How the CIWA Scale is Scored
The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWA-Ar) is a 10-item scale that quantifies alcohol withdrawal severity, with each component scored individually and summed to produce a total score ranging from 0-67 points. 1
Components of the CIWA-Ar Scale
The CIWA-Ar assesses 10 specific withdrawal symptoms, each scored on different scales 1:
- Nausea and vomiting (0-7 points)
- Tremor (0-7 points)
- Paroxysmal sweats (0-7 points)
- Anxiety (0-7 points)
- Agitation (0-7 points)
- Tactile disturbances (0-7 points)
- Auditory disturbances (0-7 points)
- Visual disturbances (0-7 points)
- Headache/fullness in head (0-7 points)
- Orientation and clouding of sensorium (0-4 points)
Score Interpretation and Clinical Thresholds
Scores below 8 indicate minimal to mild withdrawal that typically does not require pharmacological treatment. 2, 1
Scores of 8-10 or greater indicate moderate withdrawal requiring benzodiazepine treatment and continued monitoring. 2, 1
Scores of 15 or greater indicate severe withdrawal with significantly increased risk of complications including seizures and delirium tremens, absolutely requiring inpatient management. 2, 3
Research demonstrates that patients scoring greater than 15 have a 3.72-fold increased risk of severe alcohol withdrawal complications if left untreated. 3
Assessment Frequency and Clinical Application
Assessments should be performed every 1-2 hours initially during active withdrawal, then extended to every 4-8 hours as symptoms stabilize. 2, 1
Symptom-triggered dosing using CIWA-Ar scores is the recommended approach, with benzodiazepines administered when scores reach ≥8-10. 1
Treatment continues until CIWA-Ar scores remain consistently below 8 for at least 8-12 hours without additional benzodiazepine dosing. 2
Critical Distinction from Other Scales
The CIWA-Ar is specific to alcohol or benzodiazepine withdrawal and should never be confused with the COWS (Clinical Opiate Withdrawal Scale), which is an entirely different instrument for opioid withdrawal. 1
The CIWA scales should not be used for opioid, cocaine, or other substance withdrawal syndromes. 1
Common Pitfalls
While the CIWA-Ar is considered the gold standard, many items rely on subjective patient-reported symptoms, making it time-consuming and potentially less reliable in patients with altered mental status or communication barriers. 4
A small subset of patients may still develop complicated withdrawal despite low scores, requiring clinical judgment beyond the numerical threshold. 3