Screening Test for Alcohol Withdrawal
The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) is the recommended screening test for alcohol withdrawal syndrome. 1
CIWA-Ar as the Gold Standard
The CIWA-Ar is specifically designed to assess the severity of alcohol withdrawal syndrome and guide treatment decisions. 1, 2, 3 This validated scale quantifies withdrawal symptoms and allows clinicians to:
- Identify moderate withdrawal (CIWA-Ar score >8) 1
- Identify severe withdrawal (CIWA-Ar score ≥15) requiring immediate pharmacological intervention 1
- Monitor therapeutic response and adjust treatment accordingly 4, 3
Clinical Application and Risk Stratification
Patients scoring ≥15 on CIWA-Ar are at significantly increased risk of severe withdrawal complications including seizures and delirium tremens if left untreated (relative risk 3.72). 5 The scale should be administered:
- Every 8 hours for 48 hours in patients with CIWA-Ar <10 who are being observed 6
- More frequently (every 1-2 hours initially) in patients with scores ≥10 receiving active treatment 4
- Daily for up to 5 days after the last drink in outpatient settings 2
Important Clinical Pitfalls
The CIWA-Ar can safely identify patients who do not require benzodiazepine treatment. Studies demonstrate that patients with initial CIWA-Ar scores <10 can be safely observed without detoxification regimens, preventing overutilization of benzodiazepines. 6 However, a small subset of patients may develop complicated withdrawal despite low scores or adequate treatment, requiring vigilant monitoring. 5
Higher CIWA-Ar scores predict complications even before they manifest clinically. Patients who eventually develop seizures or confusion score significantly higher (21.7 vs 15.6) even in early withdrawal, making the scale valuable for preemptive intervention. 5
Distinguishing from Alcohol Use Disorder Screening
Note that CIWA-Ar is distinct from screening tools for alcohol use disorder itself. The AUDIT questionnaire is the preferred screening tool for identifying hazardous drinking and alcohol use disorder in primary care settings. 1 CIWA-Ar is used specifically once withdrawal syndrome is suspected or present to assess its severity and guide acute management with benzodiazepines using symptom-triggered regimens. 1