The Cardiovascular
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COWS score for opiate withdrawal

Severity of opioid withdrawal.

COWS score for opiate withdrawal
Resting pulse rate
Sweating (past 30 min, not from activity)
Restlessness
Pupil size
Bone or joint aches
Runny nose or tearing
GI upset (past 30 min)
Tremor (outstretched hands)
Yawning
Anxiety or irritability
Gooseflesh skin
Result0 points

Minimal opioid withdrawal (total range 0-48).

Severity
minimal

When to use

  • Grading opioid withdrawal severity, including timing of buprenorphine induction.

Formula

Sum of 11 items. Bands: 5-12 mild, 13-24 moderate, 25-36 moderately severe, >36 severe.

Pearls and pitfalls

  • A COWS of roughly 8-12 or more is commonly used as a threshold for starting buprenorphine to avoid precipitated withdrawal.

References

  1. Wesson DR, Ling W. J Psychoactive Drugs. 2003;35(2):253-9.