Clinical Opioid Withdrawal Score (COWS) Resting Pulse Rate: Record beats per minute after patient is sitting or lying down for one minute • 0 - pulse rate 80 or below • 1 - pulse rate 81–100 • 2 - pulse rate 101–120 • 4 - pulse rate greater than 120 Sweating: Over past ½ hour not accounted for by room temperature or activity • 0 - no chills or flushing • 1 - subjective chills or flushing • 2 - flushed or observable moistness on face • 3 - beads of sweat on brow or face • 4 - sweat streaming off face 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 movement of legs/arms • 5 - unable to sit still for more than a few seconds Pupil size • 0 - pupils pinned or normal size for light • 1 - pupils possibly larger than normal for light • 2 - pupils moderately dilated • 5 - pupils dilated that only rim of the iris is visible Bone or joint aches: If patient was having pain previously, only the additional component attributed to opiate withdrawal is scored • 0 - not present • 1 - mild/diffuse discomfort • 2 - patient reports severe diffuse aching of joints/muscles • 4 - patient is rubbing joints or muscles and is unable to sit still because of discomfort Runny nose or tearing: Not accounted for by cold symptoms or allergy • 0 - none 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 ½ hour • 2 - nausea or loose stool • 0 - no GI symptoms • 1 - stomach cramps • 3 - vomiting or diarrhea • 5 - multiple episodes of diarrhea or vomiting 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 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/minute 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 Gooseflesh skin • 0 - skin is smooth • 3 - piloerrection of skin can be felt or hairs standing up on arms • 5 - prominent piloerrection 5—12 = mild; 13—24 = moderate; 25—36 = moderately severe; > 36 = severe withdrawal Support for Hospital Opioid Use Treatment (SHOUT) #COWS #Opiate #Withdrawal #Scale #Buprenorphine #Score #Diagnosis #Addiction #Nursing #Assessment
