Clinical Opioid Withdrawal Scale

Aka: Clinical Opioid Withdrawal Scale, COWS

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II. Indications

  1. Opioid Withdrawal Evaluation
  2. Initiation of medication assisted therapy (MAT) for Opioid Dependence

III. Criteria

  1. Resting Pulse Rate (after sitting or lying for 1 minute)
    1. Score 0: Pulse 80 or less
    2. Score 1: Pulse 81-100
    3. Score 2: Pulse 101-120
    4. Score 4: Pulse >120
  2. Sweats during prior 30 minutes (aside from activity, Ambient Temperature)
    1. Score 0: No chills or Flushing
    2. Score 1: Subjective chills or Flushing
    3. Score 2: Flushed or moisture seen on face
    4. Score 3: Sweat beads on brow or face
    5. Score 4: Sweats streams from face
  3. Restlessness
    1. Score 0: Able to sit still
    2. Score 1: Subjectively feels as if cannot sit still (but not observed)
    3. Score 3: Frequently shifts position, or moves arms or legs
    4. Score 5: Unable to sit still for more than a few seconds
  4. Pupil size
    1. Score 0: Pin-head, constricted pupils (Miosis) or normal for room light
    2. Score 1: Borderline Pupil Dilation (Mydriasis) for room light
    3. Score 2: Moderate Pupil Dilation (Mydriasis)
    4. Score 5: Severe Pupil Dilation (Mydriasis) with only a rim of iris remaining
  5. Bone or Joint aches (beyond baseline pain)
    1. Score 0: None
    2. Score 1: Mild diffuse discomfort
    3. Score 2: Subjective report of severe diffuse joint or Muscle aches
    4. Score 4: Pain results in patient rubbing joints, and is unable to sit still
  6. Runny nose or eye tearing (aside from Upper Respiratory Infection or Allergic Rhinitis)
    1. Score 0: None
    2. Score 1: Nasal congestion or eyes moist
    3. Score 2: Nose runs or eyes tear
    4. Score 4: Constant nasal drainage or constant eye tearing down cheeks
  7. Gastrointestinal upset during prior 30 minutes
    1. Score 0: None
    2. Score 1: Stomach cramps
    3. Score 2: Nausea or loose stools
    4. Score 3: Vomiting or Diarrhea
    5. Score 5: Multiple episodes of Vomiting or Diarrhea
  8. Tremor with outstretched hands
    1. Score 0: None
    2. Score 1: Subjective Tremors not seen on exam
    3. Score 2: Mild Tremor
    4. Score 4: Gross Tremor or Muscle Twitching
  9. Yawning
    1. Score 0: None
    2. Score 1: Patient yawns 1-2 times during evaluation
    3. Score 2: Patient yawns several times during evaluation
    4. Score 4: Patient yawns several times each minute
  10. Anxiety or Irritability
    1. Score 0: None
    2. Score 1: Subjective sense of increasing irritability or anxiousness
    3. Score 2: Observed irritability or anxiousness
    4. Score 4: Irritability or anxiousness interferes with evaluation
  11. Gooseflesh Skin
    1. Score 0: Smooth skin
    2. Score 3: Palpable piloerection or arm hairs stand up
    3. Score 5: Prominent piloerection

IV. Interpretation

  1. Score 5-12: Mild Opioid Withdrawal
  2. Score 13-24: Moderate Opioid Withdrawal
  3. Score 25-36: Moderately Severe Opioid Withdrawal
  4. Score >26: Severe Opioid Withdrawal

V. References

  1. Wesson (2003) J Psychoactive Drugs 35(2): 253–9 [PubMed]

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