💊 COWS (Opioid Withdrawal)
Grade opioid withdrawal severity with the Clinical Opiate Withdrawal Scale (COWS).
Clinical takeaway
Objective withdrawal (often COWS ≥ 8–12) should precede buprenorphine.
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When to use
Time buprenorphine induction and manage opioid withdrawal.
How it works
Eleven items summed: 5–12 mild, 13–24 moderate, 25–36 moderately severe, > 36 severe.
Key points
- Objective withdrawal (often COWS ≥ 8–12) should precede buprenorphine.
- Premature dosing risks precipitated withdrawal.
- Reassess frequently during induction.
References
Decision support for licensed clinicians only; not a substitute for clinical judgement, diagnosis or local protocols.
Worked calculation
The values below come from this tool's own example placeholders and are computed server-side with the formula shown on this page, so the arithmetic can be checked quickly. It demonstrates how to substitute values only — it is not clinical advice and not a real case.
| Resting pulse rate | ≤ 80 (0) |
|---|---|
| Sweating | None (0) |
| Restlessness | None (0) |
| Pupil size | Normal (0) |
| Bone/joint aches | None (0) |
| Runny nose/tearing | None (0) |
| GI upset | None (0) |
| Tremor | None (0) |
| Yawning | None (0) |
| Anxiety/irritability | None (0) |
| Gooseflesh skin | Smooth (0) |
→COWS0
- Severity：Minimal
- Buprenorphine induction：Generally start once COWS ≥ 8–12 (objective signs present) to avoid precipitated withdrawal.
| Resting pulse rate | > 120 (4) |
|---|---|
| Sweating | Profuse (4) |
| Restlessness | Unable to sit still (5) |
| Pupil size | Only rims visible (5) |
| Bone/joint aches | Rubbing joints (4) |
| Runny nose/tearing | Streaming (4) |
| GI upset | Multiple episodes (5) |
| Tremor | Gross (4) |
| Yawning | Several/min (4) |
| Anxiety/irritability | So severe participation difficult (4) |
| Gooseflesh skin | Prominent (5) |
→COWS48
- Severity：Severe
- Buprenorphine induction：Generally start once COWS ≥ 8–12 (objective signs present) to avoid precipitated withdrawal.
Frequently asked questions
- What is COWS (Opioid Withdrawal)?
- Grade opioid withdrawal severity with the Clinical Opiate Withdrawal Scale (COWS).
- How is COWS (Opioid Withdrawal) calculated? What is the core formula?
- Eleven items summed: 5–12 mild, 13–24 moderate, 25–36 moderately severe, > 36 severe.
- When is COWS (Opioid Withdrawal) used?
- Time buprenorphine induction and manage opioid withdrawal.
- What are the key clinical points for COWS (Opioid Withdrawal)?
- Objective withdrawal (often COWS ≥ 8–12) should precede buprenorphine. Premature dosing risks precipitated withdrawal. Reassess frequently during induction.
- What are the limits and cautions when using COWS (Opioid Withdrawal)?
- For licensed clinicians and clinical researchers. Interpret results with history, investigations and local protocols; not a diagnosis or prescription, and not a substitute for multidisciplinary decision-making or local guidelines.
- How is COWS (Opioid Withdrawal) calculated in practice? Can you show a worked example?
- Inputs: Resting pulse rate ≤ 80 (0), Sweating None (0), Restlessness None (0), Pupil size Normal (0), Bone/joint aches None (0), Runny nose/tearing None (0), GI upset None (0), Tremor None (0)… → Result: COWS 0（Severity: Minimal, Buprenorphine induction: Generally start once COWS ≥ 8–12 (objective signs present) to avoid precipitated withdrawal.） Inputs: Resting pulse rate > 120 (4), Sweating Profuse (4), Restlessness Unable to sit still (5), Pupil size Only rims visible (5), Bone/joint aches Rubbing joints (4), Runny nose/tearing Streaming (4), GI upset Multiple episodes (5), Tremor Gross (4)… → Result: COWS 48（Severity: Severe, Buprenorphine induction: Generally start once COWS ≥ 8–12 (objective signs present) to avoid precipitated withdrawal.）