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COWS Score for Opiate Withdrawal

Resting Pulse Rate (BPM)
Gauge pulse rate after patient is sitting or lying down for 1 minute
≤80 0
81-100 1
101-120 2
>120 4
Heavy Sweating
Sweating not accounted for by room temperature or patient activity over the last 0.5 hours
No report of fulshing or chills 0
Subjective report of chills or flushing 1
Flushed or observable moistness on face 2
Beads of sweat on brow or face 3
Sweat streaming off face 4
Restlessness observation during assessment
Capable to sit still 0
Reports trouble sitting still, but is able to do so 1
Recurrent shifting or extraneous movements of legs/arms 3
Unable to sit still for more than a few seconds 5
Pupil size
Pupils pinned or normal size for room light 0
Pupils probably larger than normal for room light 1
Pupils fairly dilated 2
Pupils so dilated that only the rim of the iris is visible 5
Bone or joint aches
If patient was having pain previously, only the additional component attributed to opiate withdrawal is scored
Not present 0
Gentle diffuse inconvenience 1
Patient reports severe diffuse aching of joints/ muscles 2
Patient is rubbing joints or muscles and is incapable to sit still because of uneasy 4
Runny nose or tearing
Not accounted for by cold symptoms or allergies
Not present 0
Nasal stuffiness or remarkably moist eyes 1
Nose running or tearing 2
Nose always running or tears streaming down cheeks 4
GI Upset
Over last 0.5 hours
No Gastrointestinal symptoms 0
Stomach pain 1
Nausea or loose stool 2
Vomiting or diarrhea 3
Multiple episodes of vomiting or diarrhea 5
Tremor observation of outstretched hands
No tremor 0
Tremor can be felt, but not observed 1
Slight tremor observable 2
Gross tremor or muscle twitching 4
Yawning observation during assessment
No yawning 0
Yawning once or twice during assessment 1
Yawning three or more times during assessment 2
Yawning several times/minute 4
Anxiety or irritability
None 0
Patient reports increasing irritability or anxiousness 1
Patient obviously irritable/anxious 2
Patient so irritable or anxious that participation in the assessment is difficult 4
Gooseflesh skin
Skin is smooth 0
Piloerection of skin can be felt or hairs standing up on arms 3
Prominent piloerection 5


Result Interpretation

Ranges Ranges

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