Usage Signs or symptoms of alcohol withdrawal syndrome (AWS) occur in approximately one-half of patients with alcohol use disorder (AUD) who abruptly reduce or abstain from alcohol, and if left untreated can progress to delirium tremens. (Goodson et al, 2014). The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) is a 10-item questionnaire that assess the signs, symptoms and severity of alcohol withdrawal to guide treatment (Sullivan et al, 1989). AWS is classified as mild, moderate and severe by the American Society of Addiction Medicine (ASAM, 2020). Treatment protocols (i.e. supportive care, extended monitoring, benzodiazepine medication) and patient disposition (i.e. outpatient, detox center, hospitalization) will vary based on risk factors and the clinical setting (primary care or emergency department). Tiglao, Meisenheimer & Oh (2021), published an outpatient management protocol for AWS based on the CIWA-Ar questionnaire. This evaluation integrates their algorithm for AWS management to assist outpatient providers in directing appropriate treatment and disposition of patients at risk for AWS.
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Summary The Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWA-Ar) is a 10-item questionnaire that assess the signs, symptoms and severity of alcohol withdrawal to guide treatment (Sullivan et al, 1989).
Answers to the first 10 questions are assigned points. The sum of these points determines the score and AWS classification. AWS is classified as mild, moderate and severe by the American Society of Addiction Medicine (ASAM, 2020).
| Score | Withdrawal Level |
| ≤ 9 | Mild |
| 10-18 | Moderate |
| ≥ 19 | Severe |
The following recommendations will display based on the algorithm for AWS management published by Tiglao et al (2021). Included in the recommendations are tables from this publication listing oral medications used to treat mild to moderate AWS, expected symptoms of alcohol withdrawal syndrome after cessation of alcohol use and the AWS management algorithm.
| Recommendation | Criteria |
| Level 1 Withdrawal Management | - No risk factors for complicated symptoms¹
- No risk factors for potential inpatient management²
- CIWA-Ar score <10 (mild in severity)
- Low risk of developing severe symptoms
- Does not meet Level 2 criteria³
- Exception: Mild or stable psychiatric symptoms (i.e. having a limited nonsignificant effect on daily functioning).
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| Level 2 Withdrawal Management | - No risk factors for complicated symptoms
- No risk factors for inpatient management
- Presence of Level 2 Withdrawal Management³ criteria + Score ≤ 18
|
| Inpatient Management | - Risk factors for complicated symptoms
- Severe symptoms (score ≥ 19)
- Risk factors for inpatient management (at any score)
|
| Consider Inpatient Management* | - Abnormal Laboratory results:
- Abnormal electrolytes
- Elevated AST/ALT
- Elevated BUN/Cr ratio
- Elevated blood alcohol level
- Positive urine drug screen
|
¹Risk factors for complicated symptoms
- History of alcohol withdrawal-related delirium or seizures
- Multiple prior withdrawal episodes
- Comorbid illness
- Age > 65 years old
- Long duration of alcohol consumption (heavy alcohol use five or more days in the past month)
- Seizures during current withdrawal episode
- Marked autonomic hyperactivity on presentation
- Physiologic dependence on GABAergic agents
²Risk factors for inpatient management
- Medical or psychiatric condition requiring inpatient treatment
- Unstable chronic condition
- Inability to tolerate oral drugs
- Severe psychiatric or cognitive impairment
- Imminent risk of harm
³Risk factors for level 2 withdrawal management
- Physiologic dependence on opioids or opioid use disorder
- Severe withdrawal < 1 year ago
- Older age or history of epilepsy
- Mild or stable psychiatric symptoms
* The recommendation, "consider inpatient treatment," will appear with either level 1 or level 2 withdrawal management options (if criteria are met) so that the provider can fully consider all of the applicable management options.
Level 1 Withdrawal Management
Management Considerations
- A Level 1 withdrawal management treatment setting includes a typical outpatient clinic.
- If not completed, consider laboratory tests as clinically indicated and re-assess management criteria (Level 1, Level 2, inpatient). Consider including:
- CMP (BMP = hepatic panel)
- CBC with differential
- Urine drug screen
- Blood alcohol level
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
- Supportive Care
- Educating patients on course of withdrawal
- Monitoring for severe withdrawal
- Educating patients on
- Maintain low-stimulation home environment
- Consuming noncaffeinated fluids
- Daily multivitamin containing 400 mcg of folic acid
- Prescribe thiamine (typical dosage of 100 mg daily for three to five days)
- Can prescribe gabapentin (Neurontin) or carbamazepine (Tegretol)
Monitoring and Follow-up
- The frequency and setting for outpatient monitoring of AWS should be guided by symptom severity, risk of complications, and social factors, including reliable social support and a safe home environment.
- Most patients will require daily evaluations for up to five days after their last drink, but evaluations may increase or decrease in frequency as necessitated by changes in symptom severity.
- These visits can be with any health care professional. Face-to-face visits are preferred, but telemedicine appointments can alternate with in-person visits.
- Evaluation should include multiple indicators of symptom severity and overall health, including mental status, hydration, sleep, mood, suicidality, and substance use.
- Blood pressure, pulse, and alcohol breath analysis should be obtained whenever possible.
- The assessment should also include a validated measure of withdrawal symptom severity, ideally with the same instrument as the initial assessment.
- When to refer
- Continued symptoms despite multiple doses of the prescribed medication, worsening or severe symptoms (persistent vomiting, hallucinations, confusion, or seizure), signs of oversedation, worsening psychiatric symptoms, or unstable vital signs should prompt transfer to a higher level of care.
- Symptoms outside of the anticipated withdrawal period or resumption of alcohol use also warrants referral to an addiction specialist or inpatient treatment program.
Level 2 Withdrawal Management
Management Considerations
- A Level 2 withdrawal management treatment setting employs extended on-site monitoring outside the scope of most primary care clinics. Examples include day hospitals, mental health facilities, and addiction treatment facilities that can monitor each patient for several hours each day and have greater access to psychological or psychiatric specialty treatments.
- If not completed, consider laboratory tests as clinically indicated and re-assess management criteria (i.e. inpatient). Consider including:
- CMP (BMP = hepatic panel) including:
- CMP (BMP = hepatic panel)
- CBC with differential
- Urine drug screen
- Blood alcohol level
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
- Prescribe first-line benzodiazepines (long-acting to minimize breakthrough symptoms and are preferred over short-acting)
- Chlordiazepoxide (Librium)
- Diazepam (Valium)
- Lorazepam (Ativan)
- Benzodiazepine dosing can be either fixed or symptom triggered.
- Fixed dosing sets a specific dose and time and is gradually tapered on a set schedule.
- Symptom-triggered dosing is given as needed based on specific CIWA-Ar or SAWS scores. Symptom-triggered use of benzodiazepines is preferred when the patient or caregiver can reliably assess symptoms and follow the dosing guidelines.
- Patients should be monitored for oversedation and respiratory depression, especially in the presence of liver disease. In patients with liver disease, consider benzodiazepines with less hepatic metabolism, such as lorazepam (Ativan) and oxazepam (Serax)..
- If contraindications to benzodiazepines exist or if the risk of use outweighs the benefits, gabapentin, carbamazepine, and phenobarbital may be considered as alternative monotherapies
- Prescribe gabapentin, carbamazepine, and valproate (Depacon) as adjuncts if symptoms persist despite adequate benzodiazepine use.
Monitoring and Follow-up
- The frequency and setting for outpatient monitoring of AWS should be guided by symptom severity, risk of complications, and social factors, including reliable social support and a safe home environment.
- Most patients will require daily evaluations for up to five days after their last drink, but evaluations may increase or decrease in frequency as necessitated by changes in symptom severity.
- These visits can be with any health care professional. Face-to-face visits are preferred, but telemedicine appointments can alternate with in-person visits.
- Evaluation should include multiple indicators of symptom severity and overall health, including mental status, hydration, sleep, mood, suicidality, and substance use.
- Blood pressure, pulse, and alcohol breath analysis should be obtained whenever possible.
- The assessment should also include a validated measure of withdrawal symptom severity, ideally with the same instrument as the initial assessment.
- When to refer
- Continued symptoms despite multiple doses of the prescribed medication, worsening or severe symptoms (persistent vomiting, hallucinations, confusion, or seizure), signs of oversedation, worsening psychiatric symptoms, or unstable vital signs should prompt transfer to a higher level of care.
- Symptoms outside of the anticipated withdrawal period or resumption of alcohol use also warrants referral to an addiction specialist or inpatient treatment program.
Inpatient Management
Management Considerations
- Those with severe (Score ≥ 19) or complicated symptoms should be referred to the nearest emergency department for inpatient hospitalization.
- If not completed, consider laboratory tests as clinically indicated
- CMP (BMP = hepatic panel)
- CBC with differential
- Urine drug screen
- Blood alcohol level
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
Consider Inpatient Management
While the patient may NOT present with additional risk (below) for inpatient management, abnormal lab findings warrant consideration for inpatient management.
- Severe AWS (Score ≥ 19)
- Risk factors for complicated symptoms
- Risk factors for inpatient management
Management Considerations
- Correlate the patient's symptoms in relation to the time since their last drink. Assists in tracking of symptom progression, providing anticipatory guidance, and monitoring appropriateness of withdrawal management.
- Consider inpatient management
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