By Amy Niemas, RN-BC, BSN, MSW, Clinical Content Director · Psychiatric Registered Nurse
This guide is currently pending review by a licensed registered nurse.
Last updated: May 14, 2026
COWS Documentation: A Nursing Guide to Opioid Withdrawal Scoring
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Why This Matters
Regulatory bodies: Centers for Medicare & Medicaid Services (CMS), The Joint Commission, American Society of Addiction Medicine (ASAM), Substance Abuse and Mental Health Services Administration (SAMHSA)
Opioid withdrawal is rarely fatal on its own, but it still can cause patient harm and is the gateway to medication-assisted treatment (MAT). The COWS serves as a safety tool rather than merely a paperwork exercise. Protocol-driven action, such as starting buprenorphine when COWS ≥13, means the score directly triggers a clinical action; an incorrect score results in an inappropriate action - either precipitated withdrawal from premature dosing, or a missed induction window. Gaps in COWS documentation during active withdrawal are frequently tagged in surveys and expose the nurse and facility to malpractice claims, regulatory citations, and licensing board complaints if the chart is later reviewed.
- The Clinical Opiate Withdrawal Scale (COWS) — Wesson DR, Ling W. J Psychoactive Drugs. 2003;35(2):253-259 (2003)
- Opioid Withdrawal — Shah M, Huecker MR. StatPearls Publishing (Updated 2023) (2023)
What COWS Measures
The COWS (Clinical Opiate Withdrawal Scale) is an 11-item scale that assesses the severity of opioid withdrawal. Unlike the CIWA, the items use variable scales, with some ranging from 0-4 and others from 0-5. The total score ranges from 0 to 48. The 11 items include resting pulse rate (0-4), sweating (0-4), restlessness (0-5), pupil size (0-5), bone or joint aches (0-4), runny nose or tearing (0-4), GI upset (0-5), tremor (0-4), yawning (0-4), anxiety or irritability (0-4), and gooseflesh skin (0-5). Wesson and Ling published the COWS in 2003, and it is most commonly used prior to methadone or buprenorphine induction; the score determines whether the patient is experiencing sufficient withdrawal to safely begin medication-assisted treatment. Additionally, the COWS is used in detox and during medical admissions for patients with opioid use disorder. (Note: Benzodiazepine withdrawal has its own assessment tool (CIWA-B), which is less widely used. Do not use the CIWA-Ar or COWS for benzodiazepine withdrawal without confirming with the ordering provider.)
How to score each COWS item
COWS items use either a 0-4 or 0-5 descriptive scale, where 0 means the symptom is not present and the top of the scale means the symptom is at its most severe. Use the standardized descriptors on the scoring sheet, not your own interpretation. The following are examples of these descriptions, but it is not a comprehensive list. For resting pulse rate: 0 = pulse ≤80, 1 = pulse 81-100, 2 = pulse 101-120, 4 = pulse >120. For sweating: 0 = no chills or flushing reported, 1 = subjective report of chills or flushing, 2 = flushed face or observable moisture, 3 = beads of sweat on brow or face, 4 = sweat streaming off face. For pupil size: 0 = pinned or normal for room light, 1 = possibly larger than normal, 2 = moderately dilated, 5 = so dilated that only the rim of the iris is visible. Many items rely on patient self-report (aches, anxiety, GI upset). The best defense is to: document WHAT you observed alongside the score. "Pulse 2 (108 bpm)" is more defensible than "Pulse 2" alone.
Scoring and Documentation Workflow
The COWS assessment follows a score-intervene-reassess workflow.
Step 1: Assess at the ordered interval. Step 2: Score each item per the standardized descriptors. Step 3: Sum the total. Step 4: Compare the total to your facility's protocol thresholds. Step 5: Administer medication if the protocol indicates and you have an active order. Step 6: Document everything - time, item scores, total, action taken, and reassessment plan. Step 7: Schedule the next assessment per the protocol. This is a loop, not a one-time event. After medication administration, reassess within 30-60 minutes (per protocol) to document the response. The reassessment is part of the loop - do not skip it.
What to Document for Each Assessment
A complete COWS chart entry has 6 pieces of information.
1. Time of assessment (military time - COWS is time-sensitive and protocols are interval-based). 2. Item-level scores (detailing the number value for each item, not just the total score). 3. Total score. 4. Protocol action taken (medication given, none needed, or escalated to provider). 5. Patient response (if medication was given and you have reassessed). 6. Time of next scheduled assessment. Example format: "1400 COWS 14 (Pulse 1, Sweating 2, Restless 2, Pupil 2, Aches 2, Runny nose 1, GI 2, Tremor 1, Yawning 0, Anxiety 1, Gooseflesh 0). Per protocol: buprenorphine induction begun at 1410. Next assessment 1500."
Protocol Interpretation Basics
COWS protocols vary by institution - always use YOUR facility's protocol, not a generic one from the internet. That said, most follow a common pattern. A typical COWS protocol might be: score <5 - not yet in withdrawal, defer medication-assisted treatment induction. Score 5-12 - mild withdrawal, may be in induction range for buprenorphine. Score ≥13 - moderate to severe withdrawal, supports continuing treatment and likely the beginning of buprenorphine initiation. Some facilities may start with buprenorphine only (Subutex) and then move to a combination of buprenorphine and naloxone (Suboxone) for maintenance. Know your facility's re-score intervals: commonly Q1h if the score is elevated, Q2h if stable mid-range, Q4h if stable, Q8h if stable and low scoring.
Medication Compliance Tracking
Withdrawing patients are commonly on concurrent psychotropics, so medication compliance documentation shows up alongside COWS scoring in the same shift.
The framework (compliant, partial, refusing) and the refusal → education → outcome documentation loop are covered in the Psychiatric Nursing Charting guide. Use the same pattern for any psychotropic given during MAT induction or detox.
Common Mistakes
Documenting Only the Total Score
Weak: 1400 COWS 14.
Strong: 1400 COWS 14 (Pulse 1, Sweating 2, Restless 2, Pupil 2, Aches 2, Runny nose 1, GI 2, Tremor 1, Yawning 0, Anxiety 1, Gooseflesh 0).
Protocols often trigger differently based on which items are elevated, and induction decisions depend on objective signs like pupil dilation and pulse, not the total alone. A score of 14 driven by autonomic signs (pulse, pupils, gooseflesh) reads differently than one driven by self-reported symptoms.
Skipping assessments when the patient seems stable
Weak: No COWS documentation occurred between 0800 and 1400 because the patient was sleeping.
Strong: 0900 COWS 3, stable, patient resting comfortably. Next assessment 1100 per Q2h protocol.
Protocol gaps appear as missed assessments during surveys and legal reviews. "No news" does not qualify as documentation. Even a low score requires documentation at the ordered interval.
Not Documenting the Medication Response
Weak: Buprenorphine 4mg given at 1410.
Strong: Buprenorphine 4mg SL given at 1410. Reassessment at 1510: COWS 6 (decreased from 14). Patient calm, restlessness resolved. Pulse decreased from 108 to 88.
The COWS protocol follows a loop: assess, medicate, and reassess. Without the post-medication reassessment, you cannot demonstrate that the intervention was effective, document that precipitated withdrawal did not occur, or justify the next interval.
Vague descriptor language instead of scores
Weak: Patient appears restless and diaphoretic.
Strong: Restlessness 2 (unable to sit still more than a few seconds). Sweating 3 (beads of sweat on brow). Patient states, "I can't get comfortable in my own skin."
"Appears restless" is not a COWS score. Each item has standardized descriptors; use the descriptor and the number. Including the patient's own words in quotes strengthens the documentation.
Using the Wrong Scale for Withdrawal Assessment
Weak: Scoring a patient experiencing benzodiazepine withdrawal with COWS.
Strong: COWS is validated for opioid withdrawal. Benzodiazepine withdrawal requires a different assessment tool (CIWA-B). Confirm the appropriate scale with the ordering provider.
COWS was developed and validated specifically for opioid withdrawal. Off-label use for other withdrawal types can lead to misleading scores and inappropriate medication triggers.
Pro Tips
- Remember the 11 COWS items: Pulse, Sweating, Restlessness, Pupil size, Aches, Runny nose/tearing, GI upset, Tremor, Yawning, Anxiety/irritability, Gooseflesh. Reviewing this list helps you avoid missing items during a busy shift.
- Document item-level scores every time (i.e. the score for each individual item): Spending an extra minute to document item-level scores pays off when the provider asks, "What specifically was elevated?" A total of 14 holds limited clinical significance without knowing whether the score is driven by objective autonomic signs or subjective symptoms.
- Escalate right away if scores are rising quickly: When a COWS rises from 8 to 15 in one hour, this indicates rapid withdrawal progression. Use your clinical judgment and call the provider as soon as you see this. Also document it, such as: "COWS rose from 8 to 15 in one hour, provider notified, awaiting orders."
- CIWA and COWS are separate scales - don't mix them: Some patients have both alcohol and opioid use disorder and may need both assessments. Document each scale separately, using its full name (CIWA-Ar, COWS), and never combine the scores.
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Related Guides
- CIWA-Ar DocumentationThe alcohol-withdrawal counterpart. Same score-intervene-reassess loop, different scale, different protocol triggers.
- Glasgow Coma Scale ChartingNeurological monitoring plays a core role in withdrawal assessment. GCS trends paired with COWS can catch decompensation early.
- SBAR Nursing HandoffCOWS trends play a key role in any SBAR for a withdrawing patient.
- Nursing Charting Cheat SheetAll charting categories in one scannable reference.
- RASS documentation for ICU sedationThe RASS, used primarily in the ICU setting, is the closest documentation method to the COWS. Both follow the same score-intervene-reassess loop; charting habits transfer directly.
- Psychiatric Nursing Charting overviewWithdrawal monitoring is common on both psychiatric and medical units. COWS bridges clinical and psychiatric documentation.