COWS Score for Opiate Withdrawal Clinical Calculator and Pathway

Resting Pulse Rate (BPM)

Measure pulse rate after patient is sitting or lying down for 1 minute

≤80

0

81-100

+1

101-120

+2

>120

+4

Sweating

Sweating not accounted for by room temperature or patient activity over the last 0.5 hours

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

Restlessness observation during assessment

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

Pupil size

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

Bone or joint aches

If patient was having pain previously, only the additional component attributed to opiate withdrawal is scored

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

Runny nose or tearing

Not accounted for by cold symptoms or allergies

Not present

0

Nasal stuffiness or unusually moist eyes

+1

Nose running or tearing

+2

Nose constantly running or tears streaming down cheeks

+4

GI Upset

Over last 0.5 hours

No GI symptoms

0

Stomach Cramps

+1

Nausea or loose stool

+2

Vomiting or diarrhea

+3

Multiple episodes of vomiting or diarrhea

+5

Tremor observation of outstretched hands

No tremor

0

Tremor can be felt, but not observed

+1

Slight tremor observable

+2

Gross tremor or muscle twitching

+4

Yawning observation during assessment

No yawning

0

Yawning once or twice during assessment

+1

Yawning three or more times during assessment

+2

Yawning several times/minute

+4

Anxiety or irritability

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

Gooseflesh skin

Skin is smooth

0

Piloerection of skin can be felt or hairs standing up on arms

+3

Prominent piloerection

+5

COWS Score for Opiate Withdrawal

Quantifies severity of opiate withdrawal symptoms

Interpretation