CIWA-Ar for Alcohol Withdrawal

Why did you develop the CIWA-Ar for Alcohol Withdrawal? Was there a particular clinical experience or patient encounter that inspired you to create this tool for clinicians?

The CIWA-Ar is a shortened version of a previous 15 item scale CIWA (see Sullivan 1989). This program to improve recognition and treatment of alcohol withdrawal was conducted because of a lack of validated diagnostic and clinical monitoring tools that could guide and improve treatment.

What pearls, pitfalls and/or tips do you have for users of the CIWA-Ar for Alcohol Withdrawal? Do you know of cases when it has been applied, interpreted, or used inappropriately?

The CIWA-Ar has been translated into more than 20 different languages and is used very widely. There are some very good YouTube videos that are useful for training, such as this one. Almost 30 years after we published this paper, I still get approached about its implementation. The most common misinterpretation of the CIWA-Ar Score is that it is a recipe for when to use pharmacologic treatment. While scores of 10 or less rarely need pharmacologic treatment, clinical judgement is still very important with scores between 10-20. Our typical management has been to use diazePAM loading (Sellers 1983). With training, nursing staff can readily and reliably perform scoring, but the score should not be used to drive "standing orders".

What recommendations do you have for doctors once they have applied the CIWA-Ar for Alcohol Withdrawal? Are there any adjustments or updates you would make to the score based on new data or practice changes?

Our original paper still accurately outlines the reasons for using the CIWA-Ar and how to use it. We did not emphasize the importance of standardized training of all staff and the usefulness of the assessment of within and between rater reliability in the paper. Patients or standardized trained patients can be used to ensure good staff agreements on ratings.

Management of patients today is potentially more complicated than it was when the CIWA-Ar was developed because of a very high incidence of other drug abuse. Detailed histories, careful clinical examination, and urine drug screens can help sort out more complex patients.

How do you use the CIWA-Ar for Alcohol Withdrawal in your own clinical practice? Can you give an example of a scenario in which you use it?

The CIWA-Ar should used in all patients suspected of being at risk to have alcohol withdrawal. Because it takes only a minute or two to administer, the scale can be used as frequently (i.e., every 1-2 hours) and can be used early when alcohol withdrawal is viewed only as a clinical risk.

Any other research in the pipeline that you’re particularly excited about?

A number of studies have examined the use of various benzodiazepines other than diazePAM for treating alcohol withdrawal. Once dosing adjustments are made for differences in potency and duration of effect, one would expect most could be effective as long as patients are carefully observed to avoid under- or excessive dosing.

Edward M. Sellers, MD, PhD, FRCPC, FACP, is the president and principal of DL Global Partners Inc., which specializes in clinical psychopharmacology and pharmacogenetics for substance abuse. He is also professor emeritus at the University of Toronto and helped establish its clinical psychopharmacology unit. Dr. Sellers has received several awards for his research in pharmacology and drug dependence, including the Rawls-Palmer Award given by the ASCPT.