COWS — Clinical Opiate Withdrawal Scale
Clinician-rated · Completed
| Patient: ______________________ | DOB / ID: ______________________ |
| Date: 2026-07-18 | Clinician: ______________________ |
Rate each of the eleven signs and symptoms based on observation and the patient’s report at the time of assessment.
1. Resting pulse rate
☐0≤80 bpm
☐181–100 bpm
☐2101–120 bpm
☐4>120 bpm
2. Sweating
☐0No report of chills or flushing
☐1Subjective report of chills or flushing
☐2Flushed or observable moistness on face
☐3Beads of sweat on brow or face
☐4Sweat streaming off face
3. Restlessness
☐0Able to sit still
☐1Reports difficulty sitting still, but is able to do so
☐3Frequent shifting or extraneous movements of legs/arms
☐5Unable to sit still for more than a few seconds
4. Pupil size
☐0Pinned or normal size for room light
☐1Possibly larger than normal for room light
☐2Moderately dilated
☐5So dilated that only the rim of the iris is visible
5. Bone or joint aches
☐0Not present
☐1Mild diffuse discomfort
☐2Severe diffuse aching of joints/muscles
☐4Rubbing joints or muscles, unable to sit still
6. Runny nose or tearing
☐0Not present
☐1Nasal stuffiness or unusually moist eyes
☐2Nose running or tearing
☐4Nose constantly running or tears streaming down cheeks
7. GI upset
☐0No GI symptoms
☐1Stomach cramps
☐2Nausea or loose stool
☐3Vomiting or diarrhea
☐5Multiple episodes of diarrhea or vomiting
8. Tremor
☐0No tremor
☐1Tremor can be felt but not observed
☐2Slight tremor observable
☐4Gross tremor or muscle twitching
9. Yawning
☐0No yawning
☐1Yawning once or twice
☐2Yawning three or more times
☐4Yawning several times per minute
10. Anxiety or irritability
☐0None
☐1Reports increasing irritability or anxiousness
☐2Obviously irritable or anxious
☐4So irritable or anxious that participation is difficult
11. Gooseflesh skin
☐0Smooth skin
☐3Piloerection can be felt or hairs standing up on arms
☐5Prominent piloerection
Total score:
0 / 48 —
MinimalMinimal or no withdrawal.
Source: Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253–259.
For use by qualified clinicians as a decision-support aid. Scores support but do not replace clinical judgment. This is not a diagnostic instrument and no information is stored or transmitted.