What is a COWS Score (Clinical Opiate Withdrawal Scale)?

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 COWS is a standardized tool used to measure and quantify the severity of withdrawal symptoms in individuals undergoing opioid detoxification.

Opioid addiction is a serious and widespread problem that affects millions of people worldwide. When individuals decide to take the courageous step towards kickstarting their recovery, they often face the daunting challenge of opioid withdrawal. Managing withdrawal symptoms is crucial for successful recovery, and healthcare professionals rely on tools like COWS (Clinical Opiate Withdrawal Scale) to assess the severity of withdrawal and tailor treatment plans accordingly. 

In this guide, we will explore the COWS protocol and address these issues:

  • What is COWS?
  • What is a COWS score?
  • How are COWS and CIWA scores calculated?
  • How is an opiate withdrawal scale or opioid withdrawal scale used?

The COWS Scale for Opioid Withdrawal

COWS medical abbreviation stands for Clinical Opiate Withdrawal Scale. It is widely considered the gold standard in assessing opioid withdrawal, and its effectiveness has been established since its inception in the 1930s. The COWS score helps healthcare professionals monitor patients’ progress during withdrawal and enables them to provide targeted medical interventions when necessary.

Opioid withdrawal can be a challenging and distressing experience for those in recovery. Symptoms can vary in intensity, making it essential to have a reliable assessment tool to gauge the severity of withdrawal. The COWS scale is composed of 11 withdrawal symptoms, including pulse rate, GI upsets, tremors, sweating, restlessness, yawning, anxiety or irritability, pupil size, bone and joint aches, gooseflesh, and tearing or runny nose.

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How Does the COWS Assessment Work?

The COWS assessment is a systematic and comprehensive evaluation used to measure the severity of opioid withdrawal symptoms in individuals undergoing detoxification. Healthcare professionals, such as clinicians, doctors, nurses, and addiction specialists, administer the assessment at regular intervals throughout the withdrawal process to track the patient’s progress and tailor their treatment plan accordingly. Here’s how the COWS assessment works:

  • Selection of symptoms: The COWS assessment consists of 11 specific withdrawal symptoms that are commonly associated with opioid withdrawal. These symptoms are carefully chosen based on their relevance and significance in gauging the intensity of the withdrawal experience.
  • Assigning numerical values: Each of the 11 withdrawal symptoms is assigned a numerical value based on the severity or frequency of the symptom reported by the patient. The numerical values range from 0 to 5, with 0 indicating the absence of the symptom and 5 representing the most severe manifestation of the symptom.
  • Conducting the assessment: Trained healthcare professionals conduct the COWS assessment by observing and interviewing the patient. The patient’s self-report and the clinician’s observations are taken into account to ensure a comprehensive evaluation.
  • Scoring the symptoms: As the patient reports or exhibits each withdrawal symptom, the healthcare professional records the corresponding numerical value on the COWS assessment form. COWS scores are calculated by summing up the numerical values assigned to all 11 symptoms.
  • Interpreting the COWS Score: Once the assessment is complete, the COWS score provides a clear indication of the patient’s current stage in the withdrawal process. A higher total score indicates more severe withdrawal symptoms, while a lower score suggests milder symptoms.
  • Tailoring treatment: The COWS score helps in tailoring the patient’s treatment plan. Depending on the severity of the withdrawal symptoms indicated by the score, healthcare professionals can adjust medication doses, implement additional therapeutic interventions, and provide emotional support to help the patient manage the challenges of withdrawal effectively.
  • Monitoring progress: Throughout the detoxification process, the COWS assessment is repeatedly administered to monitor the patient’s progress and response to treatment. Regular assessments enable healthcare professionals to identify any changes in the severity of withdrawal symptoms and make necessary adjustments to optimize the patient’s comfort and safety.
  • Ensuring patient safety: By regularly assessing the COWS score, healthcare professionals can detect signs of potential complications during withdrawal and intervene promptly to ensure the patient’s safety. Opioid withdrawal can sometimes lead to medical emergencies like dehydration, seizures, or cardiovascular issues. Early detection and appropriate management are critical to prevent serious consequences.


What is the score on the COWS scale?

The score on the COWS scale is a numerical value and COWS scoring indicates the severity of opioid withdrawal symptoms.

What does CIWA and COWS stand for?

CIWA stands for Clinical Institute Withdrawal Assessment, and COWS stands for Clinical Opiate Withdrawal Scale.

How do you assess COWS score?

COWS score is assessed by assigning numerical values to 11 different opioid withdrawal symptoms COWS score interpretation involves adding these values. The COW score calculation determines the severity of the withdrawal.

What is the COWS scale for Suboxone?

The COWS scale is used to assess opioid withdrawal, including withdrawal from Suboxone, which is a medication used to treat opioid addiction.

What COWS score is moderate withdrawal?

A COWS score range of 13 to 24 is considered to indicate moderate opioid withdrawal.

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Get Treatment for Opioid Addiction at Ohio Recovery Centers

If you or someone you know is struggling with opioid addiction, Ohio Recovery Centers is here to help. Our center provides personalized addiction treatment programs that specifically address opioid addiction, offering a path to recovery and healing.

We understand that every individual’s journey with addiction is unique, which is why our programs are tailored to meet your specific needs. Whether your addiction stems from alcohol, prescription medications, or illicit drugs, we have effective solutions to help you regain control of your life.

Research has shown that both mild and moderate opioid addictions can respond well to intensive outpatient treatment, offering a viable alternative to residential rehab. Our outpatient treatment programs are designed to be flexible and affordable, without compromising the quality of care you receive.

At Ohio Recovery Centers, we believe in a comprehensive and science-backed approach to recovery. Our treatment programs combine pharmacological, behavioral, and holistic therapies to address all aspects of opioid addiction. We equip our patients with relapse prevention strategies, coping techniques, and ongoing therapy options for continued support on their journey to recovery.

Take the first step towards healing by contacting our admissions team today. If you or someone you care about needs immediate assistance, call us at 877-679-2132. Let us help you find hope and a path to a healthier, addiction-free life.

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Joseph Gilmore

Joseph Gilmore has been working in the addiction industry for half a decade and has been writing about addiction and substance abuse treatment during that time. He has experience working for facilities all across the country. Connect with Joe on LinkedIn.
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Christopher Glover CDCA

My name is Christopher Glover, and I am from Cincinnati, Ohio. I am currently in school and working to grow in competence to better support our community. As a recovering individual I know the struggles that you or a loved one can go through and that there is help for anything you may be struggling with.

The hardest part is asking for help and we are here as a team to best support you and your decision to start your journey towards a better future. Connect with Chris on LinkedIn

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Amanda Kuchenberg PRS CDCA

I recently joined Ohio Community Health Recovery Centers as a Clinical Case Manager. I am originally from Wisconsin but settled in the Cincinnati area in my early 20s.  My career started in the fashion industry but quickly changed as I searched to find my drive and passion through helping others who struggle with addiction. 

As someone who is also in recovery, I wanted to provide hope, share lived experience, and support others on their journey.  I currently have my Peer Recovery Support Supervision Certification along with my CDCA and plan to continue my education with University of Cincinnati so I can continue to aid in the battle against substance addiction. Connect with Amanda on LinkedIn.

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Patrick McCamley LCDC III

 Patrick McCamley (Clinical Therapist) is a Cincinnati native who has worked in substance use disorder/co-occurring mental health disorder treatment since 2019. Patrick received his bachelors degree in psychology from University of Cincinnati in 2021 and received his LCDC III (Licensed Chemical Dependency Counselor) license from the Ohio Chemical Dependency Professionals Board in 2022. Patrick has worked in Clinical Operations, Clinical Case Management, and Clinical Therapy throughout his career.

Patrick has tremendous empathy and compassion for the recovery community, being in recovery himself since 2018. Patrick is uniquely qualified to be helpful because of the specific combination of his academic background and his own experience in recovery.

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Bill Zimmerman CDCA

Bill Zimmerman is a Greater Cincinnati Area native who has worked in substance use disorder/co-occurring mental health disorder treatment since 2018. Bill received his (Chemical Dependency Counselor Assistant) license from the Ohio Chemical Dependency Professionals Board in 2020.

Bill has worked in Clinical Operations in both support and supervision, and Program facilitating and 12 step recovery support during his career. Bill has a passion for the recovery community, having been in recovery himself since 1982. Connect with Bill on LinkedIn

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Taylor Lilley CDCA, PRS

Growing up in Louisiana with addiction running rampant on both sides of my family. A life away from drugs and alcohol seemed impossible for someone like me. I remember what it was like sitting across from someone thinking there is no way they could ever understand what I was going through.

Sharing my experience offers a credibility and a certain type of trust with clients that only someone who has walked down this road can illustrate. To immerse myself further into the field of addiction, I am currently studying at Cincinnati State for Human and Social Services.  I hope I never forget where I came from, if I can do it, so can you!

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Thomas Hunter LSW

Hello my name is Thomas Hunter. I was born and raised in Cincinnati, Ohio. I am a licensed social worker.In my scope of practice I have worked in the areas of mental health and recovery for thirty years. The clients I have worked with in my career have ranged in age from seven to seventy.

I strive each day to serve my purpose of helping those in need and I believe I do so by utilizing all of my experiences to accomplish my goal of supporting those who desire to establish their sobriety and maintain it in their recovery. Connect with Thomas on LinkedIn.

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Mary D.Porter,LICDC

 My name is Mary D. Porter. I received my Masters of Social Work in 2008 from The University of Cincinnati. I received My Licensed Independent Chemical Dependency Counselor Licensure in 2001. I retired from The Department of Veteran Affairs Medical Center on April 14, 2014. Currently, I am the Associate Clinical Director for The Ohio Community Health Recovery Centers in Cincinnati.. Due to the fourth wave of the Opioid Epidemic in 2019,  I decided to enter back into the workforce to assist the addicted population.

The overdoses were astounding and I wanted to help.  I consider myself  to be an advocate for the addicted population. My compassion, resilience, empathy, wisdom, knowledge, experience and  love I have for this forgotten population goes beyond words. I consider what I do for the addicted population as a calling versus a “career,” because I too was once an “addict and alcoholic.” Today I am 45.5 years alcohol and substance free.

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Ben Lemmon LCDC III

Hello, my name is Ben Lemmon, and I’m the Vice President and Clinical Director at Ohio Community Health Recovery Centers. I’ve been working in the addiction and mental health field since 2013 and decided to enter the field after overcoming my own challenges with addiction.

When I first meet a client, I always explain to them that the reason we are meeting is because they are not capable of obtaining or maintaining sobriety, and my goal is to create a person that can maintain sobriety. I believe a person’s personality is made up of their thoughts, feelings and actions and my job is to help clients identify the thoughts, feelings and actions that have them disconnected from recovery and provide them with the tools to live a healthy and happy life. Connect with Ben on LinkedIn