score of 0 is given for no additional pain.  There are scores in between based on symptoms.
10. Gooseflesh Skin: if the client’s skin is smooth, then a score of 0 is given.  If on the other hand, the opiate withdrawals are causing the client’s skin to have goose bumps and their arm hair is standing up, then a score of 5 is appropriate.
11. Runny Nose or Tearing: if the client doesn’t have a cold or allergies, but their nose is constantly running or there are tears running down their cheeks then they warrant a score of 4 for their opiate withdrawals.  0 is appropriate if these symptoms are not present.

Once each criteria has been assessed then all of the scores are summed up to get a total.  The following scale is then applied to determine the level of opiate withdrawals: 5-12 mild; 13-24 moderate; 25-36 moderately severe; more than 36 severe opiate withdrawals.

The COWS assessment should be given only by a trained professional, but if you believe you or a loved one is undergoing opiate withdrawals then it would be beneficial to know the signs to look for in order to receive opiate withdrawals treatment. 

Get a Downloadable Version of the COWS Test HERE >>