Clinical Institute Withdrawal Assessment

of Alcohol Scale, Revised (CIWA – Ar)

Many qualification instruments have been developed for monitoring alcohol withdrawal (Guthrie, 1989; Sullivan
et al., 1989; Sellers & Naranjo, 1983). No single instrument is significantly superior to others. What is clear is
that there are significant clinical advantages to quantifying the alcohol withdrawal syndrome. Quantification is
key to preventing excess morbidity and mortality in a group of patients who are at risk for alcohol withdrawal.
Such instruments help clinical personnel recognize the process of withdrawal before it progresses to more
advanced stages, such as delirium tremens. By intervening with appropriate pharmacotherapy in those
patients who require it, while sparing the majority of patients whose syndromes do not progress to that point,
the clinician can prevent over- and undertreatment of the alcohol withdrawal syndrome. Finally, by quantifying
and monitoring the withdrawal process, the treatment regimen can be modified as needed.

The best known and most extensively studied scale is the Clinical Institute Withdrawal Assessment – Alcohol
(CIWA – A) and a shortened version, the CIWA – A revised (CIWA – Ar). This scale has well-documented
reliability, reproducibility and validity, based on comparison to ratings by expert clinicians (Knott, et al., 1981;
Wiehl, et al., 1994; Sullivan, et al., 1989). From 30 signs and symptoms, the scale has been carefully refined
to a list of 10 signs and symptoms in the CIWA – Ar (Wiehl, et al., 1994). It is thus easy to use and has been
shown to be feasible to use in a variety of clinical settings, including detoxification units (Naranjo, et al., 1983;
Hoey, et al., 1994), psychiatry units (Heinala, et al., 1990), and general medical/surgical wards (Young, et al.,
1987; Katta, 1991). The CIWA – Ar has added usefulness because high scores, in addition to indicating
severe withdrawal, are also predictive of the development of seizures and delirium (Naranjo, et al., 1983;
Young, et al., 1987).

Copied from: ASAM Patient Placement Criteria, Second Edition - Revised

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 CLINICAL PRACTICE GUIDELINES: ALCOHOL DETOXIFICATION

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA - Ar)

What it Measures:

The CIWA – Ar can measure 10 symptoms. Scores of less than 8 to 10 indicate minimal to mild withdrawal.
Scores of 8 to 15 indicate moderate withdrawal (marked autonomic arousal); and scores of 15 or more indicate
severe withdrawal. The assessment requires 2 minutes to perform (Sullivan, et al, 1989).

CIWA – Ar categories, with the range of scores in each category, are as follows:

Agitation (0 – 7)
Anxiety (0 – 7)
Auditory Disturbances (0 – 7)
Clouding of Sensorium (0 – 4)
Headache (0 – 7)
Nausea/Vomiting (0 – 7)
Paroxysmal Sweats (0 – 7)
Tactile Disturbances (0 – 7)
Tremor (0 – 7)
Visual Disturbances (0 – 7)

A study of the revised version of the CIWA predicted that those with a score of >15 were at increased risk for
severe alcohol withdrawal (RR 3.72; 95% confidence interval 2.82 – 4.85); the higher the score the greater the
risk. Some patients (6.4%) still suffered complications, despite low scores, if left untreated (Foy, et al., 1988).

EXAMPLE - ALCOHOL DETOXIFICATION PROTOCOL The following is an example of a protocol

developed around the use of the CIWA – Ar in an alcohol detoxification program:

1. CIWA to be completed on admission and q 8 hours for a period of 24 hours.

2. Determine and record blood alcohol concentration (BAC) by breathalyzer on admission.
3. Vital signs: pulse rate and BP q 4 hours. Call physician if patient has HR > 110mmHg, DBP > 120
mmHg, or SBP > 180 mmHg.
4. Obtain serum glucose, HFP (hepatic function profile), CMEP (comprehensive metabolic panel, CBC
w/DIFF and urine for drug screen.
5. Give Thiamine 100 mg IM now, and then Thiamine 100 mg PO bid times 3 days.
6. If CIWA score is > 0 but < 8 and vital signs are stable, no medication is required. Repeat vital signs q 4
hours and the CIWA q 8 hours. (May repeat CIWA and vital signs as needed.)
7. If CIWA is > 8 but < 15, give Lorazepam (Ativan) 2 mg PO/IM and repeat vital signs q 2 hours and the
CIWA q 4 hours.
8. If CIWA is >15 or DBP > 110 mmHg, give Lorazepam (Ativan) 2 mg PO/IM q 1 hour until patient has a
CIWA of < 15 or DBP < 110 mmHg (CIWA and vital signs checked q 1 hour until patient’s CIWA is < 15
and DBP < 110 mmHg.) When CIWA is between 8 and 15, give Lorazepam (Ativan) 2 mg PO/IM and
resume vital signs q 2 hours and the CIWA q 4 hours.
9. CALL MD IF PATIENT REQUIRES > 6 mg OF LORAZEPAM (ATIVAN) IN THREE HOURS.
10. May awaken patient to complete CIWA and vital signs.
11. When CIWA is < 8 for 3 consecutive 8 hour increments, d/c CIWA protocol.

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 Addiction Research Foundation
Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA – Ar)

Patient: _____________________________________ Pulse or heart rate, take for 1 minute: ___________

Date: __________________________ Time: _________________ Blood Pressure: __________________

Nausea and Vomiting: Ask, “Do you feel sick to your Tactile Disturbance: Ask, “Have you any itching, pins and
stomach? Have you vomited?” Observation: needles sensations, any burning, any numbness, or do you
feel bugs crawling under your skin?” Observation:
0 No nausea and no vomiting
1 Mild nausea and no vomiting 0 None
2 1 Very mild itching, pins and needles, burning or
3 numbness
4 Intermittent nausea with dry heaves 2 Mild itching, pins and needles, burning or numbness
5 3 Moderate itching, pins and needles, burning or numbness
6 4 Moderate severe hallucinations
7 Constant nausea, frequent dry heaves and vomiting. 5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

Tremor: Arms extended and fingers spread apart. Auditory Disturbances: Ask, “Are you more aware of sounds
Observation: around you? Are they harsh? Do they frighten you? Are you
hearing anything that is disturbing to you? Are you hearing
0 No tremor things you know are not there?” Observation:
1 Not visible but can be felt fingertip to fingertip
2 0 Not present
3 1 Very mild harshness or ability to frighten
4 Moderate, with patient’s arm extended 2 Mild harshness or ability to frighten
5 3 Moderate harshness or ability to frighten
6 4 Moderately severe hallucinations
7 Severe, even with arms not extended 5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

Paroxysmal Sweats: Observation: Visual Disturbances: Ask, “Does the light appear to be too
bright? Is the color different? Does it hurt your eyes? Are you
0 No sweat visible seeing anything that is disturbing to you? Are you seeing
1 things you know are not there?” Observation:
2
3 0 Not present
4 Beads of sweat obvious on forehead 1 Very mild sensitivity
5 2 Mild sensitivity
6 3 Moderate sensitivity
7 Drenching sweats 4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

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 Addiction Research Foundation
Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA – Ar)

Patient: _____________________________________ Pulse or heart rate, take for 1 minute: ___________

Date: __________________________ Time: _________________ Blood Pressure: __________________

Anxiety: Ask, “Do you feel nervous?” Observation: Headache, Fullness in Head: Ask, “Does your head feel
different? Does it feel like there is a band around your head?”
0 No anxiety, at ease Do not rate dizziness or lightheadedness. Otherwise, rate
1 Mildly anxious severity.
2
3 0 Not present
4 Moderately anxious, or guarded, so anxiety is inferred 1 Very mild
5 2 Mild
6 3 Moderate
7 Equivalent to acute panic states, as seen in severe delirium 4 Moderately severe
or acute schizophrenic reactions 5 Severe
6 Very severe
7 Extremely severe

Agitation: Observation Orientation and Clouding of Sensorium: Ask, “What day is

this? Where are you? Who am I?” Observation:
0 Normal activity
1 Somewhat more than normal activity 0 Oriented and can do serial additions
2 1 Cannot do serial additions or is uncertain about date
3 2 Disoriented for date by no more than 2 calendar days
4 Moderately fidgety and restless 3 Disoriented for date by more than 2 calendar days
5 4 Disoriented for place and/or person
6
7 Paces back and forth during most of the interview, or
constantly thrashes about

Total CIWA – Ar Score __________

(maximum possible score = 67) Patients scoring less than 10 do not usually
need additional medication for withdrawal.
Rater’s Initials _____________

Note: The CIWA – Ar is not copyrighted and may be used freely. Source: Sullivan JT, Sykora K, Schneiderman J, Naranjo CA
& Sellers EM (1989) Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale
(CIWA – Ar) British Journal of Addiction 84:1353 – 1357

ASAM Patient Placement Criteria, Second Edition - Revised