Key takeaway
The Clinical Opiate Withdrawal Scale is an 11-item form a clinician fills out to rate opioid withdrawal. NIDA's copy sets the total as mild, moderate, moderately severe, or severe. SAMHSA's TIP 63 names the scale as a way to document signs. A number is not a taper and not a reason to skip emergency help.
Last updated: Mon Oct 05 2026 00:00:00 GMT+0000 (Coordinated Universal Time)
Withdrawal feels like the flu and a panic attack at once, and you want a number that says the night is safe to ride out at home. The Clinical Opiate Withdrawal Scale, usually called COWS, is one number clinics actually use. What detox is, as a level of care, is already on the medically supervised detox guide and the detox versus rehab guide. What follows stays with the form: who fills it out, what the items are, and what the bands on NIDA's copy say. There is no column here for you to add up tonight.
A clinician's form, not a symptom diary
NIDA publishes the scale as an 11-item tool designed to be given by a clinician. It can be used in an inpatient unit or an outpatient clinic. The point of repeating it is to rate common signs the same way each time and to watch them change. The total can help the clinician judge the stage or severity of withdrawal and how physically dependent the person appears to be.
The introduction answers a doubt clinicians raise, that some items sound subjective. Opioid withdrawal, it says, has been compared to a severe flu: nausea, vomiting, sweating, joint aches, agitation, tremor. The form's rule is that, in most categories, the person should not be scored above the lowest mark unless some sign can be observed. Feeling awful is real. The scale still wants something the rater can see or measure. That is why a self-score is a different activity. You cannot watch your own pupils and your own tremor the way the form asks, and you should not try to while you are the patient.
Rate only what seems tied to the withdrawal. The form's example is pulse: if the heart is fast because the person was jogging just before the check, that rise does not get points. Resting pulse is measured after one minute of sitting or lying down. Sweating is judged over the past half hour and is not counted when the room or the person's activity explains it. Tremor is an observation of outstretched hands. Restlessness and yawning are what the rater sees during the assessment. Pupil size is compared with normal for the light in the room. Bone or joint aches count only the extra pain attributed to withdrawal, not pain the person already had. Runny nose or tearing is not counted when a cold or allergies explain it. Gastrointestinal upset is what happened over the last half hour. Anxiety or irritability and gooseflesh, the skin that stands up, are the last two items.
Those rules are why the point values are not lined up here as a worksheet. A list of "pulse over 120 equals 4" becomes a home sheet the moment someone photographs it. The alcohol scale guide made the same choice for CIWA-Ar. The instrument exists so staff can record a total. It does not exist so a family member can decide the night is safe.
The bands on the NIDA copy
The copy NIDA hosts says the total is the sum of all 11 items. It prints four bands. A score of 5 to 12 is mild. A score of 13 to 24 is moderate. A score of 25 to 36 is moderately severe. More than 36 is severe withdrawal. The source line on that form is Wesson and Ling, Journal of Psychoactive Drugs, volume 35, number 2, 2003. The form says that version may be copied and used clinically. Clinical use is the permission. It is not an invitation to treat yourself.
A band is a label for a moment. It does not say how long the next band will last, and it does not say which medicine to start. TIP 63's time windows for short-acting and long-acting opioids are already on the opioid withdrawal guide, kept from turning into a home schedule. Use that guide for the clock. Use the bands above for the instrument. Do not add the two into a plan.
What TIP 63 asks the score to do
In SAMHSA's TIP 63, on the NCBI Bookshelf, opioid withdrawal is described as extremely uncomfortable, like gastroenteritis, a bad flu, anxiety, and low mood at once. How severe it is can say something about physical dependence and can inform medication choices and doses. The choice and the dose stay with the prescriber.
The TIP says to assess withdrawal on exam, using the physical signs in its exhibit, and that structured measures can make the record more consistent. It names COWS and the Clinical Institute Narcotic Assessment Scale for Withdrawal Symptoms as examples. The purposes it lists are diagnosis, initial management, and treatment planning. It sends readers to the scales themselves. Part 3 of the TIP is where documentation for starting medication is covered. Starting buprenorphine or naltrexone too soon can precipitate withdrawal. That warning already lives on the medication guide and the fentanyl guide. A COWS total is one piece of a prescriber's decision. It is not a threshold you apply from a printout.
What the number does not clear
Uncomplicated opioid withdrawal is not the same emergency as alcohol or barbiturate withdrawal. The opioid guide cites SAMHSA on that difference, and on the danger that comes after the symptoms fade, when a person uses again with a lower tolerance. A mild band is not a certificate that the next use will be survivable. A severe band is not a reason to ride it out because someone online said opioid withdrawal cannot kill you. Vomiting and diarrhea can dehydrate a person. Slowed breathing is an overdose until proven otherwise.
Call 911 for trouble breathing, blue lips, a collapse, a seizure, or someone who will not wake. Call or text 988 for suicidal thoughts. Do not pause to finish the 11 items.
SmarterRecovery is a referral helpline. SMART Recovery is a separate mutual-help program. Nobody on a referral call can see pupils, take a pulse, or sign the form. They can help you look for a program where a clinician does those things.
SAMHSA's National Helpline is 1-800-662-HELP (4357). Call or text (800) 653-9376 if you need help finding care that monitors opioid withdrawal. Do not detox from a photographed scale.
Additional Resources
Sources cited on this page:
- NIDA: Clinical Opiate Withdrawal Scale (Wesson and Ling, 2003)
- SAMHSA TIP 63, Part 2: opioid withdrawal assessment and scales (NCBI Bookshelf)
- Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). Journal of Psychoactive Drugs. 2003;35(2):253-259. Cited on the NIDA form.
- SAMHSA FindTreatment.gov
- SAMHSA National Helpline
- 988 Suicide & Crisis Lifeline
Common Questions
Is COWS the opioid version of CIWA-Ar?
They are both clinician ratings, and they are not interchangeable. CIWA-Ar, on the alcohol scale guide, is the revised alcohol instrument, with a maximum of 67. COWS is the opioid instrument NIDA hosts, with 11 items and bands that top out above 36 for severe withdrawal. Do not add an alcohol score to an opioid score. Do not use either form to manage a benzodiazepine stop. The alcohol scale guide already refuses that shortcut.
What are the 11 items?
NIDA's copy lists resting pulse, sweating, restlessness, pupil size, bone or joint aches, runny nose or tearing, stomach upset, tremor, yawning, anxiety or irritability, and gooseflesh. Score only what seems related to opioid withdrawal. A hot room, exercise, a cold, allergies, or pain the person already had are not automatic points. Pulse is taken after a minute of sitting or lying still. The notes below explain the rest. The form is not something to complete alone.
What do the totals mean?
The form says 5 to 12 is mild, 13 to 24 is moderate, 25 to 36 is moderately severe, and more than 36 is severe. The total adds the 11 items. The bands help a clinician judge the stage and how physically dependent someone appears. They are not a promise about tomorrow, and a low number is not permission to stay home. Most items should not go above the lowest score without a sign the rater can see. A self-score skips that rule.
Does SAMHSA tell programs to use it?
TIP 63 says structured measures such as COWS, and the Clinical Institute Narcotic Assessment scale, can standardize documentation of withdrawal signs. The point it names is diagnosis, the first management steps, and treatment planning. It points readers to the scales rather than pasting a dosing chart in that paragraph. Part 3 of the TIP is where medication starts are documented. The notes here stop before any dose. A score that falls after a medicine is still the prescriber's record, not a recipe.
Can I use the score to decide I am safe to detox alone?
No. The opioid withdrawal guide has the time windows from TIP 63 and the warning that a later return to use is when tolerance is low and breathing can stop. Uncomplicated opioid withdrawal is usually not the life-threatening event alcohol or barbiturate withdrawal can be. Dehydration and the next use still hurt people. Call 911 for slowed breathing, collapse, or a seizure. A printed total does not replace that call, and it does not start buprenorphine safely.