CIWA-Ar Calculator (alcohol withdrawal severity score)

Understanding the CIWA-Ar calculator — concept and principle

This calculator adds up the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar), a 10-item scale that nurses and doctors use to rate alcohol withdrawal, and places the total in mild, moderate or severe bands. Hospital staff, addiction services and students use it to document and track withdrawal.

How it is calculated

• Nine items score 0–7: nausea and vomiting, tremor, sweating, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances and headache
• Orientation and clouding of the senses scores 0–4
• Total 0–67
• Commonly used bands: 10 or less mild; 11–15 moderate; 16 or more severe

The principle

Sullivan and colleagues (1989) revised an earlier withdrawal scale to make it shorter and reliable between raters. Each item reflects a sign or symptom of the nervous system's over-activity when alcohol is stopped after heavy use. Only some steps on each item have descriptions; the others lie in between. In the original study a score above 15 was linked to a higher risk of severe complications such as seizures and delirium. Repeated scores show whether withdrawal is easing or worsening.

Worked example

Defaults: nausea 1, tremor 1, sweating 1, anxiety 1, agitation 1, tactile 0, auditory 0, visual 0, headache 1, orientation 0.

1. Score = 1 + 1 + 1 + 1 + 1 + 0 + 0 + 0 + 1 + 0 = 6.
2. Band 0–10: Mild withdrawal.

How to read the result

A low score suggests mild withdrawal at the time of assessment, but withdrawal can progress over the following days, so the scale is repeated at intervals. Hospitals use their own protocols to decide on treatment based on repeated scores; this page does not suggest any medicine or dose. The scale needs a patient who can communicate.

Common mistakes

• Scoring once and not repeating.
• Using the scale in patients who cannot answer questions.
• Mistaking symptoms of other illnesses, such as infection or low blood sugar, for withdrawal.
• Treating the bands as a treatment protocol.

Frequently asked questions

What CIWA-Ar score is severe?

16 or more is commonly used as severe withdrawal.

How often is CIWA-Ar repeated?

At intervals set by the hospital protocol, often every few hours during active withdrawal.

Can I use CIWA-Ar on myself?

It is designed for trained clinicians; if you are withdrawing from alcohol, seek medical help.

Sources: 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