The Clinical Opiate Withdrawal Scale (COWS) is a widely used assessment tool for evaluating opioid withdrawal severity. Developed as a structured, clinician-administered scale, it helps guide treatment decisions in patients with opioid dependence. Withdrawal symptoms can vary greatly in intensity, and accurate assessment is essential for safe and effective management.

COWS includes 11 symptom categories: 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. Each item is scored from 0 to 4 or 5, depending on severity. The total score can range from 0 to 48.

Scores provide a standardized method to determine the degree of withdrawal: mild, moderate, moderately severe, or severe. This helps clinicians decide when to initiate medications such as buprenorphine or methadone and adjust dosing as symptoms evolve. For example, initiating buprenorphine too early (before moderate withdrawal) can precipitate withdrawal, making careful scoring especially important.