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    Chief Complaint


    Organ System


    Patent Pending

    CIWA-Ar for Alcohol Withdrawal

    Objectifies alcohol withdrawal severity to help guide therapy.
    When to Use
    Why Use

    Patients in a variety of settings, including outpatient, emergency, psychiatric, and general medical-surgical units, for whom there is clinical concern for alcohol withdrawal.

    • The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale has ten items, each evaluated independently then aggregated to yield a score correlating with severity of alcohol withdrawal.
    • There is no absolute relationship between alcohol use pattern and risk of physiologic dependence or withdrawal for a given individual. In general, any suspicion of daily alcohol use over several weeks or more, regardless of quantity, should raise concern for potential alcohol withdrawal.
    • Cannot be used effectively in intubated/sedated patients. A sedation scale such as the Richmond Agitation-Sedation Scale (RASS) is more appropriate in this setting.
    • Additional variables that may contribute to risk include age, medical comorbidities like hepatic dysfunction, concomitant medication use, and low seizure threshold. (Roffman JL 2006)
    • The CIWA-Ar provides an efficient (<5 mins) and objective means of assessing alcohol withdrawal that can then be utilized in treatment protocols.
    • Patients frequently under-report alcohol use and physicians often overlook alcohol problems in patients. (Kitchens JM 1994) It is estimated that 1 of every 5 patients admitted to a hospital abuses alcohol. (Schuckit 2001)
    • Unrecognized alcohol withdrawal can lead to potentially life-threatening consequences including seizures and delirium tremens.


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    Creator Insights


    • Benzodiazepines are generally used to control psychomotor agitation and prevent progression to more severe withdrawal.
    • Diazepam (Valium), lorazepam (Ativan), and chlordiazepoxide (Librium) are the most frequently used benzodiazepines. Follow your hospital's own alcohol withdrawal protocol; frequently treatment begins with benzodiazepines when CIWA-Ar scores reach 8-10, with standing or as needed dosing for scores 10-20. Some protocols even include transfer to the ICU for scores >20.
    • Consider additional supportive care, including intravenous fluids, nutritional supplementation, and frequent clinical reassessment including vital signs.


    Assessment protocols utilizing CIWA-Ar vary and include medication dosing triggered by symptoms only and combined symptom-triggered + fixed-dose medication dosing.

    Critical Actions

    Other conditions can mimic or coexist with alcohol withdrawal, including:

    • Drug overdose
    • Trauma (eg, intracranial hemorrhage)
    • Infection (eg, meningitis)
    • Metabolic derangements
    • Hepatic failure
    • Gastrointestinal bleeding

    Consider additional testing to rule out alternative diagnoses, especially if presentation includes altered mental status and/or fever.


    Addition of the selected points.

    Facts & Figures

    Score Withdrawal Level
    ≤8 Absent or minimal withdrawal
    9-19 Mild to moderate withdrawal
    ≥20 Severe withdrawal


    Other References

    Research PaperKitchens JM. Does this patient have an alcohol problem? JAMA. 1994 Dec 14;272(22):1782-7. PubMed PMID: 7966928.Research PaperSchuckit M. Alcohol and alcoholism. In: Brunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL. Harrison’s Principles of Internal Medicine.Vol. 2. 15th ed. New York, NY: McGraw-Hill Professional Publishing; 2001:2561–2566.Research PaperRoffman JL, Stern TA. Alcohol Withdrawal in the Setting of Elevated Blood Alcohol Levels. Primary Care Companion to The Journal of Clinical Psychiatry. 2006;8(3):170-173. PubMed PMID: 16912820.Research PaperWartenberg AA, Nirenberg TD, Liepman MR, Silvia LY, Begin AM, Monti PM. Detoxification of alcoholics: improving care by symptom-triggered sedation. Alcohol Clin Exp Res. 1990 Feb;14(1):71-5. PubMed PMID: 2178476.Research PaperNuss MA, Elnicki DM, Dunsworth TS, Makela EH. Utilizing CIWA-Ar to assess use of benzodiazepines in patients vulnerable to alcohol withdrawal syndrome. W V Med J. 2004 Jan-Feb;100(1):21-5. PubMed PMID: 15119493.Research PaperMayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. 1997 Jul 9;278(2):144-51. PubMed PMID: 9214531.Research PaperSaitz R, Mayo-Smith MF, Roberts MS, et al. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA 1994; 272:519. PubMed PMID: 8046805.Research PaperJaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc 2001; 76:695. PubMed PMID:11444401.Research PaperDaeppen JB, Gache P, Landry U, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med 2002; 162:1117. PubMed PMID:12020181.Research PaperNg K, Dahri K, Chow I, Legal M. Evaluation of an alcohol withdrawal protocol and a preprinted order set at a tertiary care hospital. Can J Hosp Pharm. 2011 Nov;64(6):436-45. PubMed PMID: 22479099.Research PaperBird RD, Makela EH. Alcohol withdrawal: what is the benzodiazepine of choice? Ann Pharmacother 1994; 28:67.PubMed PMID:8123967.
    Dr. Edward M. Sellers

    From the Creator

    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.

    About the Creator

    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.

    To view Dr. Edward M. Sellers's publications, visit PubMed