CIWA System Components
The CIWA (Clinical Institute Withdrawal Assessment) system is not a single scale but refers to multiple validated withdrawal assessment tools, most commonly the CIWA-Ar for alcohol withdrawal, which contains 10 items assessing specific withdrawal symptoms.
CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol - Revised)
The CIWA-Ar is the gold standard tool for alcohol withdrawal assessment and contains the following 10 components 1, 2:
Scored Items (0-7 points each):
- Nausea and vomiting - Ranges from no symptoms (0) to constant nausea with frequent vomiting (7) 3
- Tremor - Assessed with arms extended and fingers spread, ranging from no tremor (0) to severe tremor even with arms not extended (7) 3
- Paroxysmal sweats - From no sweating (0) to drenching sweats (7) 3
- Anxiety - Subjective assessment from none (0) to acute panic states (7) 3
- Agitation - Observed restlessness from normal activity (0) to constant pacing or thrashing about (7) 3
- Tactile disturbances - Includes itching, pins and needles, burning sensations, or hallucinations, from none (0) to continuous severe hallucinations (6) 3
- Auditory disturbances - From not present (0) to continuous severe auditory hallucinations (7) 3
- Visual disturbances - From not present (0) to continuous severe visual hallucinations (7) 3
- Headache/fullness in head - From not present (0) to extremely severe (7) 3
- Orientation and clouding of sensorium - Assesses orientation to person, place, date, and time, from oriented (0) to disoriented to all spheres (4) 3
Scoring Interpretation:
- Score <8: Minimal to mild withdrawal - typically does not require pharmacological treatment 1
- Score 8-15: Moderate withdrawal - consider benzodiazepine treatment 3
- Score >15: Severe withdrawal - high risk for complications including seizures and delirium tremens; requires aggressive benzodiazepine treatment 3
- Score >20: Very high risk for severe complications 3
Clinical Application:
- Symptom-triggered dosing using CIWA-Ar scores is the recommended approach, with benzodiazepines administered when scores reach ≥8-10 1
- Assessments should be performed every 1-2 hours initially during active withdrawal, then extended to every 4-8 hours as symptoms stabilize 1
- Treatment continues until CIWA-Ar scores remain consistently below threshold, which may extend beyond 72 hours in some patients 1
CIWA-B (Clinical Institute Withdrawal Assessment - Benzodiazepines)
The CIWA-B is a separate 22-item scale specifically designed for benzodiazepine withdrawal assessment, distinct from the CIWA-Ar 4. This scale was developed by analyzing symptoms that distinguished withdrawal from pre-withdrawal states in both high-dose abusers and therapeutic-dose users 4.
Important Clinical Pitfalls:
- Do not confuse CIWA with COWS: The Clinical Opiate Withdrawal Scale (COWS) is an entirely different 11-item scale for opioid withdrawal, not alcohol withdrawal 5
- CIWA-Ar reliability concerns: Recent psychometric analysis shows the tool may have limited reliability in acutely ill or injured hospitalized patients, with Cronbach's alphas as low as 0.62-0.69 for certain subscales 6
- Subjective components: Many CIWA-Ar items rely on patient self-report, making it time-consuming and potentially unreliable in confused or uncooperative patients 7
- Not validated for other substances: CIWA scales are specific to alcohol or benzodiazepine withdrawal and should never be used for opioid, cocaine, or other substance withdrawal 5, 8