Rating alcohol withdrawal
When someone who drinks heavily every day stops or cuts down suddenly, the nervous system, used to the calming effect of alcohol, becomes overexcited. Symptoms usually start 6 to 24 hours after the last drink: tremor, sweating, nausea, anxiety and a racing heart. A minority of people develop seizures or delirium tremens, a medical emergency with confusion, hallucinations and fever.
The CIWA-Ar (revised Clinical Institute Withdrawal Assessment for Alcohol), published by John Sullivan and colleagues in 1989, gives nurses and doctors a quick, repeatable way to measure how severe withdrawal is.
The ten items
Nine items are scored from 0 to 7:
- Nausea and vomiting
- Tremor, observed with arms extended and fingers spread
- Paroxysmal sweats
- Anxiety
- Agitation
- Tactile disturbances: itching, pins and needles, a feeling of bugs crawling on the skin
- Auditory disturbances: sounds seeming harsh or frightening, hearing things
- Visual disturbances: light seeming too bright, seeing things
- Headache or a feeling of fullness in the head
The tenth item, orientation and clouding of the senses, is scored from 0 to 4. The total ranges from 0 to 67. The descriptions in the calculator paraphrase the main anchor points of each item.
Worked example
A patient has mild nausea (1), moderate tremor (3), moist palms and some sweat (2), moderate anxiety (3), slight restlessness (1), no perceptual disturbance (0, 0, 0), a mild headache (2) and is fully oriented (0). The total is 12: moderate withdrawal, for which medication is usually indicated.
Interpreting the score
- 8 or less: absent or mild withdrawal. Monitoring and supportive care are often enough.
- 9 to 15: moderate withdrawal.
- 16 or more: severe withdrawal, with a high risk of seizures and delirium tremens.
Protocols differ on the exact thresholds. Many hospitals use symptom-triggered treatment: the scale is repeated every one to four hours and a benzodiazepine is given only when the score passes a threshold. Studies have found this approach uses less medication and shortens treatment compared with fixed schedules.
Limits
The CIWA-Ar measures severity; it does not diagnose withdrawal. Infection, low blood sugar, head injury, liver failure and withdrawal from other drugs can look similar. It requires a patient who can answer questions, so it is not suited to someone who is delirious, sedated or intubated. Thiamine and nutrition are part of care for heavy drinkers. Anyone who drinks heavily every day should talk to a doctor before stopping; in the United States, the SAMHSA helpline at 1-800-662-4357 is free and confidential.
This calculator is for general information and education. It is not medical advice and does not replace the judgment of a doctor, nurse or pharmacist who knows the full clinical picture.