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COWS (Clinical Opiate Withdrawal Scale)

Home Glossary COWS (Clinical Opiate Withdrawal Scale)

Opiate withdrawal management is one of the most pressing clinical challenges in correctional healthcare. Many individuals entering custody are experiencing opioid use disorder (OUD) or early withdrawal. The withdrawal process, if unmanaged, can lead to severe complications, including dehydration, seizures, or even death, and can significantly impact facility safety and stability.

The Clinical Opiate Withdrawal Scale (COWS) is a standardized assessment tool that helps clinicians objectively evaluate the severity of opioid withdrawal symptoms. In correctional facilities, using COWS ensures that each patient receives appropriate monitoring, medication, and care, while helping staff make informed, consistent clinical decisions that align with the standards of the American Correctional Association (ACA) and the National Commission on Correctional Health Care (NCCHC).

By applying the COWS protocol, facilities can reduce medical emergencies, enhance patient outcomes, and strengthen compliance with evidence-based guidelines for addiction treatment.

What Is COWS (Clinical Opiate Withdrawal Scale)?

The Clinical Opiate Withdrawal Scale (COWS) is a scoring system designed to quantify the severity of opioid withdrawal symptoms. Developed by Wesson and Ling in 2003, COWS is widely used in both correctional and community healthcare settings as an evidence-based assessment for guiding opioid detoxification and medication-assisted treatment (MAT).

COWS assesses 11 physical and psychological symptoms commonly associated with opioid withdrawal, including:

  • Resting pulse rate
  • Sweating
  • Restlessness
  • Pupil size
  • Bone or joint aches
  • Runny nose or tearing
  • Gastrointestinal upset
  • Tremor
  • Yawning
  • Anxiety or irritability
  • Gooseflesh skin



Each symptom is rated on a scale (usually from 0 to 4 or 5), and the total score determines the withdrawal severity category:

  • 5–12: Mild withdrawal
  • 13–24: Moderate withdrawal
  • 25–36: Moderately severe withdrawal
  • >36: Severe withdrawal


This structured approach helps clinicians initiate and adjust withdrawal management protocols safely and consistently.

The Role of COWS in Correctional Settings

Opioid withdrawal is not only a medical issue, it’s a safety concern for inmates and staff. Proper use of the COWS assessment provides a standardized, objective framework for identifying and managing withdrawal cases.

In correctional facilities, COWS scoring is used to:

  • Identify Withdrawal Early: Detect symptoms promptly during intake screenings or medical evaluations to ensure timely treatment.
  • Guide Treatment Decisions: Determine when to initiate or adjust medication-assisted treatment (e.g., buprenorphine or methadone).
  • Monitor Patient Progress: Track changes in withdrawal severity over time.
  • Document Care Consistently: Maintain clear, audit-ready clinical records.
  • Support Continuity of Care: Communicate withdrawal management data across medical, behavioral, and custody teams.


By embedding COWS into intake and ongoing assessments, facilities ensure consistency in care and reduce the likelihood of clinical oversight or underreporting.

The Risks of Not Using a Standardized Withdrawal Scale

Without a validated tool like COWS, withdrawal management becomes subjective and inconsistent. Facilities that rely on observation alone face several risks:

  • Inconsistent Assessments: Different staff may rate symptoms differently without standardized criteria.
  • Delayed Interventions: Withdrawal symptoms can escalate quickly without proper monitoring.
  • Medication Errors: Dosing adjustments may be inaccurate if based on incomplete symptom tracking.
  • Increased Medical Emergencies: Untreated withdrawal can lead to severe complications or self-harm.
  • Compliance Gaps: Lack of documented, standardized assessments can lead to ACA or NCCHC deficiencies.


Standardized tools like COWS turn withdrawal management from a reactive process into a predictable, evidence-based practice that supports safety and compliance.

How Technology Enhances COWS Assessment and Monitoring

Modern correctional Electronic Health Record (EHR) systems integrate COWS scoring directly into clinical workflows, ensuring that assessments are accurately documented and consistently reviewed.

With EHR integration, facilities can:

  • Digitally Record COWS Scores: Capture and store all assessments in real time.
  • Automate Scoring Calculations: Reduce manual entry errors by using automated total scoring.
  • Trigger Clinical Alerts: Notify staff when scores reach moderate or severe thresholds.
  • Track Trends Over Time: Visualize patient progress during detoxification or treatment.
  • Link to Treatment Protocols: Automatically suggest or document interventions based on score ranges.
  • Ensure Audit Readiness: Produce complete, timestamped documentation for ACA and NCCHC reviews.


Technology transforms COWS from a paper checklist into a dynamic clinical management tool that enhances patient safety and operational oversight.

Supporting Safer Withdrawal Management and Compliance

When used consistently, the COWS scale helps facilities achieve both clinical and administrative goals. Facilities experience:

  • Fewer medical emergencies and hospital transports.
  • Better outcomes for inmates undergoing withdrawal.
  • More confident decision-making among clinical staff.
  • Improved transparency and accountability during audits.
  • Enhanced continuity for patients transitioning to MAT or reentry programs.

Ultimately, standardized withdrawal management through tools like COWS reinforces the correctional system’s responsibility to provide humane, high-quality medical care.

At CorrecTek, we understand that withdrawal management demands both precision and compassion. Our correctional EHR supports the COWS process by integrating the Clinical Opiate Withdrawal Scale into daily workflows, enabling staff to record scores, track trends, and generate audit-ready documentation with ease.
Connect with us to learn how CorrecTek’s EHR helps correctional facilities strengthen withdrawal management and deliver safer, more compliant care.