The COWS rates eleven signs of opioid withdrawal at the bedside, from the resting pulse to gooseflesh skin. Its total, from 0 to 48, shows how severe withdrawal is right now and helps time the first dose of buprenorphine. See the eleven signs, what each band means, and how protocols use the score, then record the result with the free template.
COWS result template
FreeCOWS ASSESSMENT Date and time: [Date, clock time] Patient: [Name or ID, age] Location: [Emergency department, inpatient unit, withdrawal management, clinic, or other] Rated by: [Name, credentials] Purpose: [Baseline, before a first buprenorphine dose, after a dose, taper check, or new symptoms] OPIOID HISTORY Last opioid: [Which opioid, route, and usual daily amount] Time of last use: [Date and clock time; hours since] Fentanyl exposure: [Known, possible, unlikely, or test result] Current treatment: [Methadone or buprenorphine dose and time of the last dose, taper step, or none] Other substances: [Alcohol, benzodiazepines, stimulants, or none] VITALS Pulse at rest: [Beats a minute after one minute still] BP and temperature: [Readings] Fluids: [Vomiting or diarrhea in the past day, and whether fluids stay down] SIGN SCORES Resting pulse: [Points] Sweating: [Points] Restlessness: [Points] Pupil size: [Points] Bone or joint aches: [Points] Runny nose or tearing: [Points] GI upset: [Points] Tremor: [Points] Yawning: [Points] Anxiety or irritability: [Points] Gooseflesh skin: [Points] Total score: [0 to 48] Severity: [No active withdrawal, mild, moderate, moderately severe, or severe] Not counted: [Any sign left out because another cause explains it, or none] TREATMENT GIVEN Opioid treatment: [Drug, dose, route, and clock time; or none, and why] Symptom relief: [Clonidine, loperamide, antiemetic, pain relief, or none] Response: [Effect seen, or precipitated withdrawal suspected] REASSESSMENT Next COWS due: [Clock time and interval] Call the prescriber if: [Score limit, a rise after a dose, vital sign limits, or heavy vomiting] Naloxone: [Kit given and use taught, already has one, or declined] Handover: [Who was told, and when]
Use it for
Find out which opioid was used, how much, and when. The same score means something different 8 hours after heroin and 2 days after the last methadone dose.
Avoid: Scoring before you know the time of the last use. A low score 6 hours after use and a low score 30 hours after use lead to different plans.
Most of the eleven signs are seen; aches, stomach upset, and anxiety are asked about as well. The assessment takes a few minutes, close to the patient.
Avoid: Rating pupils and gooseflesh from the doorway. They are the most telling signs, and they need a close look.
Add the eleven scores for a total from 0 to 48. The band shows how severe withdrawal is now.
Avoid: Reading one score on its own. Compare it with the time since the last use and the last score: is withdrawal building, peaking, or settling?
Buprenorphine binds to opioid receptors more tightly than heroin, fentanyl, or methadone, but switches them on less. Given too early, it pushes the other opioid off and causes sudden withdrawal.
Avoid: Giving the first dose on hours since use alone. Score the COWS first, every time.
During a methadone or buprenorphine taper, or while withdrawal runs its course, the COWS shows whether the current step is bearable.
Each one follows the recording template. Use them to judge how much to write.
Emergency department, walk-in asking for help with withdrawal, rated by the emergency physician
31-year-old man. Injects heroin, about half a gram a day, for 3 years. Last use at 18:00 yesterday, 16 hours before this check. Urine positive for fentanyl as well as opiates; he thinks his supply is cut with it. No methadone or buprenorphine now. No alcohol or benzodiazepines in the past week.
10:00: pulse 104 after a minute seated, BP 142/88, temperature 37.2 °C, oxygen saturation 98%. Vomited twice overnight; keeping water down.
Resting pulse 2, sweating 1, restlessness 1, pupil size 2, bone or joint aches 2, runny nose or tearing 2, GI upset 2, tremor 0, yawning 1, anxiety or irritability 1, gooseflesh 0. Total 14, moderate. Nothing left out.
Buprenorphine 4 mg sublingual at 10:15: the department starts at a COWS of 13 or more when fentanyl is likely. Ondansetron 4 mg by mouth at 10:15 for nausea.
11:15: total 7, mild, pulse 90. No rise, so no sign of precipitated withdrawal. Second dose of buprenorphine 4 mg at 11:20, 8 mg so far. 12:20: total 3, pulse 84, comfortable. Discharged with buprenorphine-naloxone 16 mg daily until his addiction clinic visit in 2 days. Naloxone kit given and use taught. Told to return for vomiting he can’t control or withdrawal that comes back worse.
Inpatient withdrawal management unit, day 6 of a methadone taper, rated by the unit nurse
44-year-old woman. On methadone maintenance for 5 years; chose to come off before moving away from her clinic. Admitted on 30 mg, reduced by 5 mg every 2 days. Today’s dose 20 mg at 08:00, 7 hours before this check. No other opioids, alcohol, or benzodiazepines; urine negative for fentanyl on admission.
15:00: pulse 88 after a minute seated, BP 128/80, temperature 36.8 °C. Loose stool once this morning; eating and drinking normally. Slept about 4 hours last night.
Resting pulse 1, sweating 0, restlessness 1, pupil size 1, bone or joint aches 1, runny nose or tearing 1, GI upset 0, tremor 0, yawning 0, anxiety or irritability 1, gooseflesh 0. Total 6, mild. Yesterday at 15:00: 4.
Taper continues as written; no extra methadone for a mild score. Clonidine 0.1 mg by mouth at 15:15 for restlessness and aches, after a BP check. Ibuprofen 400 mg by mouth at 15:15.
Next COWS at 19:00 and before tomorrow’s dose. Hold clonidine if systolic BP is under 100 or pulse under 55. Call the prescriber if the score reaches 13, or stays above 8 on two checks in a row: the plan is then to hold at 20 mg for 2 more days. Naloxone kit and teaching booked before discharge, since her tolerance is falling; relapse prevention options to discuss with the physician tomorrow.
Hours since the last use are a guide, not a green light. A low score at 14 hours, especially after fentanyl, means the first dose could precipitate withdrawal. Score first.
A fast pulse from pain or fever, or a runny nose from a cold, isn’t withdrawal. Rate each sign only as far as withdrawal explains it, and note what you left out.
The repeat score shows whether the dose worked or precipitated withdrawal. Take it within the hour, before any further dose.
Tolerance falls fast during withdrawal and after a taper, so a usual amount can now be fatal. Give naloxone and teach its use before the patient leaves.
Vero Scribe records the COWS result in your template from the visit, with the patient’s consent, or from your dictation: the opioid and the time of last use, each sign’s points, the total, the dose given, and when to score again. You review and edit every line, then copy it into your record. Vero works in 60+ languages.
Rate eleven signs: resting pulse, sweating, restlessness, pupil size, bone or joint aches, runny nose or tearing, GI upset, tremor, yawning, anxiety or irritability, and gooseflesh skin. Each scores from 0 up to 4 or 5 points, and the official form describes each level. Add them for a total from 0 to 48. Count a sign only as far as it seems due to opioid withdrawal.
A total of 5 to 12 is mild withdrawal, 13 to 24 moderate, 25 to 36 moderately severe, and more than 36 severe. Under 5 is usually read as no active withdrawal. The score shows how severe withdrawal is now, so it changes from hour to hour.
For a standard start, most protocols wait for at least mild to moderate withdrawal, often a COWS of 8 to 12 or more. Many emergency departments use 8; some wait for 13 or more after fentanyl or methadone, when precipitated withdrawal is more likely. Low-dose starts overlap small buprenorphine doses with the current opioid and don’t wait for withdrawal. Follow your own protocol’s threshold.
Buprenorphine binds to opioid receptors more tightly than full opioids but switches them on less. Given while heroin, fentanyl, or methadone is still active, it can push them off and bring on sudden, severe withdrawal, usually within an hour or two of the dose. On the COWS it shows as a sharp rise after the first dose. Many protocols treat it with more buprenorphine and medicines for the symptoms.
Before a first buprenorphine dose, then 30 to 60 minutes after each dose until withdrawal settles. On a ward or withdrawal unit, protocols usually repeat it every few hours or each shift while symptoms last. During a taper, once or twice a day is common, and again whenever symptoms change.
The COWS is rated by a clinician from eleven signs. The SOWS, the Subjective Opiate Withdrawal Scale, has patients rate 16 symptoms themselves from 0 to 4, for a total from 0 to 64; some services use both. The CIWA-Ar does the COWS’s job for alcohol withdrawal.
Nurses give most COWS assessments, along with physicians, nurse practitioners, physician assistants, pharmacists, paramedics, and trained withdrawal management staff. It takes a few minutes at the bedside. Some services adapt it for video visits, with the patient checking their own pulse.
Yes, for patient care. Wesson and Ling appended a version to their 2003 paper for clinicians to copy and use, and many health services and addiction medicine societies post free copies. Get the official form, with the wording for each level, from the paper or your service’s protocol. The recording template on this page is free to copy or download too.
Three questions on how often and how much someone drinks, scored 0 to 12: positive at 4 or more for men, 3 or more for women.
The WHO’s 10 questions on drinking, dependence, and harm, scored 0 to 40 into four zones that each come with an intervention.
Four yes-or-no questions on drinking problems at any point in life: positive at 2 or more of 4.
Ten signs rated at the bedside: how severe alcohol withdrawal is now, scored 0 to 67.
A teen alcohol and drug screen for ages 12 to 21: days of use, then six yes-or-no questions scored 0 to 6, high risk at 2 or more.
The full assessment: use history, withdrawal risk, diagnosis, and level of care.
Assessments, buprenorphine starts, and follow-up notes for addiction teams.
Every tool, by area, with what its scores mean.
Vero records scores, findings, and plans in the templates you choose, so you review instead of type.
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