CIWA-Ar Alcohol Withdrawal Calculator
CIWA-Ar Alcohol Withdrawal Calculator
Score the ten CIWA-Ar items. Nine run 0 to 7 and one runs 0 to 4, so the maximum is 67 and not 70 — and the two sources read for this page band the same total differently. No dose appears anywhere here.
CIWA-Ar alcohol withdrawal score
10 items, 0 to 67Mild nausea (1); moderate tremor at 2; palms moist (1); anxiety at 2; somewhat more than normal activity (1); no tactile, auditory or visual disturbance (0, 0, 0); mild headache (2); disoriented for date by up to two days (2)
Scoring
Maximum possible score 67
- nine sevens and one four
- the published form prints “Maximum Possible Score 67” in terms. Nine items run 0 to 7 and orientation runs 0 to 4. An implementation that gives all ten items the same range returns a maximum of 70 and silently rescales every band on the page
- eight of the ten items need an answer
- nausea, anxiety, headache, orientation and the three perceptual items are all scored from what the patient says, and only tremor, sweats and agitation are pure observation. So the instrument requires a patient who can communicate: it cannot be scored in someone intubated, sedated or too delirious to answer, and a total assembled from the three observed items alone is not a CIWA-Ar score
- most things in a hospital move this score
- the Australian guidelines name sepsis, hepatic encephalopathy, severe pain, other causes of tremor, anxiety disorder and withdrawal from benzodiazepines, stimulants or opiates, and say the scales “should not be used to guide treatment in individuals concurrently withdrawing from other substances”, which “includes most hospitalised patients”
- not a diagnostic instrument
- “Alcohol withdrawal rating scales are not to be used as diagnostic tools” is the Australian guidelines’ own sentence. The scale quantifies the severity of a syndrome somebody has already decided is alcohol withdrawal; it does not establish that it is
Worked example
Mild nausea (1); moderate tremor at 2; palms moist (1); anxiety at 2; somewhat more than normal activity (1); no tactile, auditory or visual disturbance (0, 0, 0); mild headache (2); disoriented for date by up to two days (2)
1 + 2 + 1 + 2 + 1 + 0 + 0 + 0 + 2 + 2 = 11 points
11 falls in the published form's 8-to-15 band and in the Australian guidelines' 10-to-20 band, so on this total the two sources agree
Change one item and they stop agreeing: raise the tremor from 2 to 7 and tactile disturbances from 0 to 2 and the total is 18 — severe on the form, still moderate in the guidelines
Note where two of these eleven points came from. The orientation item scored 2 for being unsure of the date by a day or so, which is also what a tired inpatient scores at three in the morning
And note what the total does not say: nothing here establishes that the syndrome is alcohol withdrawal rather than sepsis, pain or a second drug withdrawing at the same time
The ten items, their ranges and what the form anchors
| Item | Range | Descriptors printed on the form |
|---|---|---|
| Nausea and vomiting | 0 to 7 | 0, 1, 4, 7 |
| Tremor | 0 to 7 | 0, 1, 4, 7 |
| Paroxysmal sweats | 0 to 7 | 0, 1, 4, 7 |
| Anxiety | 0 to 7 | 0, 1, 4, 7 |
| Agitation | 0 to 7 | 0, 1, 4, 7 |
| Tactile disturbances | 0 to 7 | all eight |
| Auditory disturbances | 0 to 7 | all eight |
| Visual disturbances | 0 to 7 | all eight |
| Headache, fullness in head | 0 to 7 | all eight |
| Orientation and clouding of sensorium | 0 to 4 | all five |
Two published bandings of the same instrument
| Total | Published CIWA-Ar form (NIAAA) | Guidelines for the Treatment of Alcohol Problems (Australia) |
|---|---|---|
| 0 to 7 | Minimal to mild | Mild |
| 8, 9 | In both its minimal-to-mild and its moderate sentence | Mild |
| 10 | In both sentences | Moderate |
| 11 to 14 | Moderate, marked autonomic arousal | Moderate |
| 15 | In both its moderate and its severe sentence | Moderate |
| 16 to 20 | Severe, impending delirium tremens | Moderate |
| 21 to 67 | Severe, impending delirium tremens | Severe |
A severity measure for a syndrome that is dangerous when it is under-treated
The CIWA-Ar quantifies how severe an alcohol withdrawal syndrome is at the moment it is scored. Sullivan and colleagues published it in 1989 as a ten-item shortening of the fifteen-item CIWA-A, and the abstract’s claim is modest and worth quoting: the shorter scale “offers an increase in efficiency while at the same time retaining clinical usefulness, validity and reliability”. The abstract states no sample size and publishes no reliability or validity statistic, so this page quotes none.
Why it matters that this is a severity measure and not a risk score: alcohol withdrawal can be fatal, and the mechanism by which it kills — seizures, and then delirium tremens with its autonomic storm — is a function of time since the last drink and of the patient’s history, not of the number on the form. Withdrawal seizures cluster early and delirium tremens characteristically appears later, so a total of 4 at six hours tells you about six hours. The published thresholds exist because symptom-triggered dosing — established by the 1994 JAMA trial of 101 patients, which cut the median duration of treatment from 68 hours to 9 against a fixed schedule — needs a number to trigger on. This page gives the number and the thresholds and names the protocol, and renders no part of it.
The two limitations that decide whether a total means anything are structural. First, eight of the ten items are scored from what the patient says, so the instrument needs someone who can answer: it cannot be scored in a sedated, intubated or profoundly delirious patient, and three observed items alone are not a CIWA-Ar. Second, the signs it counts are not specific to alcohol. The Australian Guidelines for the Treatment of Alcohol Problems list sepsis, hepatic encephalopathy, severe pain, other causes of tremor, anxiety disorder and concurrent benzodiazepine, stimulant or opiate withdrawal, and add that the scales have “a limited role” in circumstances that “include most hospitalised patients”. They also report that scoring in practice is “typically highly variable” and “often not reproducible”, which the form’s forty blank rows help to explain.
Attribution. The CIWA-Ar is Sullivan and colleagues’, from the British Journal of Addiction, 1989, shortened from the fifteen-item CIWA-A. The published form states “The CIWA-Ar is not copyrighted and may be reproduced freely”, and the derivation paper says the same.
A total on this page is a number, not a diagnosis. These instruments quantify what a person reports, or what an observer records at one moment; a diagnosis rests on a clinical assessment that no questionnaire total stands in for. A low total does not exclude a dangerous course. This is a severity measurement of the moment it was scored, no source read for this page publishes a sensitivity or a predictive value for it, and the phases of this syndrome that kill people characteristically appear later than the first score. This page renders no dose, no treatment and no disposition. Every cut-off, sensitivity, specificity and severity band here is printed with the cohort it was measured in, or with a statement that no source read for this page attaches one — because an instrument’s accuracy is a property of the population it was measured in and not of the instrument. If you are reading this about yourself and you are in distress or thinking about harming yourself, please contact your local emergency number or a crisis line now rather than treating a number as an answer: 999 or Samaritans on 116 123 in the UK and Ireland, 988 in the United States and Canada, or your local emergency service elsewhere.
Frequently asked questions
What is the maximum CIWA-Ar score?
67. The published form says so in terms. Nine of the ten items are scored 0 to 7 and orientation and clouding of sensorium is scored 0 to 4, so the sum of the maxima is 9 × 7 + 4 = 67. An implementation that treats all ten items as 0 to 7 produces 70 and shifts every threshold on the page relative to the scale.
What CIWA-Ar score counts as severe withdrawal?
The two sources read for this page disagree. The published form’s text puts severe withdrawal at “15 or more”; the Australian Guidelines for the Treatment of Alcohol Problems put it above 20. Between 16 and 20 the same patient is severe on one and moderate on the other. Neither source attaches a derivation cohort or an outcome study to its cuts, so neither can be preferred on evidence.
Can the CIWA-Ar be used in a patient who cannot talk?
No. Eight of the ten items are scored from the patient’s answers — nausea, anxiety, headache, orientation and the three perceptual items all begin with a question. Only tremor, paroxysmal sweats and agitation are pure observation. A total built from those three is not a CIWA-Ar score and the scale is not valid in a sedated, intubated or profoundly delirious patient.
Does a low CIWA-Ar score mean the withdrawal will stay mild?
It does not. The score measures the present moment. Withdrawal seizures cluster in the first day or two and delirium tremens characteristically appears later, so a total taken early carries no information about what the next forty-eight hours will do. This page renders no dose, no treatment and no disposition.
Why do so many hospital patients score on the CIWA-Ar?
Because tremor, sweating, anxiety, agitation, nausea and disorientation are the common currency of acute illness. The Australian guidelines name sepsis, hepatic encephalopathy, severe pain, anxiety disorder and withdrawal from other substances as conditions that produce the same signs, and conclude that the scales have “a limited role” in those circumstances — which, they add, covers most hospitalised patients.
Related calculators
References
- Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) — the published scoring form as distributed by the National Institute on Alcohol Abuse and Alcoholism, and the identical form hosted by the University of Maryland School of Medicine emergency medicine department. Source of every item and numbered anchor, of “Maximum Possible Score 67”, of the severity text (“Scores of less than 8 to 10 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal (marked autonomic arousal); scores of 15 or more indicate severe withdrawal (impending delirium tremens)”), and of the licence statement “The CIWA-Ar is not copyrighted and may be reproduced freely”.
- Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict. 1989;84(11):1353–1357. Abstract read: “A shortened 10-item scale for clinical quantitation of the severity of the alcohol withdrawal syndrome has been developed”, retaining “clinical usefulness, validity and reliability”. It states no sample size and publishes no reliability or validity statistic, which is why none is quoted on this page.
- Guidelines for the Treatment of Alcohol Problems (Australia), “Limitations of Withdrawal Scales” and “Clinical Institute Withdrawal Assessment for Alcohol”. Source of “Alcohol withdrawal rating scales are not to be used as diagnostic tools”, of “typically highly variable in clinical practice and often not reproducible”, of the confounders this page names and of “includes most hospitalised patients”, of the description of the CIWA-Ar as “a 10-item, validated scale designed for use by trained inpatient nurses”, and of the SECOND, different severity banding — mild below 10, moderate between 10 and 20, severe above 20.
- Individualized treatment for alcohol withdrawal: a randomized double-blind controlled trial. JAMA. 1994;272(7):519–523. Abstract read: 101 patients, symptom-triggered dosing against a fixed schedule, with “a validated measure of the severity of alcohol withdrawal” driving the symptom-triggered arm; median duration of treatment 9 hours against 68, P < .001. This page names the trial and reproduces none of its medication figures.
Not medical advice. For healthcare professionals and education. Reference intervals vary by laboratory and assay — always use your own laboratory's. Never base a dose or a treatment decision on this page alone. Full disclaimer at calcengines.com/disclaimer/