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MedikQuantis
Informational · does not replace consultation with a healthcare professional.

COWS Opioid Withdrawal

Clinical Opiate Withdrawal Scale for quantitative opioid withdrawal rating (11 items, max 48).

Switch how results are explained

Resting pulse rate (bpm)
Sweating over past 1/2 hour
Restlessness observed during assessment
Pupil size
Bone or joint aches
Runny nose or tearing
GI upset (nausea, vomiting, diarrhea)
Tremor (observation of hands)
Yawning (observation during assessment)
Anxiety or irritability
Gooseflesh skin (piloerection)
Score0low risk
low riskmoderate riskhigh risk

Minimal or no withdrawal (score 0–4). Buprenorphine induction is not indicated.

Evidence grade
A

What it is and when to use it

The Clinical Opiate Withdrawal Scale (COWS) is an 11-item clinician-administered instrument for objective opioid withdrawal scoring.

How to interpret it

Scores 5–12: Mild withdrawal; 13–24: Moderate withdrawal; 25–36: Moderately severe withdrawal; >36: Severe withdrawal.

Limitations and when not to use it

Buprenorphine induction before reaching a COWS score of at least 12–13 may cause severe precipitated withdrawal.

Frequently asked questions

Why is COWS timing crucial for buprenorphine?
Buprenorphine is a partial agonist with high receptor affinity. Initiating it too early displaces full opioids and precipitates acute severe withdrawal.

Formulas and cut-offs are from the original authors of each score; see the references.

Last reviewed: June 2026

References
  1. Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253-259. PMID:12924748