Clinical Opiate Withdrawal Scale (COWS)

Resting Pulse Rate

Measured after patient is sitting or lying 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 patient activity.

0: No report of chills or flushing 1: Subjective report of 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 movements of legs/arms 5: Unable to sit still for more than a few seconds

Pupil Size

0: Pinned or normal size for room light 1: Possibly larger than normal for room light 2: Moderately dilated 5: So dilated that only the 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 allergies.

0: Not 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.

0: No GI symptoms 1: Stomach cramps 2: Nausea or loose stool 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: Piloerection of skin can be felt or hairs standing up on arms 5: Prominent piloerection