CIWA-AR Assessment for Alcohol Withdrawal

What is the CIWA-AR?

The Clinical Institute Withdrawal Assessment Alcohol Scale Revised (CIWA-AR) is an instrument used by medical professionals to assess and diagnose the severity of alcohol withdrawal.¹ The CIWA-AR is one of the most common methods of treating alcohol withdrawal and is often used by family physicians.²

The CIWA-AR allows physicians to measure the severity of patients’ alcohol withdrawal syndrome, and thus prevent further health complications and treat the withdrawal syndrome accordingly.¹

The CIWA-AR can measure 10 alcohol withdrawal symptoms, including:¹

1. Agitation (0-7).
2. Anxiety (0-7).
3. Auditory disturbances (0-7).
4. Clouding of sensorium (0-7).
5. Headache (0-7).
6. Nausea/vomiting (0-7).
7. Paroxysmal sweats (0-7).
8. Tactile disturbances (0-7).
9. Tremor (0-7).
10. Visual disturbances (0-7).

How Should the CIWA-AR Assessment Be Used?

The CIWA-AR assessment should be used by a licensed physician in a professional medical setting. Family doctors may use the CIWA-AR assessment in their practices, along with physicians in residential and outpatient treatment programs.

How is the CIWA-AR Scored?

The CIWA-AR scores on a scale from 0-7 for each symptom and takes less than 2 minutes to complete. By adding up the scores of each 10 symptoms into a total, physicians can determine a severity range for patients’ withdrawal syndrome.

Cumulative scores of less than 8-10 indicate mild withdrawal. Next, scores of 8-15 indicate moderate withdrawal, and scores of 15 or more than 15 indicate severe withdrawal with impending possible delirium tremens.

The CIWA-AR Screening Questions¹

1. Do you feel sick to your stomach and have you vomited?

0 – No nausea and no vomiting

1 – mild nausea with no vomiting

2,3,4 – intermittent nausea with dry heaves

5,6,7 – constant nausea, frequent dry heaves and vomiting

2. Do you have any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?

0 – No tactile disturbances

1 – very mild itching, pins and needles, burning or numbness

2 – mild itching, pins and needles, burning or numbness

3 – moderate itching, pins and needles, burning or numbness

4 – moderately severe hallucinations

5 – severe hallucinations

6 – extremely severe hallucinations

7 – continual severe hallucinations

3. Observe tremors in the patient by having the patient extend their arms and spread their fingers.

0 – no tremor

1 – not visible, but can be felt fingertip to fingertip

2,3,4 – moderate, with patient’s arms extended

5,6,7 – severe, even with arms not extended

4. Are you hearing things you know are not there? (And other related questions)

0 – not present

1 – very mild harshness or ability to frighten 2 mild harshness or ability to frighten

3 – moderate harshness or ability to frighten

4 – moderately severe hallucinations

5 – severe hallucinations

6 – extremely severe hallucinations

7 – continuous hallucinations

5. Paroxysmal Sweats — Observation.

0 – no sweat visible

1 – barely perceptible sweating, palms moist

2,3,4 – beads of sweat obvious on forehead

5,6,7 – drenching sweats

6. Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?

0 – not present

1 – very mild sensitivity

2 – mild sensitivity

3 – moderate sensitivity

4 – moderately severe hallucinations

5 – severe hallucinations

6 – extremely severe hallucinations

7 – continuous hallucinations

7. Do you feel nervous?

0 – no anxiety, at ease

1 – mild anxious

2,3,4 – moderately anxious, or guarded, so anxiety is inferred

5,6,7 – equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

8. Does your head hurt or feel different? Does it feel like there is a band around your head?

0 – no present

1 – very mild

2 – mild

3 – moderate

4 – moderately severe

5 – severe

6 – very severe

7 – extremely severe

9. Agitation — Observation.

0 – normal activity

1 – somewhat more than normal activity

2,3,4 – moderately fidgety and restless

5,6,7 – paces back and forth during most of the interview, or constantly thrashes about

10. What day is this? Where are you? Who am I?

0 – oriented and can do serial additions

1 – cannot do serial additions or is uncertain about date

2 – disoriented for date by no more than 2 calendar days

3 – disoriented for date by more than 2 calendar days

4 – disoriented for place/or person

 

The Validity & Reliability of the CIWA-AR

Researchers have raised questions within the past decade regarding the legitimacy and reliability of the CIWA-AR. For example, one researcher pointed out that only 3 of the 10 components of the assessment (sweats, tremor, and agitation) can be measured by observation alone, while the other 7 must require discussion with a patient.²

This can be tricky in cases where a patient and physician experience a language barrier, thus preventing the conversations necessary for accurate and precise scoring. Similarly, by having to discuss symptoms with patients who are inherently struggling with alcohol abuse, some patients may not be in the best state of mind to answer questions regarding their condition while being assessed and scored.^1,2

The CIWA-AR test alone isn’t enough to treat an alcohol use disorder. If you believe you or someone you love may be dealing with issues in relation to alcohol use or abuse, call us at There, an admissions advisor will listen to your story and discuss your treatment options and alcohol rehab. If you believe you need treatment and want to know whether insurance is able to cover all or part of the cost of treatment, find out instantly below.

Take Our “Am I an Alcoholic?” Self-Assessment

Take our free, 5-minute “Am I an Alcoholic?” self-assessment below if you think you or someone you love might be struggling with an alcohol use disorder (AUD). The evaluation consists of 11 yes or no questions that are intended to be used as an informational tool to assess the severity and probability of an AUD. The test is free, confidential, and no personal information is needed to receive the result.

Sources:

1. American Society for Addiction Medicine. (2001). Addiction Medicine Essentials.
2. Knight, E., & Lappalainen, L. (2017). Clinical Institute Withdrawal Assessment for Alcohol-Revised might be an unreliable tool in the management of alcohol withdrawal. Canadian family physician Medecin de famille canadien, 63(9), 691–695.