Calculators / Substance use and withdrawal

CIWA-Ar

Clinical Institute Withdrawal Assessment for Alcohol, revised. Alcohol withdrawal severity.

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The CIWA-Ar calculator is in the Library.

Every rating scale calculator comes with the Library, along with the prescribing guides, medication handouts, DSM-5 criteria and sheets, and the Guide Builder.

Use it for

  • Rating the severity of alcohol withdrawal in a person who is awake, can talk and has recently reduced or stopped drinking.
  • Guiding symptom-triggered medication in a setting where the person is reassessed regularly.
  • Following a person through withdrawal and documenting the trend.

Do not use it for

  • Diagnosing alcohol withdrawal, or deciding who will develop complications. Use history and a risk tool such as the PAWSS.
  • People who cannot communicate: sedated, intubated or delirious. The scale relies on what the person tells you.
  • Withdrawal from other sedatives, or symptoms caused by another illness. The items are not specific to alcohol.

Rate now, from observation and a few direct questions. Use the highest rating that fits. Record the time of the last drink and the vital signs next to the score, because the scale does not include them.

1Nausea and vomitingAsk: Do you feel sick to your stomach? Have you vomited? Anchors: 0 no nausea and no vomiting; 1 mild nausea with no vomiting; 4 intermittent nausea with dry heaves; 7 constant nausea, frequent dry heaves and vomiting.
2TremorArms extended and fingers spread. Anchors: 0 no tremor; 1 not visible, but can be felt fingertip to fingertip; 4 moderate, with the arms extended; 7 severe, even with the arms not extended.
3Paroxysmal sweatsAnchors: 0 no sweat visible; 1 barely perceptible sweating, palms moist; 4 beads of sweat obvious on the forehead; 7 drenching sweats.
4AnxietyAsk: Do you feel nervous? Anchors: 0 no anxiety, at ease; 1 mildly anxious; 4 moderately anxious, or guarded, so anxiety is inferred; 7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions.
5AgitationAnchors: 0 normal activity; 1 somewhat more than normal activity; 4 moderately fidgety and restless; 7 paces back and forth during most of the interview, or constantly thrashes about.
6Tactile disturbancesAsk: Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin? Anchors: 0 not present; 1 very mild; 2 mild; 3 moderate; 4 moderately severe hallucinations; 5 severe hallucinations; 6 extremely severe hallucinations; 7 continuous hallucinations.
7Auditory disturbancesAsk: Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there? Anchors: 0 not present; 1 very mild; 2 mild; 3 moderate; 4 moderately severe hallucinations; 5 severe hallucinations; 6 extremely severe hallucinations; 7 continuous hallucinations.
8Visual disturbancesAsk: Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there? Anchors: 0 not present; 1 very mild; 2 mild; 3 moderate; 4 moderately severe hallucinations; 5 severe hallucinations; 6 extremely severe hallucinations; 7 continuous hallucinations.
9Headache, fullness in headAsk: Does your head feel different? Does it feel like there is a band around your head? Do not rate dizziness or lightheadedness. Anchors: 0 not present; 1 very mild; 2 mild; 3 moderate; 4 moderately severe; 5 severe; 6 very severe; 7 extremely severe.
10Orientation and clouding of sensoriumAsk: What day is this? Where are you? Who am I? Anchors: 0 oriented and can do serial additions; 1 cannot do serial additions or is uncertain about the date; 2 disoriented for the date by no more than 2 calendar days; 3 disoriented for the date by more than 2 calendar days; 4 disoriented for place or person.

CIWA-Ar

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More about the CIWA-Ar

About the CIWA-ArWhat it is and what it is for

The CIWA-Ar measures how severe alcohol withdrawal is at a given moment. A nurse or clinician asks a few questions and observes the person, then rates ten items. Nine are rated from 0 to 7 and the last, orientation, from 0 to 4. The total runs from 0 to 67.

It was built to guide symptom-triggered treatment: reassess often, give medicine when the score crosses a threshold, and stop when it falls. It tracks withdrawal once it has started. It does not tell you who will go on to have a seizure or delirium tremens.

How to use itGiving it and scoring it

Ask the person the questions, observe them, and rate each item from the anchors. Rate the highest level that fits. Add the ten items for a total from 0 to 67.

Record the time of the last drink, the vital signs and the time of the assessment with every score. Repeat at the interval your protocol sets and after each medication dose.

Interpreting the scoreScore ranges and what they suggest
CIWA-Ar totalWhat it suggestsUsual response
0 to 9MildMild or minimal withdrawal. The usual threshold for medication has not been reached.Monitor and repeat. Supportive care. Medication only if risk is high or the protocol calls for it.
10 to 18ModerateModerate withdrawal. At or above the usual threshold to start symptom-triggered medication.Treat per protocol, reassess after each dose, and look for complications.
19 to 67SevereSevere withdrawal. High risk of seizure and delirium.Treat now in a monitored setting and consider a higher level of care.

Bands follow the sample regimens in the ASAM 2020 alcohol withdrawal guideline: mild below 10, moderate 10 to 18, severe 19 or more, with symptom-triggered dosing starting at 10. Older and many local protocols start medication at 8 and call 15 or more severe. Use the thresholds in your own protocol.

Pearls and pitfallsTips and common mistakes
  • Ask when the last drink was. Withdrawal usually starts 6 to 24 hours after the last drink, seizures peak around 24 to 48 hours, and delirium tremens usually begins 48 to 96 hours after the last drink.
  • Pulse, blood pressure and temperature are not on the CIWA-Ar. A person with a low score and a pulse of 130 is not low risk.
  • Do not rate dizziness or lightheadedness as headache.
  • Rate the highest severity you see. If the person is asleep and comfortable, record that and reassess when they wake.
  • If the score does not fall after several doses, stop and look for another cause.
EvidenceAccuracy and reliability
  • Sullivan and colleagues (1989) revised the original CIWA into the 10-item CIWA-Ar and validated it against clinicians' ratings of withdrawal severity.
  • A randomized trial (Saitz 1994) found that symptom-triggered treatment guided by the CIWA-Ar reduced the total benzodiazepine dose and the duration of treatment compared with a fixed schedule, with no increase in complications.
  • The ASAM 2020 guideline recommends symptom-triggered dosing in monitored settings, risk stratification with tools such as the PAWSS, and front-loaded long-acting benzodiazepines for high-risk or severe withdrawal.
Source, license and referencesWhere it comes from

The CIWA-Ar was published by Sullivan, Sykora, Schneiderman, Naranjo and Sellers (Addiction Research Foundation, Toronto) in 1989 and is widely used in clinical practice without a license. Item wording follows the published form.

  1. 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.
  2. Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR, Calkins DR. Individualized treatment for alcohol withdrawal: a randomized double-blind controlled trial. JAMA. 1994;272(7):519-523.
  3. American Society of Addiction Medicine. The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. J Addict Med. 2020;14(3S Suppl 1):1-72.
  4. Maldonado JR, Sher Y, Das S, et al. Prospective validation study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in medically ill inpatients. Alcohol Alcohol. 2015;50(5):509-518.

Clinical decision support, not a diagnosis. Each calculator scores a published scale the way its authors intended. A score informs a clinical interview and examination and never replaces them. If you are a patient using this page, please review the result with your clinician. In an emergency, call 911 or call or text 988 in the United States.