What Is the CIWA Protocol for Alcohol Withdrawal?

Key Takeaways

• The CIWA protocol helps healthcare professionals assess and manage alcohol withdrawal symptoms.
• The protocol’s scoring system guides the intensity of treatment based on symptom severity. 

The CIWA protocol for alcohol withdrawal is a questionnaire that measures the severity of an individual’s alcohol withdrawal symptoms.

The goal of the CIWA protocol is to minimize the risk of complications and optimize the patient’s recovery. It is also known as the Clinical Institute Withdrawal Assessment for Alcohol scale.

History of the CIWA Protocol for Alcohol Withdrawal

The CIWA protocol was designed to standardize the care of patients with alcohol withdrawal and to improve outcomes. The original CIWA protocol included 30 items, but has since been reduced to include 10 in the revised version (CIWA-Ar).

More recently, the CIWA protocol has been shown to be an effective tool for managing alcohol withdrawal. A study published in Hospital Pharmacy in 2016 found that patients who were managed with the CIWA protocol had a reduced daily dose of diazepam without any apparent safety issues.

What Is the CIWA Protocol for Alcohol Withdrawal Used For?

The CIWA protocol is used to assess and manage the symptoms of alcohol withdrawal. It can be used in both inpatient and outpatient settings. Scores can be used to guide the intensity of treatment.

For example, a patient with a score of 16 or higher may require more intensive treatment—such as IV fluids or medications—than a patient with a score of 7 or lower. In addition to assessing the severity of symptoms, the CIWA protocol can also be used to monitor the patient’s response to treatment.

Below is a list of different uses for the CIWA protocol:

• Inpatient detoxification: The CIWA protocol is often used in patients who are undergoing inpatient detoxification from alcohol. It is used to assess the severity of withdrawal symptoms and to guide the intensity of treatment.
• Outpatient management: The CIWA protocol can also be used in outpatient settings, such as primary care or addiction counseling offices. It can be used to assess the severity of symptoms and to monitor the patient’s response to treatment.
• Emergency department: The CIWA protocol is sometimes used in the emergency department to assess and manage alcohol withdrawal.
• Research: The CIWA protocol is also used in research studies on alcohol withdrawal and its treatment.

How Do You Score the CIWA?

The CIWA protocol items are scored on a scale of 0-7, with higher scores indicating more severe symptoms. The final item regarding orientation to time and place is rated from 0-4. The CIWA score is based on the patient’s self-reported symptoms and observable signs. It takes two minutes to administer the assessment. Below are the total score ranges and their meaning:

• 7 or below: minimal to mild withdrawal
• 8-15: moderate withdrawal
• 16 or more: severe withdrawal (impending delirium tremens)

Below are the categories covered by the 10 items:

• Agitation
• Anxiety
• Auditory disturbances
• Clouding of sensorium
• Headache
• Nausea/vomiting
• Paroxysmal sweats
• Tactile disturbances
• Tremor
• Visual disturbances

Scoring the CIWA protocol is simple and can be done by any healthcare professional who has been trained in its use.

The patient is first asked a question regarding the severity of their symptoms for each item where required. Next, the healthcare professional observes the patient for signs of withdrawal and rates the severity of each sign on a scale of 0-7. The total score is then calculated by adding up the scores for all 10 items.

What Are the Treatment Guidelines for the CIWA Protocol?

The treatment guidelines for the CIWA protocol are based on the severity of the patient’s symptoms.

• Mild symptoms: Patients with mild symptoms may be treated with supportive care, such as IV fluids and close monitoring.
• Moderate symptoms: Patients with moderate symptoms may be treated with more intensive interventions, such as IV medications or sedation.
• Severe symptoms: Patients with severe symptoms may require intensive treatment in an inpatient setting, such as ICU care.

Impact of the CIWA Protocol for Alchohol Withdrawal

The CIWA protocol is a widely used tool for the assessment and treatment of alcohol withdrawal. It is simple to use and has been shown to be an effective way to manage the symptoms of withdrawal.

The impact of the protocol has shown to be positive, both in terms of the patient’s symptoms and the overall course of their treatment. Below are some specific examples of the positive impact of the CIWA protocol:

• It can be used to guide the treatment of alcohol withdrawal, ensuring that patients receive the level of care they need.
• It has been shown to be an effective way to manage the symptoms of alcohol withdrawal.
• Implementation can lead to better outcomes for patients with alcohol withdrawal, including reduced need for medication.

Tips for Using the CIWA Protocol

Here are some tips to keep in mind when using the CIWA protocol for alcohol withdrawal:

• Start the CIWA protocol as soon as the patient arrives at the facility.
• Repeat the assessment at regular intervals until the patient’s symptoms are under control.
• Have a trained healthcare professional implement the CIWA protocol.
• Follow the treatment guidelines based on the severity of the patient’s symptoms.

Potential Pitfalls of the Protocol

There are some potential pitfalls to be aware of when using the CIWA protocol for alcohol withdrawal. These include the following:

• Failure to start the CIWA protocol in a timely manner
• Inadequate training resulting in incorrectly scoring the CIWA
• Not repeating the assessment frequently enough
• Not following the treatment guidelines based on the severity of the patient’s symptoms

Verywell Mind uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

1. American Society of Addiction Medicine. Clinical Institute Withdrawal Assessment

   of Alcohol Scale, Revised (CIWA-Ar).

2. Eberly ME, Lockwood AG, Lockwood S, Davis KW. Outcomes After Implementation of an Alcohol Withdrawal Protocol at a Single Institution. Hosp Pharm. 2016;51(9):752-758. doi:10.1310/hpj5109-752

3. 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. doi:10.1111/j.1360-0443.1989.tb00737.x

4. Steel TL, Giovanni SP, Katsandres SC, et al. Should the CIWA-Ar be the standard monitoring strategy for alcohol withdrawal syndrome in the intensive care unit?. Addict Sci Clin Pract. 2021;16(1):21. Published 2021 Mar 24. doi:10.1186/s13722-021-00226-w

5. Bacon O, Robert S, VandenBerg A. Evaluating nursing satisfaction and utilization of the Clinical Institute Withdrawal Assessment for Alcohol, revised version (CIWA-Ar). Ment Health Clin. 2016;6(3):114-119. Published 2016 May 6. doi:10.9740/mhc.2016.05.114

By Arlin Cuncic, MA

Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master’s degree in clinical psychology.

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