CIWA-Ar for Alcohol Withdrawal
Objectifies severity of alcohol withdrawal & provides an outpatient algorithm for AWS management.
Jennifer Glen
Provided by
EVAL Foundation
Ask 'Do you feel sick to your stomach? Have you vomited?'
Usage
Summary
Signs or symptoms of alcohol withdrawal syndrome (AWS) occur in approximately one-half of patients with alcohol use disorder (AUD) who abruptly reduce or abstain from alcohol, and if left untreated can progress to delirium tremens. (Goodson et al, 2014). The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) is a 10-item questionnaire that assess the signs, symptoms and severity of alcohol withdrawal to guide treatment (Sullivan et al, 1989). AWS is classified as mild, moderate and severe by the American Society of Addiction Medicine (ASAM, 2020). Treatment protocols (i.e. supportive care, extended monitoring, benzodiazepine medication) and patient disposition (i.e. outpatient, detox center, hospitalization) will vary based on risk factors and the clinical setting (primary care or emergency department). Tiglao, Meisenheimer & Oh (2021), published an outpatient management protocol for AWS based on the CIWA-Ar questionnaire. This evaluation integrates their algorithm for AWS management to assist outpatient providers in directing appropriate treatment and disposition of patients at risk for AWS.
.Summary
The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) is a 10-item questionnaire that assess the signs, symptoms and severity of alcohol withdrawal to guide treatment (Sullivan et al, 1989).
Answers to the first 10 questions are assigned points. The sum of these points determines the score and AWS classification. AWS is classified as mild, moderate and severe by the American Society of Addiction Medicine (ASAM, 2020).
| Score | Withdrawal Level |
| ≤ 9 | Mild |
| 10-18 | Moderate |
| ≥ 19 | Severe |
The following recommendations will display based on the algorithm for AWS management published by Tiglao et al (2021). Included in the recommendations are tables from this publication listing oral medications used to treat mild to moderate AWS, expected symptoms of alcohol withdrawal syndrome after cessation of alcohol use and the AWS management algorithm.
| Recommendation | Criteria |
| Level 1 Withdrawal Management |
|
| Level 2 Withdrawal Management |
|
| Inpatient Management |
|
| Consider Inpatient Management* |
|
¹Risk factors for complicated symptoms
- History of alcohol withdrawal-related delirium or seizures
- Multiple prior withdrawal episodes
- Comorbid illness
- Age > 65 years old
- Long duration of alcohol consumption (heavy alcohol use five or more days in the past month)
- Seizures during current withdrawal episode
- Marked autonomic hyperactivity on presentation
- Physiologic dependence on GABAergic agents
²Risk factors for inpatient management
- Medical or psychiatric condition requiring inpatient treatment
- Unstable chronic condition
- Inability to tolerate oral drugs
- Severe psychiatric or cognitive impairment
- Imminent risk of harm
³Risk factors for level 2 withdrawal management
- Physiologic dependence on opioids or opioid use disorder
- Severe withdrawal < 1 year ago
- Older age or history of epilepsy
- Mild or stable psychiatric symptoms
* The recommendation, "consider inpatient treatment," will appear with either level 1 or level 2 withdrawal management options (if criteria are met) so that the provider can fully consider all of the applicable management options.
Level 1 Withdrawal Management
Management Considerations
- A Level 1 withdrawal management treatment setting includes a typical outpatient clinic.
- If not completed, consider laboratory tests as clinically indicated and re-assess management criteria (Level 1, Level 2, inpatient). Consider including:
- CMP (BMP = hepatic panel)
- CBC with differential
- Urine drug screen
- Blood alcohol level
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
- Supportive Care
- Educating patients on course of withdrawal
- Monitoring for severe withdrawal
- Educating patients on
- Maintain low-stimulation home environment
- Consuming noncaffeinated fluids
- Daily multivitamin containing 400 mcg of folic acid
- Prescribe thiamine (typical dosage of 100 mg daily for three to five days)
- Can prescribe gabapentin (Neurontin) or carbamazepine (Tegretol)
Monitoring and Follow-up
- The frequency and setting for outpatient monitoring of AWS should be guided by symptom severity, risk of complications, and social factors, including reliable social support and a safe home environment.
- Most patients will require daily evaluations for up to five days after their last drink, but evaluations may increase or decrease in frequency as necessitated by changes in symptom severity.
- These visits can be with any health care professional. Face-to-face visits are preferred, but telemedicine appointments can alternate with in-person visits.
- Evaluation should include multiple indicators of symptom severity and overall health, including mental status, hydration, sleep, mood, suicidality, and substance use.
- Blood pressure, pulse, and alcohol breath analysis should be obtained whenever possible.
- The assessment should also include a validated measure of withdrawal symptom severity, ideally with the same instrument as the initial assessment.
- When to refer
- Continued symptoms despite multiple doses of the prescribed medication, worsening or severe symptoms (persistent vomiting, hallucinations, confusion, or seizure), signs of oversedation, worsening psychiatric symptoms, or unstable vital signs should prompt transfer to a higher level of care.
- Symptoms outside of the anticipated withdrawal period or resumption of alcohol use also warrants referral to an addiction specialist or inpatient treatment program.
Level 2 Withdrawal Management
Management Considerations
- A Level 2 withdrawal management treatment setting employs extended on-site monitoring outside the scope of most primary care clinics. Examples include day hospitals, mental health facilities, and addiction treatment facilities that can monitor each patient for several hours each day and have greater access to psychological or psychiatric specialty treatments.
- If not completed, consider laboratory tests as clinically indicated and re-assess management criteria (i.e. inpatient). Consider including:
- CMP (BMP = hepatic panel) including:
- CMP (BMP = hepatic panel)
- CBC with differential
- Urine drug screen
- Blood alcohol level
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
- Prescribe first-line benzodiazepines (long-acting to minimize breakthrough symptoms and are preferred over short-acting)
- Chlordiazepoxide (Librium)
- Diazepam (Valium)
- Lorazepam (Ativan)
- Benzodiazepine dosing can be either fixed or symptom triggered.
- Fixed dosing sets a specific dose and time and is gradually tapered on a set schedule.
- Symptom-triggered dosing is given as needed based on specific CIWA-Ar or SAWS scores. Symptom-triggered use of benzodiazepines is preferred when the patient or caregiver can reliably assess symptoms and follow the dosing guidelines.
- Patients should be monitored for oversedation and respiratory depression, especially in the presence of liver disease. In patients with liver disease, consider benzodiazepines with less hepatic metabolism, such as lorazepam (Ativan) and oxazepam (Serax)..
- If contraindications to benzodiazepines exist or if the risk of use outweighs the benefits, gabapentin, carbamazepine, and phenobarbital may be considered as alternative monotherapies
- Prescribe gabapentin, carbamazepine, and valproate (Depacon) as adjuncts if symptoms persist despite adequate benzodiazepine use.
Monitoring and Follow-up
- The frequency and setting for outpatient monitoring of AWS should be guided by symptom severity, risk of complications, and social factors, including reliable social support and a safe home environment.
- Most patients will require daily evaluations for up to five days after their last drink, but evaluations may increase or decrease in frequency as necessitated by changes in symptom severity.
- These visits can be with any health care professional. Face-to-face visits are preferred, but telemedicine appointments can alternate with in-person visits.
- Evaluation should include multiple indicators of symptom severity and overall health, including mental status, hydration, sleep, mood, suicidality, and substance use.
- Blood pressure, pulse, and alcohol breath analysis should be obtained whenever possible.
- The assessment should also include a validated measure of withdrawal symptom severity, ideally with the same instrument as the initial assessment.
- When to refer
- Continued symptoms despite multiple doses of the prescribed medication, worsening or severe symptoms (persistent vomiting, hallucinations, confusion, or seizure), signs of oversedation, worsening psychiatric symptoms, or unstable vital signs should prompt transfer to a higher level of care.
- Symptoms outside of the anticipated withdrawal period or resumption of alcohol use also warrants referral to an addiction specialist or inpatient treatment program.
Inpatient Management
Management Considerations
- Those with severe (Score ≥ 19) or complicated symptoms should be referred to the nearest emergency department for inpatient hospitalization.
- If not completed, consider laboratory tests as clinically indicated
- CMP (BMP = hepatic panel)
- CBC with differential
- Urine drug screen
- Blood alcohol level
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
Consider Inpatient Management
While the patient may NOT present with additional risk (below) for inpatient management, abnormal lab findings warrant consideration for inpatient management.
- Severe AWS (Score ≥ 19)
- Risk factors for complicated symptoms
- Risk factors for inpatient management
Management Considerations
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
- Consider inpatient management
All questions & possible results
Default SectionTitle not visible
Nausea or vomiting
Ask 'Do you feel sick to your stomach? Have you vomited?'
Select one option:
- No nausea and no vomiting (0 pts)
- Mild nausea and no vomiting (1 pt)
- Increasing severity (2 pts)
- Increasing severity (3 pts)
- Intermittent nausea with dry heaves (4 pts)
- Increasing severity (5 pts)
- Increasing severity (6 pts)
- Constant nausea, frequent dry heaves and vomiting (7 pts)
Tremor
Assess: Arms extended and fingers spread apart
Select one option:
- No tremor (0 pts)
- Not visible, but can be felt fingertip to fingertip (1 pt)
- Increasing severity (2 pts)
- Increasing severity (3 pts)
- Moderate, with patient's arms extended (4 pts)
- Increasing severity (5 pts)
- Increasing severity (6 pts)
- Severe, even with arms not extended (7 pts)
Paroxysmal sweats
Select one option:
- No sweat visible (0 pts)
- Barely perceptible sweating, palms moist (1 pt)
- Increasing severity (2 pts)
- Increasing severity (3 pts)
- Beads of sweat obvious on forehead (4 pts)
- Increasing severity (5 pts)
- Increasing severity (6 pts)
- Drenching sweats (7 pts)
Anxiety
Ask, 'Do you feel nervous?'
Select one option:
- No anxiety, at ease (0 pts)
- Mildly anxious (1 pt)
- Increasing severity (2 pts)
- Increasing severity (3 pts)
- Moderately anxious, or guarded, so anxiety is inferred (4 pts)
- Increasing severity (5 pts)
- Increasing severity (6 pts)
- Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions (7 pts)
Agitation
Select one option:
- Normal activity (0 pts)
- Somewhat more activity than normal activity (1 pt)
- Increasing severity (2 pts)
- Increasing severity (3 pts)
- Moderately fidgety and restless (4 pts)
- Increasing severity (5 pts)
- Increasing severity (6 pts)
- Paces back and forth during most of the interview, or constantly thrashes about (7 pts)
Tactile disturbances
Ask, 'Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?'
Select one option:
- None (0 pts)
- Very mild itching, pin and needles, burning or numbness (1 pt)
- Mild itching, pin and needles, burning, or numbness (2 pts)
- Moderate itching, pin and needles, burning, or numbness (3 pts)
- Moderately severe hallucinations (4 pts)
- Severe hallucinations (5 pts)
- Extremely severe hallucinations (6 pts)
- Continuous hallucinations (7 pts)
Auditory disturbances
Ask, 'Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing you? Are you hearing things you know are not there?'
Select one option:
- Not present (0 pts)
- Very mild harshness or ability to frighten (1 pt)
- Mild harshness or ability to frighten (2 pts)
- Moderate harshness or ability to frighten (3 pts)
- Moderately severe hallucinations (4 pts)
- Severe hallucinations (5 pts)
- Extremely severe hallucinations (6 pts)
- Continuous hallucinations (7 pts)
Visual disturbances
Ask, 'Does the light appear to be too bright? Does it hurt your eyes? Are you seeing anything that is disturbing you? Are you seeing things you know are not there?'
Select one option:
- Not present (0 pts)
- Very mildly sensitive (1 pt)
- Mild sensitivity (2 pts)
- Moderate sensitivity (3 pts)
- Moderately severe hallucinations (4 pts)
- Severe hallucinations (5 pts)
- Extremely severe hallucinations (6 pts)
- Continuous hallucinations (7 pts)
Headache or fullness in head
Ask, Does your head feel different? Does it feel like there is a band around your head?' Do not rate for dizziness or lightheadedness. Otherwise, rate 'severity.'
Select one option:
- Not present (0 pts)
- Very mild (1 pt)
- Mild (2 pts)
- Moderate (3 pts)
- Moderately severe (4 pts)
- Severe (5 pts)
- Very severe (6 pts)
- Extremely severe (7 pts)
Orientation of clouding of sensorium
Ask, 'What day is this? Where are you? Who am I?'
Select one option:
- Orientated, can do serial additions (0 pts)
- Can't do serial additions or is uncertain about date (1 pt)
- Disorientated for date by no more than 2 calendar days (2 (pts)
- Disoriented for date by more than 2 calendar days (3 pts)
- Disoriented to place or person (4 pts)
Risk factors that may warrant Level 2 withdrawal management
Does the patient have any of these risk factors?
- Physiologic dependence on opioids or opioid use disorder
- Severe withdrawal < 1 year ago
- Older age or history of epilepsy
- Mild or stable psychiatric symptoms (having a significant effect on daily functioning)
Select one option:
- No
- Yes
Risk factors for inpatient management
Does the patient have any of the following?
- Medical or psychiatric condition requiring inpatient treatment
- Unstable chronic condition
- Inability to tolerate oral drugs
- Severe psychiatric or cognitive impairment
- Imminent risk of harm
Select one option:
- No
- Yes
Risk factors for complicated symptoms
Does the patient have any of the following?
- History of alcohol withdrawal-related delirium or seizures
- Multiple prior withdrawal episodes
- Comorbid illness
- Age > 65 years old
- Long duration of alcohol consumption (heavy alcohol use five or more days in the past month)
- Seizures during current withdrawal episode
- Marked autonomic hyperactivity on presentation
- Physiologic dependence on GABAergic agents.
Select one option:
- No
- Yes
Abnormal laboratory results
Are any of the following lab results abnormal?
- Abnormal electrolytes
- Elevated AST/ALT
- Elevated BUN/Cr ratio
- Elevated blood alcohol level
- Positive urine drug screen
Select one option:
- No
- Yes
Possible results
Mild Symptoms (CIWA-Ar Score < 10)
Level 1 Withdrawal Management
Criteria
- No risk factors for complicated symptoms
- No risk factors for potential inpatient management
- CIWA-Ar score <10 (mild in severity)
- Low risk of developing severe symptoms
- Does not meet Level 2 criteria
- Exception: Mild or stable psychiatric symptoms (i.e. having a limited nonsignificant effect on daily functioning).
Management Considerations
- A Level 1 withdrawal management treatment setting includes a typical outpatient clinic.
- If not completed, consider laboratory tests as clinically indicated and re-assess management criteria (Level 1, Level 2, inpatient). Consider including:
- CMP (BMP = hepatic panel)
- CBC with differential
- Urine drug screen
- Blood alcohol level
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
- Supportive Care
- Educating patients on course of withdrawal
- Monitoring for severe withdrawal
- Educating patients on
- Maintain low-stimulation home environment
- Consuming noncaffeinated fluids
- Daily multivitamin containing 400 mcg of folic acid
- Prescribe thiamine (typical dosage of 100 mg daily for three to five days)
- Can prescribe gabapentin (Neurontin) or carbamazepine (Tegretol)
Monitoring and Follow-up
- The frequency and setting for outpatient monitoring of AWS should be guided by symptom severity, risk of complications, and social factors, including reliable social support and a safe home environment.
- Most patients will require daily evaluations for up to five days after their last drink, but evaluations may increase or decrease in frequency as necessitated by changes in symptom severity.
- These visits can be with any health care professional. Face-to-face visits are preferred, but telemedicine appointments can alternate with in-person visits.
- Evaluation should include multiple indicators of symptom severity and overall health, including mental status, hydration, sleep, mood, suicidality, and substance use.
- Blood pressure, pulse, and alcohol breath analysis should be obtained whenever possible.
- The assessment should also include a validated measure of withdrawal symptom severity, ideally with the same instrument as the initial assessment.
- When to refer
- Continued symptoms despite multiple doses of the prescribed medication, worsening or severe symptoms (persistent vomiting, hallucinations, confusion, or seizure), signs of oversedation, worsening psychiatric symptoms, or unstable vital signs should prompt transfer to a higher level of care.
- Symptoms outside of the anticipated withdrawal period or resumption of alcohol use also warrants referral to an addiction specialist or inpatient treatment program.
Based on the algorithm for AWS management published by Tiglao et al (2021).
Level 2 Withdrawal Management
Criteria
- No risk factors for complicated symptoms
- No risk factors for inpatient management
- Presence of Level 2 Withdrawal Management criteria + Score ≤ 18
Management Considerations
- A Level 2 withdrawal management treatment setting employs extended on-site monitoring outside the scope of most primary care clinics. Examples include day hospitals, mental health facilities, and addiction treatment facilities that can monitor each patient for several hours each day and have greater access to psychological or psychiatric specialty treatments.
- If not completed, consider laboratory tests as clinically indicated and re-assess management criteria (i.e. inpatient). Consider including:
- CMP (BMP = hepatic panel) including:
- CMP (BMP = hepatic panel)
- CBC with differential
- Urine drug screen
- Blood alcohol level
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
- Prescribe first-line benzodiazepines (long-acting to minimize breakthrough symptoms and are preferred over short-acting)
- Chlordiazepoxide (Librium)
- Diazepam (Valium)
- Lorazepam (Ativan)
- Benzodiazepine dosing can be either fixed or symptom triggered.
- Fixed dosing sets a specific dose and time and is gradually tapered on a set schedule.
- Symptom-triggered dosing is given as needed based on specific CIWA-Ar or SAWS scores. Symptom-triggered use of benzodiazepines is preferred when the patient or caregiver can reliably assess symptoms and follow the dosing guidelines.
- Patients should be monitored for oversedation and respiratory depression, especially in the presence of liver disease. In patients with liver disease, consider benzodiazepines with less hepatic metabolism, such as lorazepam (Ativan) and oxazepam (Serax)..
- If contraindications to benzodiazepines exist or if the risk of use outweighs the benefits, gabapentin, carbamazepine, and phenobarbital may be considered as alternative monotherapies
- Prescribe gabapentin, carbamazepine, and valproate (Depacon) as adjuncts if symptoms persist despite adequate benzodiazepine use.
Monitoring and Follow-up
- The frequency and setting for outpatient monitoring of AWS should be guided by symptom severity, risk of complications, and social factors, including reliable social support and a safe home environment.
- Most patients will require daily evaluations for up to five days after their last drink, but evaluations may increase or decrease in frequency as necessitated by changes in symptom severity.
- These visits can be with any health care professional. Face-to-face visits are preferred, but telemedicine appointments can alternate with in-person visits.
- Evaluation should include multiple indicators of symptom severity and overall health, including mental status, hydration, sleep, mood, suicidality, and substance use.
- Blood pressure, pulse, and alcohol breath analysis should be obtained whenever possible.
- The assessment should also include a validated measure of withdrawal symptom severity, ideally with the same instrument as the initial assessment.
- When to refer
- Continued symptoms despite multiple doses of the prescribed medication, worsening or severe symptoms (persistent vomiting, hallucinations, confusion, or seizure), signs of oversedation, worsening psychiatric symptoms, or unstable vital signs should prompt transfer to a higher level of care.
- Symptoms outside of the anticipated withdrawal period or resumption of alcohol use also warrants referral to an addiction specialist or inpatient treatment program.
Based on the algorithm for AWS management published by Tiglao et al (2021).
Severe Symptoms (CIWA-Ar Score ≥ 19)
Inpatient Management
Criteria (any of the following)
- Risk factors for complicated symptoms
- Severe symptoms (score ≥ 19)
- Risk factors for inpatient management (at any score)
- Note: The published algorithm (Tiglao et al, 2021), specifies inpatient management for moderate symptoms (Score 10-18) + presence of inpatient risk factors, but does not specify if symptoms are mild (Score < 10) + presence of inpatient risk factors. Due to the significance of risk factors associated with inpatient management, inpatient management will trigger for any score.
Management Considerations
- Those with severe (Score ≥ 19) or complicated symptoms should be referred to the nearest emergency department for inpatient hospitalization.
- If not completed, consider laboratory tests as clinically indicated
- CMP (BMP = hepatic panel)
- CBC with differential
- Urine drug screen
- Blood alcohol level
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
Based on the algorithm for AWS management published by Tiglao et al (2021).
Consider Inpatient Management
Criteria
- Abnormal Laboratory results:
- Abnormal electrolytes
- Elevated AST/ALT
- Elevated BUN/Cr ratio
- Elevated blood alcohol level
- Positive urine drug screen
While the patient may NOT present with additional risk (below) for inpatient management, abnormal lab findings warrant consideration for inpatient management.
- Severe AWS (Score ≥ 19)
- Risk factors for complicated symptoms
- Risk factors for inpatient management
Management Considerations
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
- Consider inpatient management
Based on the algorithm for AWS management published by Tiglao et al (2021).
Moderate Symptoms (CIWA-Ar Score 10-18)
Literature
- Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. 1989 Nov;84(11):1353-7. — Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM.
- Routine hospital alcohol detoxification practice compared to symptom triggered management with an Objective Withdrawal Scale (CIWA-Ar). Am J Addict. 2000 Spring;9(2):135-44. — Reoux JP, Miller K.
- Alcohol withdrawal syndrome: outpatient management. Am Fam Physician. 2021; 104(3):253-262. — Tiglao SM, Meisenheimer ES, Oh RC
- The ASAM clinical practice guidelines on alcohol withdrawal management [published correction appears in J Addict Med. 2020; 14(5):e280]. J Addict Med. 2020;14(3S suppl 1):1-72. — American Society of Addiction Medicine (ASAM)
- Predictors of severe alcohol withdrawal syndrome: a systematic review and meta-analysis. Alcohol Clin Exp Res. 2014 Oct;38(10):2664-77. — Goodson CM, Clark BJ, Douglas IS.
