Alcohol Withdrawal CIWA Score

Evaluates AWS symptoms to help with initiation of alcoholism detoxification therapy.

You can find more information about alcohol withdrawal syndrome in the text below the calculator.

The CIWA-Ar for alcohol withdrawal is an evaluation tool (consisting of 10 questions) designed by Sullivan et al. in 1989, as a mean of assessing the severity of acute alcohol withdrawal symptoms.

This is one of the evaluations used before detoxification protocol is started.

Patients who score above 8 require some form of prophylactic medication whilst patients who score above 15 (moderate withdrawal intensity) should get additional therapy as required.

Scores above 21 indicate severe withdrawal syndrome and in this case, patients may require hospitalization if outpatient treatment is not possible.






Paroxysmal sweats


Headache/fullness in head


Orientation/clouding of sensorium






Visual disturbances


Tactile disturbances


Auditory disturbances

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CIWA-Ar explained

The Clinical Institute Withdrawal Assessment for Alcohol revised scale is aimed at evaluating the severity of alcohol withdrawal symptoms.

CIWA-Ar was published by Sullivan et al. in 1989 and consists of 10 questions with different answer choices, all weighing from 0 to 7 points. It can also be used for monitoring therapy results during benzodiazepine medication, the therapy of choice for alcohol withdrawal.

The following table summarizes the withdrawal symptoms evaluated under CIWA score:

Symptom Possible questions to accompany evaluation Other information
Nausea/vomiting Do you feel sick to your stomach? Have you vomited? Assessor to ask about symptom frequency
Tremor n/a Observation of tremor state, in relaxed position and with arms extended
Paroxysmal sweats n/a Observation of sweating degree, localization and trigger factors
Headache/sensation of fullness in head Does your head feel different? Does it feel like there is a band around your head? Headache severity should be accounted for
Orientation/clouding of sensorium Questions about current date and time, recognition of people and surroundings Evaluation of orientation degree
Anxiety Are you feeling anxious? Does something worry you? Evaluation of general degree of nervousness and the display of anxious signs
Agitation n/a Observation of agitation degree
Visual disturbances Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there? Checks for visual or hallucinatory events
Tactile disturbances Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin? Checks for abnormal tactile sensations
Auditory disturbances Are you more aware of sounds around you? Are they harsh? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there? Evaluation of auditory sensations

The main criticism of the model refers to the fact that it can only be used for alcohol dependency and the results are only as reliable as the input from the patient.


Result interpretation

Each of the 10 items in the CIWA-Ar weight between 0 and 7 points, depending on the severity of the experienced symptoms. The table below summarizes the CIWA-Ar scores and their interpretation:

CIWA-Ar score Interpretation (Withdrawal severity)
0 – 9 Absent or minimal
10 – 15 Mild
16 – 20 Moderate
21 – 67 Severe

Intervention with prophylactic medication should take place in the case of patients who score above 8. For patients with scores above 15, additional PRN therapy should be added to traditional medication.

Patients who score above 21 may carry hospitalization indication if outpatient management of withdrawal is not possible.


Alcohol withdrawal protocol

Alcohol withdrawal syndrome occurs within 6 to 24 hours from the last drink. The intensity of symptoms tends to be greater in people with developed alcoholism, who drink more than 8 drinks per day.

Withdrawal symptoms include:

■ Nausea;

■ Sweats;

■ Tremor;

■ Restlessness;

■ Hallucinations;

■ Headaches;

■ Elevated blood pressure;

■ Lack of appetite;

■ Diarrhea;

■ Seizures;

■ Confusion.

Delirium tremens (worsening of symptoms) consists of hallucinations, disorientation, tachycardia, fever, diaphoresis and hypertension.

The patient in withdrawal is usually given a first fixed dose of detox treatment with a Benzodiazepine (Diazepam 20 mg). This is repeated every 90 minutes until cessation of withdrawal symptoms and no blood alcohol concentration.

If the CIWA-Ar is below 8, the assessment should be repeated every 4 hours, if the score is between 8 and 19, the evaluation should take place every 2 hours and if the score is greater than 20, the evaluation should be hourly.

Withdrawal seizure prophylaxis usually follows:

■ Day 0: Diazepam 20 mg two hourly by weight to 80 mg if <90 kg and 100 mg if 90 kg;

■ Day 1, 2: Diazepam 10 mg orally BD;

■ Day 3: Diazepam 5 mg orally BD.


Original reference

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):1353-7.


Reoux JP, Miller K. Routine hospital alcohol detoxification practice compared to symptom triggered management with an Objective Withdrawal Scale (CIWA-Ar). Am J Addict. 2000; 9(2):135-44.

Other references

1. Bakhla AK, Khess CR, Verma V, Hembram M, Praharaj SK, Soren S. Factor Structure of CIWA-Ar in Alcohol Withdrawal. J Addict; 2014:745839.

2. Nuss 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; 100(1):21-5.

3. Wartenberg 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; 14(1):71-5.

Specialty: Miscellaneous

Objective: Evaluation

Type: Score

No. Of Items: 10

Year Of Study: 1989

Abbreviation: CIWA-Ar

Article By: Denise Nedea

Published On: August 29, 2017 · 03:10 AM

Last Checked: August 29, 2017

Next Review: August 29, 2023