[{"data":1,"prerenderedAt":385},["ShallowReactive",2],{"assessment-cows":3,"assessments-related-cows":362},{"id":4,"title":5,"body":6,"category":287,"categoryTitle":288,"clinicalCitations":289,"copyright":296,"description":297,"downloadLink":287,"extension":298,"faqs":299,"featured":315,"firstPublished":316,"i18nReady":315,"icon":287,"inHiBoop":287,"interpreter":317,"interpreterExempt":287,"lastReviewed":346,"meta":347,"navigation":348,"path":349,"permissionsNote":350,"published":348,"recommendedFrequency":287,"relatedCodes":287,"relatedConditions":287,"relevantSpecialty":351,"reviewedBy":287,"seo":354,"slug":355,"status":356,"stem":357,"summary":358,"takeaways":287,"timeline":287,"type":359,"usedToDiagnose":360,"__hash__":361},"assessments\u002Fassessments\u002Fcows.md","COWS Scale: Clinical Opiate Withdrawal Scale Scoring",{"type":7,"value":8,"toc":276},"minimark",[9,18,23,29,32,49,72,76,81,110,113,117,123,175,178,182,217,221,256,260],[10,11,12,13,17],"p",{},"The COWS (Clinical Opiate Withdrawal Scale) is an 11-item clinician-administered scale that rates common signs and symptoms of opioid withdrawal ",[14,15],"cite-ref",{"n":16},"1",". The summed score helps a care team judge the intensity of withdrawal and make inferences about a client's level of physical dependence on opioids. It is used in medical, addiction treatment and withdrawal management settings and supports, rather than replaces, a medical assessment.",[19,20,22],"h2",{"id":21},"what-does-the-cows-measure","What does the COWS measure?",[10,24,25,26,28],{},"The COWS measures the current intensity of opioid withdrawal. Wesson and Ling published it in 2003 with a review of opioid withdrawal scales going back to the 1930s, and appended a version that can be copied and used clinically ",[14,27],{"n":16},".",[10,30,31],{},"The 11 items are:",[33,34,35,43],"ul",{},[36,37,38,42],"li",{},[39,40,41],"strong",{},"Observed signs:"," resting pulse rate, sweating, restlessness, pupil size, runny nose or tearing, tremor, yawning and gooseflesh skin.",[36,44,45,48],{},[39,46,47],{},"Reported or observed symptoms:"," bone or joint aches, gastrointestinal upset, and anxiety or irritability.",[10,50,51,52,57,58,62,63,67,68,28],{},"Most items are observed by the rater rather than reported by the client. The COWS does not screen for opioid use or an opioid use disorder; for drug use screening see the ",[53,54,56],"a",{"href":55},"\u002Fassessments\u002Fdast-10\u002F","DAST-10",", ",[53,59,61],{"href":60},"\u002Fassessments\u002Fassist\u002F","ASSIST"," or ",[53,64,66],{"href":65},"\u002Fassessments\u002Fcage-aid\u002F","CAGE-AID",". For alcohol withdrawal, the comparable scale is the ",[53,69,71],{"href":70},"\u002Fassessments\u002Fciwa-ar\u002F","CIWA-Ar",[19,73,75],{"id":74},"how-do-you-give-the-cows","How do you give the COWS?",[10,77,78,79,28],{},"A clinician completes the COWS by observing the client and asking a few short questions. It is a pen-and-paper scale ",[14,80],{"n":16},[33,82,83,89,95,101],{},[36,84,85,88],{},[39,86,87],{},"Rate what belongs to withdrawal."," The form asks the rater to score each item only by its apparent relationship to opioid withdrawal; a pulse raised by recent exercise, or a runny nose from a cold, does not add to the score.",[36,90,91,94],{},[39,92,93],{},"Item windows."," Pulse is measured after the client has sat or lain still for one minute, and sweating and gastrointestinal upset are rated over the past half hour.",[36,96,97,100],{},[39,98,99],{},"Repeat ratings."," The scale can be repeated to follow withdrawal over time, in inpatient and outpatient settings.",[36,102,103,106,107,109],{},[39,104,105],{},"Buprenorphine."," Wesson and Ling note that buprenorphine, a partial agonist, can precipitate withdrawal in a person with a high level of opioid dependence who is not yet in withdrawal, one reason withdrawal intensity is rated before treatment ",[14,108],{"n":16},". Medication timing and dose follow the prescriber's protocol.",[10,111,112],{},"For clinical use and educational reference only. A COWS score does not replace a medical assessment.",[19,114,116],{"id":115},"how-do-you-score-and-interpret-the-cows","How do you score and interpret the COWS?",[10,118,119,120,122],{},"Add the 11 item ratings. Item maxima are 4 or 5, so totals run from 0 to 48. The form prints these bands ",[14,121],{"n":16},":",[124,125,126,139],"table",{},[127,128,129],"thead",{},[130,131,132,136],"tr",{},[133,134,135],"th",{},"COWS total",[133,137,138],{},"Severity on the published form",[140,141,142,151,159,167],"tbody",{},[130,143,144,148],{},[145,146,147],"td",{},"5 to 12",[145,149,150],{},"Mild",[130,152,153,156],{},[145,154,155],{},"13 to 24",[145,157,158],{},"Moderate",[130,160,161,164],{},[145,162,163],{},"25 to 36",[145,165,166],{},"Moderately severe",[130,168,169,172],{},[145,170,171],{},"More than 36",[145,173,174],{},"Severe",[10,176,177],{},"The form defines no band below 5. Read any score with the client's history, the time since their last opioid dose, other medical causes of the same signs, and the trend across repeat ratings.",[19,179,181],{"id":180},"psychometric-properties","Psychometric properties",[33,183,184,193,201,209],{},[36,185,186,192],{},[39,187,188,189,122],{},"Before validation ",[14,190],{"n":191},"2"," The COWS was in common clinical use for several years before it was systematically validated.",[36,194,195,200],{},[39,196,197,198,122],{},"Concurrent validity ",[14,199],{"n":191}," In 46 opioid-dependent volunteers stabilized on morphine and given double-blind naloxone and placebo challenges, peak COWS and CINA (Clinical Institute Narcotic Assessment) scores correlated at r = 0.85. Peak COWS scores also correlated with self-rated \"bad drug effect\" and \"feeling sick\" (both r = 0.57).",[36,202,203,208],{},[39,204,205,206,122],{},"Discriminant validity ",[14,207],{"n":191}," Placebo produced no significant rise in COWS scores, while naloxone did; mean peak COWS after naloxone was 7.6, about 30 minutes after injection.",[36,210,211,216],{},[39,212,213,214,122],{},"Internal consistency ",[14,215],{"n":191}," Cronbach's alpha was 0.78.",[19,218,220],{"id":219},"limitations","Limitations",[33,222,223,234,240,248],{},[36,224,225,228,229,233],{},[39,226,227],{},"Not a diagnosis."," The COWS rates current withdrawal signs; it does not diagnose an ",[53,230,232],{"href":231},"\u002Ficd-10\u002Ff11-20-opioid-use-disorder\u002F","opioid use disorder"," and does not tell a care team which medicine to give or when.",[36,235,236,239],{},[39,237,238],{},"Signs have other causes."," Pulse, sweating, pupil size, gastrointestinal upset and anxiety can come from infection, other substances or other medical problems. The form asks raters to exclude these, which takes judgement.",[36,241,242,245,246,28],{},[39,243,244],{},"Limited validation data."," The main validation study was small (46 volunteers) and used a controlled naloxone challenge in a residential research setting, which differs from spontaneous withdrawal in routine care ",[14,247],{"n":191},[36,249,250,253,254,28],{},[39,251,252],{},"No band below 5."," The form leaves low scores unlabelled, so a low total is not by itself a sign of no withdrawal ",[14,255],{"n":16},[19,257,259],{"id":258},"cows-vs-ciwa-ar","COWS vs CIWA-Ar",[10,261,262,263,265,266,270,271,275],{},"The COWS rates opioid withdrawal with 11 mostly observable signs and a 0 to 48 total. The ",[53,264,71],{"href":70}," rates alcohol withdrawal with 10 items scored 0 to 67, several of which depend on what the client reports. Both are repeated over time to follow withdrawal, and neither is a screen for substance use. For screening, see the ",[53,267,269],{"href":268},"\u002Fassessments\u002Faudit\u002F","AUDIT"," for alcohol, the DAST-10 or ASSIST for drugs, and the ",[53,272,274],{"href":273},"\u002Fassessments\u002Fcrafft\u002F","CRAFFT"," for adolescents.",{"title":277,"searchDepth":278,"depth":278,"links":279},"",3,[280,282,283,284,285,286],{"id":21,"depth":281,"text":22},2,{"id":74,"depth":281,"text":75},{"id":115,"depth":281,"text":116},{"id":180,"depth":281,"text":181},{"id":219,"depth":281,"text":220},{"id":258,"depth":281,"text":259},null,"Substance Use",[290,293],{"text":291,"link":292},"Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253-259.","https:\u002F\u002Fdoi.org\u002F10.1080\u002F02791072.2003.10400007",{"text":294,"link":295},"Tompkins DA, Bigelow GE, Harrison JA, Johnson RE, Fudala PJ, Strain EC. Concurrent validation of the Clinical Opiate Withdrawal Scale (COWS) and single-item indices against the Clinical Institute Narcotic Assessment (CINA) opioid withdrawal instrument. Drug Alcohol Depend. 2009;105(1-2):154-159.","https:\u002F\u002Fpubmed.ncbi.nlm.nih.gov\u002F19647958\u002F","Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003. The appended form states: \"This version may be copied and used clinically.\"","COWS scale (Clinical Opiate Withdrawal Scale) scoring guide: 11 items, totals 0 to 48, with the published bands from mild to severe opioid withdrawal.","md",[300,303,306,309,312],{"question":301,"answer":302},"What does COWS stand for?","COWS stands for Clinical Opiate Withdrawal Scale. It is an 11-item scale, published by Wesson and Ling in 2003, that a clinician uses to rate the signs and symptoms of opioid withdrawal. It is not related to any alcohol scale; for alcohol withdrawal the comparable scale is the CIWA-Ar.",{"question":304,"answer":305},"What is the COWS score range?","Totals run from 0 to 48. Each of the 11 items has its own scale, with top ratings of 4 or 5. The published form bands the total as 5 to 12 mild, 13 to 24 moderate, 25 to 36 moderately severe and more than 36 severe withdrawal. The form gives no band below 5.",{"question":307,"answer":308},"How is the COWS scored?","A clinician rates resting pulse rate, sweating, restlessness, pupil size, bone or joint aches, runny nose or tearing, gastrointestinal upset, tremor, yawning, anxiety or irritability, and gooseflesh skin, then adds the 11 ratings. The form asks the rater to score only what appears related to opioid withdrawal, so a pulse raised by recent exercise does not count.",{"question":310,"answer":311},"Why is the COWS used before starting buprenorphine?","Buprenorphine is a partial opioid agonist. Wesson and Ling note that it can bring on withdrawal in a person with a high level of opioid dependence who is not yet in withdrawal, which renewed interest in rating withdrawal intensity. Care teams use the COWS to document withdrawal before and during treatment; the timing and dose of any medicine follow the prescriber's protocol, not the score alone.",{"question":313,"answer":314},"Is the COWS free to use?","The version appended to the 2003 article states that it may be copied and used clinically, and the U.S. National Institute on Drug Abuse distributes that version. Cite Wesson and Ling (2003) when you use it.",false,"2003",{"heading":318,"scaleLabel":135,"min":319,"max":320,"note":321,"source":322,"bands":323},"COWS Score Interpreter",0,48,"11 items with item maxima of 4 or 5, summed for a total of 0 to 48. Higher scores mean more severe opioid withdrawal at the time of rating. Rate only signs that appear related to opioid withdrawal.","Wesson DR, Ling W. J Psychoactive Drugs. 2003;35(2):253-259, Appendix 1 (score bands printed on the form).",[324,329,333,338,342],{"min":325,"label":326,"level":327,"note":328},37,"Severe withdrawal","error","More than 36 on the published form. Severe opioid withdrawal calls for prompt medical assessment and management under the setting's protocol.",{"min":330,"label":331,"level":327,"note":332},25,"Moderately severe withdrawal","25 to 36 on the published form. Management follows the treating team's medical protocol and clinical judgement.",{"min":334,"label":335,"level":336,"note":337},13,"Moderate withdrawal","warning","13 to 24 on the published form.",{"min":339,"label":340,"level":336,"note":341},5,"Mild withdrawal","5 to 12 on the published form. Repeat the rating as withdrawal may still be developing.",{"min":319,"label":343,"level":344,"note":345},"Below the form's mild range","success","The published form defines no band for scores under 5. Interpret a low score with the history, the time since last opioid use and repeat ratings.","2026-10-30",{},true,"\u002Fassessments\u002Fcows","The COWS form appended to Wesson and Ling (2003) states: \"This version may be copied and used clinically.\" The U.S. National Institute on Drug Abuse distributes that version (https:\u002F\u002Fnida.nih.gov\u002Fsites\u002Fdefault\u002Ffiles\u002FClinicalOpiateWithdrawalScale.pdf). Cite the original article when you use it.",[352,353],"Psychiatric","PrimaryCare",{"title":5,"description":297},"cows","published","assessments\u002Fcows","The COWS (Clinical Opiate Withdrawal Scale) is an 11-item clinician-rated scale that measures the severity of opioid withdrawal from observable signs and reported symptoms. Totals run 0 to 48; the published form bands 5 to 12 as mild, 13 to 24 moderate, 25 to 36 moderately severe and more than 36 severe withdrawal.","assessment","Opioid withdrawal","rvlLjtcXtMZvm4ikImdkUAzcbMSoE7oJgQQTI4Dunn4",[363,368,371,374,378,381],{"slug":364,"title":365,"tier":366,"weight":367},"assist","Alcohol, Smoking and Substance Involvement Screening Test (ASSIST v3.1)","same",100,{"slug":369,"title":370,"tier":366,"weight":367},"arc","Assessment of Recovery Capital (ARC)",{"slug":372,"title":373,"tier":366,"weight":367},"audit","AUDIT Scoring & AUDIT-C · Alcohol Use Disorders Identification Test",{"slug":375,"title":376,"tier":39,"weight":377},"mdq","MDQ: Mood Disorder Questionnaire",45,{"slug":379,"title":380,"tier":39,"weight":377},"ymrs","Young Mania Rating Scale (YMRS): Scoring and Cutoffs",{"slug":382,"title":383,"tier":39,"weight":384},"aces","ACE Score: Scoring & Interpretation of the ACE Questionnaire",40,1794129716807]