Free tool · Scored assessments

Withdrawal Scores.

Alcohol and opioid withdrawal scoring in one place. Toggle between CIWA-Ar (alcohol withdrawal) and COWS (clinical opiate withdrawal) — score the symptom items, get the total, the severity band, and the symptom-triggered / induction framing.

Score the 10 CIWA-Ar items

Rate each item on the patient in front of you. Nine items score 0–7; orientation scores 0–4. The total updates as you go. Requires a communicative patient — see the caveat below for sedated or intubated patients.

Nausea & vomiting "Do you feel sick to your stomach? Have you vomited?"

Tremor Arms extended, fingers spread. Observation.

Paroxysmal sweats Observation.

Anxiety "Do you feel nervous?" Observation.

Agitation Observation.

Tactile disturbances "Any itching, pins-and-needles, burning, numbness, or bugs crawling on/under the skin?"

Auditory disturbances "More aware of sounds? Harsh? Frightening? Hearing things that aren't there?"

Visual disturbances "Light too bright? Colors different? Hurts your eyes? Seeing things that aren't there?"

Headache / fullness in head "Does your head feel different — a band around it?" Do not rate dizziness.

Orientation & clouding of sensorium "What day is this? Where are you? Who am I?"

0 / 67 · 0 of 10 items scored

Score all ten items to see the total and severity band.

Severity bands & what they mean [2][3]

CIWA-Ar	Severity	Typical approach (confirm with your protocol)
< 10	Minimal–mild	Patients scoring <10 do not usually need additional medication for withdrawal.[3]
10–18	Moderate (marked autonomic arousal)	At risk of severe/complicated withdrawal; symptom-triggered benzodiazepine per orders; reassess frequently.[2]
≥ 19	Severe (impending delirium tremens)	ASAM supports a front-loading benzodiazepine strategy at this level; high risk of seizures and DTs.[2]

The original ASAM-supplement form describes <8–10 as minimal/mild, 8–15 as moderate, and ≥15 as severe (impending DTs); a revised-scale study found patients scoring >15 were at increased risk of severe withdrawal (RR 3.72).[3] The bands above use the 2020 ASAM operating thresholds (≥10, ≥19).[2] Either way, the score guides — your facility's order set sets the actual triggers.

The 10 items at a glance [1]

Item	Range	How it's rated
Nausea & vomiting	0–7	Ask + observe
Tremor	0–7	Arms extended, observe
Paroxysmal sweats	0–7	Observe
Anxiety	0–7	Ask + observe
Agitation	0–7	Observe
Tactile disturbances	0–7	Ask + observe (1–3 paresthesias, 4–7 hallucinations)
Auditory disturbances	0–7	Ask + observe (1–3 harshness, 4–7 hallucinations)
Visual disturbances	0–7	Ask + observe (1–3 sensitivity, 4–7 hallucinations)
Headache / fullness in head	0–7	Ask; do not rate dizziness
Orientation & clouding of sensorium	0–4	Ask

Maximum possible score 67 (nine items ×7 + orientation ×4). The CIWA-Ar is not copyrighted and may be reproduced freely.[1]

Disclaimer: Educational tool only — not a clinical decision-support device, not a diagnosis, and not a substitute for your assessment, your provider's orders, or your facility's CIWA protocol and order set. The CIWA-Ar was validated in communicative patients; it can be unreliable in sedated, intubated, delirious, or non-English-speaking patients, and symptoms like tremor and sweats overlap with other conditions (sepsis, thyroid storm, stimulant toxicity) — never assume a high score is "just withdrawal." A low score never overrides clinical concern; escalate any patient who worries you. Enter de-identified values only; nothing is stored or transmitted. Confirm the trigger thresholds and dosing your unit actually uses.

References

Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353–1357. doi:10.1111/j.1360-0443.1989.tb00737.x. (Original 10-item scale; item anchors and maximum score 67 transcribed from this instrument; not copyrighted.)
The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. J Addict Med. 2020;14(3S Suppl 1):1–72. asam.org. (Symptom-triggered benzodiazepines preferred over fixed-dose; CIWA-Ar ≥10 = at least moderate / at risk of severe withdrawal; ≥19 supports front-loading; reassess every 1–4 h in moderate–severe withdrawal; extend monitoring once <10 for 24 h.)
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar). Supplement to ASAM News, Vol. 16, No. 1, Jan–Feb 2001 (reproduced, U.S. Dept. of Veterans Affairs). ci2i.research.va.gov. (Band descriptions: <8–10 minimal/mild, 8–15 moderate, ≥15 severe/impending DTs; "patients scoring less than 10 do not usually need additional medication"; >15 RR 3.72 for severe withdrawal.)

Item wording and thresholds were transcribed directly from these primary sources. Your facility may use a locally adapted CIWA protocol and order set — those take precedence at the bedside.

Score the 11 COWS items

Rate each item on the patient in front of you for symptoms not better explained by another cause (room temperature, allergies, pre-existing pain). The total updates as you go.

Resting pulse rate After sitting/lying for 1 minute.

GI upset Over the last ½ hour.

Sweating Past ½ hour, not from room temp / activity.

Tremor Observation of outstretched hands.

Restlessness Observation during assessment.

Yawning Observation during assessment.

Pupil size Relative to room light.

Anxiety or irritability Observation + report.

Bone or joint aches Only the component attributed to withdrawal.

Runny nose or tearing Not from cold symptoms or allergies.

Gooseflesh skin Observation.

0 / 48 · 0 of 11 items scored

Score all eleven items to see the total and severity band.

Severity bands [1]

COWS total	Severity
5–12	Mild withdrawal
13–24	Moderate withdrawal
25–36	Moderately severe withdrawal
> 36	Severe withdrawal

A score of 4 or less indicates minimal or no withdrawal. The total ranges 0–48 across the 11 clinician-observed items.[1] COWS is commonly used to time buprenorphine induction: many protocols wait until the patient is in at least moderate objective withdrawal (often a COWS in the low double digits, per your protocol) before the first buprenorphine dose, to reduce the risk of precipitated withdrawal.[3] Your facility's order set defines the exact induction threshold.

The 11 items at a glance [1]

Item	Possible points
Resting pulse rate	0, 1, 2, 4
GI upset	0, 1, 2, 3, 5
Sweating	0, 1, 2, 3, 4
Tremor	0, 1, 2, 4
Restlessness	0, 1, 3, 5
Yawning	0, 1, 2, 4
Pupil size	0, 1, 2, 5
Anxiety or irritability	0, 1, 2, 4
Bone or joint aches	0, 1, 2, 4
Runny nose or tearing	0, 1, 2, 4
Gooseflesh skin	0, 3, 5

Maximum possible score 48. Items are scored on what the clinician can observe and what the patient reports during the assessment.[1]

Disclaimer: Educational tool only — not a clinical decision-support device, not a diagnosis, and not a substitute for your assessment, your provider's orders, or your facility's protocol and order set. The COWS reflects physical withdrawal signs only — it does not capture craving and does not replace a full evaluation. Several items (tachycardia, sweating, tremor, GI upset) overlap with other conditions such as sepsis, stimulant toxicity, thyroid storm, or hypoglycemia — never assume a high score is "just withdrawal." Buprenorphine timing in particular is protocol-driven: dosing before adequate objective withdrawal can precipitate withdrawal. Enter de-identified values only; nothing is stored or transmitted. Confirm the thresholds and dosing your unit actually uses.

References

Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs. 2003;35(2):253–259. PMID: 12924748. (Original 11-item scale; item anchors, point values, maximum 48, and the mild/moderate/moderately-severe/severe bands transcribed from this instrument.)
Clinical Opiate Withdrawal Scale (COWS). National Institute on Drug Abuse (NIDA), reproduced form. nida.nih.gov. (Standard reproduced version of the Wesson & Ling form used to confirm item wording and scoring.)
Substance Abuse and Mental Health Services Administration (SAMHSA). TIP 63: Medications for Opioid Use Disorder. Rockville, MD: SAMHSA. samhsa.gov. (Buprenorphine induction is timed to objective opioid withdrawal — commonly assessed with the COWS — to reduce the risk of precipitated withdrawal; the exact threshold is set by local protocol.)

Item wording, point values, and bands were transcribed from the COWS instrument. Your facility may use a locally adapted COWS protocol and induction threshold — those take precedence at the bedside.

Pairs well with

Withdrawal Scores.

Score the 10 CIWA-Ar items

Severity bands & what they mean [2][3]

The 10 items at a glance [1]

References

Score the 11 COWS items

Severity bands [1]

The 11 items at a glance [1]

References

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