What Is the CIWA-Ar Score? How Clinicians Measure Alcohol Withdrawal Severity

Medically reviewed by Erika Kamish, PA, and Harsh Brar, FNP-C.

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, revised) is a 10-item scale clinicians use to measure how severe alcohol withdrawal is, with scores from 0 to 67. It is administered by a trained nurse or clinician who observes and interviews the patient. It is not a self-test.

For people who want this kind of monitoring at home, In-Home Alcohol Detox brings a medical team to the home.

What is the CIWA-Ar?

The CIWA-Ar was published in 1989 by Sullivan and colleagues as a shorter, revised version of an earlier withdrawal assessment. It has become one of the most widely used tools for measuring alcohol withdrawal syndrome in hospitals, detox programs, and supervised home settings. The American Society of Addiction Medicine (ASAM) describes it as a reliable measure in patients who can communicate, once a clinician has diagnosed alcohol withdrawal.

The scale does two jobs. It gives the care team a shared number for how severe withdrawal is right now, and, repeated over time, it shows whether withdrawal is getting better or worse. That trend guides how often the person is checked and whether the prescriber adjusts care.

What does the CIWA-Ar measure?

The scale covers 10 symptom areas. Nine are scored from 0 to 7, and orientation is scored from 0 to 4, for a maximum of 67.

Some items are observed, such as tremor and sweating, and others depend on what the person reports, such as anxiety and headache. That mix is why the scale needs a trained rater and a person who can answer questions.

What does a CIWA-Ar score mean?

ASAM’s 2020 guideline uses these general ranges to describe withdrawal severity:

• Below 10: mild. Mild or moderate anxiety, sweating, and trouble sleeping, without tremor.
• 10 to 18: moderate. Moderate anxiety, sweating, trouble sleeping, and a mild tremor.
• 19 or higher: severe. Severe anxiety and a moderate to severe tremor.

Withdrawal with seizures or delirium is classed as complicated regardless of the number. ASAM also stresses that classification is ultimately up to the clinician’s judgment, and that the score should not be used to diagnose withdrawal, because other conditions such as infection, anxiety disorders, or other substances can raise a score.

Who should be scored, and how often?

Scoring is used for people the care team has assessed as being in, or at risk of, alcohol withdrawal. Before withdrawal starts, clinicians also look at risk factors for complicated withdrawal. ASAM lists a history of withdrawal seizures or delirium, many prior withdrawal episodes, other medical illness, age over 65, long-term heavy drinking, and dependence on other sedating substances.

How often scoring happens depends on severity and setting. For moderate to severe withdrawal, ASAM describes reassessment every 1 to 4 hours for 24 hours. For mild withdrawal with low risk, it notes that people may be observed for up to 36 hours, after which more severe withdrawal is unlikely to develop. The care team sets the actual schedule.

How does in-home monitoring use the score?

In a supervised home setting, the nurse scores the person at set intervals, records the result, and reports it to the prescriber. Rising scores or new symptoms, such as worsening tremor or changes in orientation, prompt closer monitoring, a call to the prescriber, or a move to a higher level of care. Steady or falling scores show that withdrawal is easing as expected.

Clinicians often use the score to guide symptom-triggered treatment, where medication is given only when symptoms cross a set threshold. ASAM notes that outside of settings with extended monitoring, this approach fits only when the patient or caregivers can reliably use the scale, which is one reason a nurse, not a family member, does the scoring in supervised home detox. Any medication decision belongs to the prescriber. Related decisions, such as medications to stop drinking after detox, are part of the longer plan.

What are the limits of the CIWA-Ar?

The scale relies on the person being able to describe how they feel. ASAM advises against using it in delirium, and recommends a scale based on objective signs for people who have difficulty communicating. High scores in hospitalized patients should be read with caution, because illness, pain, or other medications can produce similar symptoms.

The CIWA-Ar also does not predict who will develop severe withdrawal before symptoms begin. That is the role of a risk assessment, such as the Prediction of Alcohol Withdrawal Severity Scale (PAWSS), which ASAM recommends for medically ill hospitalized patients. Thiamine and nutrition are assessed separately, because heavy drinking can lead to Wernicke-Korsakoff syndrome, which a withdrawal score does not measure.

What can families watch for?

For a broader view of the symptoms and timeline, the guide to alcohol withdrawal covers what to expect, and the article on whether home detox is safe for alcohol withdrawal explains who is a good fit for care at home.

Frequently asked questions

What is a CIWA score?

It is the total from the CIWA-Ar, a 10-item clinician-administered scale that measures alcohol withdrawal severity. Scores range from 0 to 67.

What is the CIWA protocol?

The term usually refers to a care plan in which nurses score withdrawal at set intervals and the prescriber’s orders specify what happens at each score range, including when to call, when to treat, and when to escalate care. Protocols differ between programs.

What CIWA score is considered severe?

ASAM’s guideline describes 19 or higher as severe, 10 to 18 as moderate, and below 10 as mild. Clinical judgment decides the final classification.

Can I score myself with the CIWA-Ar at home?

No. The scale is designed for trained raters, and self-scoring can miss warning signs. If you are worried about withdrawal, talk with a clinician before you stop drinking.

How long does CIWA-Ar monitoring last?

It continues until scores stay low and symptoms have settled, which for many people is a few days. ASAM notes that people with mild, low-risk withdrawal may be observed for up to 36 hours, after which more severe withdrawal is unlikely to develop. The care team decides when monitoring ends.

Is the CIWA-Ar the only way to measure withdrawal?

No. It is a widely used scale for alcohol, but clinicians also use risk tools such as PAWSS before symptoms begin, and scales based on objective signs for people who cannot communicate clearly.

Does a low score mean withdrawal is safe?

Not on its own. A low score describes symptoms at that moment. Risk factors such as past seizures or delirium still matter, and symptoms can rise over the first days.

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). British Journal of Addiction. 1989;84:1353-1357 (scale reproduced by Stanford University)
• ASAM, Clinical Practice Guideline on Alcohol Withdrawal Management (2020)
• MedlinePlus, Alcohol withdrawal