At what CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) or COWS (Clinical Opiate Withdrawal Scale) score can a patient be discharged?

Discharge Criteria Based on Withdrawal Assessment Scores

For alcohol withdrawal, patients can be safely discharged when CIWA-Ar scores remain consistently below 8, indicating minimal to mild withdrawal that does not require pharmacological treatment. 1

Alcohol Withdrawal (CIWA-Ar) Discharge Criteria

Score Thresholds for Clinical Decision-Making

• CIWA-Ar scores <8 indicate minimal to mild withdrawal and typically do not require pharmacological treatment, making this the threshold for considering discharge 1, 2
• Scores ≥8-10 indicate moderate withdrawal requiring benzodiazepine treatment and continued monitoring 1
• Scores ≥15 indicate severe withdrawal with significantly increased risk of complications (seizures, delirium tremens) and absolutely require inpatient management 3, 4

Specific Discharge Requirements

Patients must meet ALL of the following criteria before discharge:

• CIWA-Ar scores consistently <8 for at least 8-12 hours without additional benzodiazepine dosing 1, 5
• No evidence of autonomic instability (stable vital signs, no tachycardia >100 bpm, no hypertension, no fever) 5
• Treatment may need to continue beyond 72 hours in some patients, as withdrawal symptoms can persist and require ongoing management until complete resolution 5
• Adequate social support and follow-up arrangements in place 5

Critical Monitoring Considerations

• Assessments should be performed every 1-2 hours initially during active withdrawal, then extended to every 4-8 hours as symptoms stabilize 1
• Do not discontinue benzodiazepines prematurely based on day of admission alone—treat until symptom resolution 5
• More than 70% of cirrhotic patients may not require pharmacological treatment, but when symptoms are present, continue dosing until resolution 5

Opioid Withdrawal (COWS) Discharge Criteria

Score Thresholds for Clinical Decision-Making

• COWS scores <8 indicate mild or no withdrawal, and buprenorphine is not indicated for treatment 6
• COWS scores >8 indicate moderate to severe withdrawal requiring buprenorphine treatment (4-8 mg sublingual based on severity) 6
• The COWS scoring ranges are: 5-12 (mild), 13-24 (moderate), 25-36 (moderately severe), >36 (severe) 6

Emergency Department Discharge Protocol

For ED discharge after buprenorphine initiation:

• Re-assess COWS score 30-60 minutes after initial buprenorphine dose 6
• Target total dose of 16 mg sublingual buprenorphine for most patients before discharge 6
• X-waivered providers should prescribe 16 mg sublingual buprenorphine/naloxone daily for 3-7 days or until follow-up appointment 6
• Non-X-waivered providers can have patients return for up to 3 consecutive days for interim treatment 6

Essential Discharge Components

• Provide overdose prevention education and take-home naloxone kit 6
• Arrange follow-up for medication-assisted treatment continuation, as this approach demonstrates better short-term improvement in treatment and reduced illicit opioid use compared to referral only 6

Critical Distinctions Between Scales

CIWA-Ar and COWS are entirely different scales and must never be confused or used interchangeably 1:

• CIWA-Ar is specific to alcohol or benzodiazepine withdrawal only 1
• COWS is specific to opioid withdrawal only 1
• Using the wrong scale for the wrong substance will result in inappropriate treatment decisions 1

Common Pitfalls to Avoid

• Never discharge based solely on time elapsed (e.g., "day 3" or "72 hours")—discharge only when scores are consistently low and symptoms resolved 5
• Infection (pneumonia, spontaneous bacterial peritonitis in cirrhotics) commonly complicates management around day 4 and may be mistaken for persistent withdrawal 5
• Anxiety symptoms can be misinterpreted as withdrawal; when masked patients on long-term opioids received placebo for 60 hours, only 30% had true withdrawal symptoms 6
• Patients with history of complicated withdrawal (seizures, delirium tremens), significant medical/psychiatric comorbidities, or inadequate social support should not be discharged to outpatient management regardless of current score 5, 3