Text equivalent of “Clinical Opiate Withdrawal Scale”

Introduction


The Clinical Opiate Withdrawal Scale (COWS) is an 11-item scale designed to be administered by a clinician. This tool can be used in both inpatient and outpatient settings to reproducibly rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time. The summed score for the complete scale can be used to help clinicians determine the stage or severity of opiate withdrawal and assess the level of physical dependence on opioids. Practitioners sometimes express concern about the objectivity of the items in the COWS; however, the symptoms of opioid withdrawal have been likened to a severe influenza infection (e.g., nausea, vomiting, sweating, joint aches, agitation, tremor), and patients should not exceed the lowest score in most categories without exhibiting some observable sign or symptom of withdrawal.

http://www.drugabuse.gov/nidamed-medical-health-professionals

Clinical Opiate Withdrawal Scale


For each item, circle the number that best describes the patient’ s signs or symptom. Rate on just the apparent relationship to opiate withdrawal. For example, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score.

[Form asks for patient’s name, date and time, reason for this assessment.]

Resting Pulse Rate [X beats per minute]

Measured after patient is sitting or lying for one minute.

  • 0. pulse rate eighty or below.
  • 1. pulse rate eighty one to one hundred.
  • 2. pulse rate one hundred one to one hundred twenty.
  • 4. pulse rate greater than one hundred twenty.

Sweating

Over past half 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.


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.


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.


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 a minute.

Pupil size

  • 0. pupils pinned or normal size for room light.
  • 1. pupils possibly larger than normal for room light.
  • 2. pupils moderately dilated.
  • 5. pupils so dilated that only the rim of the iris is visible.


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.


Bone or Joint aches

If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored.

  • 0. not present.
  • 1. mild diffuse discomfort.
  • 2. patient reports severe diffuse aching of joints and or muscles.
  • 4. patient is rubbing joints or muscles and is unable to sit still because of discomfort.


Gooseflesh skin

  • 0. skin is smooth.
  • 3. piloerection of skin can be felt or hairs standing up on arms.
  • 5. prominent piloerection.


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 half hour.

  • 0. no GI symptoms.
  • 1. stomach cramps.
  • 2. nausea or loose stool.
  • 3. vomiting or diarrhea.
  • 5. multiple episodes of diarrhea or vomiting.


Total Score


The total score is the sum of all eleven items. Initials of person completing assessment.

  • five to twelve is mild.
  • thirteen to twenty four is moderate.
  • Twenty five to thirty six is moderately severe.
  • more than thirty six is severe withdrawal.

Fine Print

This version may be copied and used clinically.

Journal of Psychoactive Drugs Volume thirty five issue two, April to June 2003.

Source: Wesson, D. R., & Ling, W. (2003). The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive
Drugs, 35(2), 253–9.