A Guide To the CIWA-Ar Scale for Alcohol Detox

Detoxing is when your body rids itself of all traces of alcohol. While this period can be quite uncomfortable depending on how dependent a person has become, it is the only way to get beat an alcohol addiction.

The symptoms of alcohol detox are caused by the brain being forced to create chemicals it had been previously relying on the alcohol to provide.

The initial stages can produce such withdrawal symptoms as irregular heartbeat, anxiety, headaches, fever, nausea, and even hallucinations. Detoxing is vital because it is the first step towards a full recovery.

To create a quick and efficient way to determine if someone will potentially suffer from alcohol withdrawal syndrome, along with what treatments they might require, some official signs and symptoms can be used to assess.

Criteria for alcohol withdrawal

The American Psychiatric Association lists the following criteria in their Diagnostic and Statistical Manual of Mental Disorders for alcohol withdrawal.

The first criterion that must be met is that the person is reducing or entirely stopping their intake of alcohol after a significant period of heavy use.

The second criterion takes place within twelve to forty-eight hours after the absence of alcohol intake. It includes the introduction of two or more of the symptoms which are listed on the 10-point scale (later discussed below.)

The third criteria are if the symptoms listed cause distress in the individual, or issues with other areas of functioning in their life, including with friends, family, and at work.

The final criteria that must be met are if all of these cannot be explained away by a different mental issue or medical condition.

The CIWA score explained

The Clinical Institute Withdrawal Assessment-Alcohol or CIWA is a score used to objectively determine the severity of alcohol withdrawal syndrome someone may potentially experience. This makes it easier to determine the course of action for treatment. Following CIWA guidelines saves lives, and these guidelines are far safer than attempting a so-called “cold turkey” alcohol detox

The 10 symptoms listed on the CIWA-Ar scale

As previously mentioned, the revised CIWA-Ar scale has only ten listed symptoms. They are scaled from 0-7, except for the question on orientation, which is scaled 0-4.

Below are the ten things that the CIWA-Ar looks at to determine the level of alcohol withdrawal.

• Sweating & high pulse rate: Alcohol is known to affect the central nervous system and the body’s circulation, which causes an increase in heart rate and therefore a dilation in our skin’s blood vessels. This triggers the sweat glands to overwork, which is why most people suffering from alcohol withdrawal often relay experiences of ‘night sweats.’ This effect is only a temporary one and will only present itself in the first couple of days after cessation
• Hand tremors: This withdrawal symptom is one of the most easily spotted indicators that someone is struggling with alcohol addiction. This effect can occur just six hours after the last drink. As we know, alcohol depresses the central nervous system and decreases the body’s energy levels. If large amounts of alcohol are regularly consumed, the body adapts to its presence by releasing more neurotransmitters in the brain than it is used to. This alters the brain chemistry so drastically that when alcohol intake is suddenly stopped, the brain still thinks it should produce enough neurotransmitters to account for the alcohol it is used to. This is what causes a heightened sense of anxiety, stress on the body – and therefore, ‘the shakes.’
• Insomnia: Alcohol disrupts the brain’s natural system of assessing how much sleep is needed per night, in relative comparison to how long they have been awake for. Alcohol also impacts the quality of sleep, including its nature as a diuretic which increases the need to get up and use the bathroom during the night
• Nausea: Several factors contribute to the feeling of nausea experienced during alcohol withdrawal. Firstly, alcohol affects the body’s levels of hydration. It causes the body to produce a higher amount of urine which consequently can lead to dehydration. This is most often accompanied by dizziness, a lightheaded sensation, and extreme thirst. Alcohol is also known to aggravate the stomach lining and contributes to the production of nasty acids in the gut which cause nausea and even vomiting. It also hammers the immune system which can cause a lack of concentration and a loss of appetite which can contribute to the feeling of lightheadedness and nausea
• Vomiting: Alcohol acts as an irritant to the stomach and disrupts the lining of the gut. Vomiting after alcohol occurs in a forced sequence by the body: first, nausea sets in due to the stomach’s gastric muscles contracting. Secondly, the ‘dry heaves’ entail which means the stomach’s largest part goes into respiratory spasm. Finally, the vomit is propelled from the contents of the small intestine and up through the mouth. Vomiting during alcohol withdrawal is a serious condition and should be treated with severity
• Hallucinations: Hallucinations during alcohol withdrawal fall under the umbrella of what is known as ‘delirium tremens.’ This usually sets in after day two. ‘The shakes’ as we mentioned above may now have progressed from the hands to the head and body, causing incoordination and severe cognitive confusion. This is often accompanied by terrors, delusions, and hallucinations
• Agitation: We know that alcohol alters brain chemistry: it also reduces the levels of serotonin (a neurotransmitter) which controls our memory, sleep ability, and mood. Reduced levels of this natural chemical results in poor sleep quality, memory trouble, and mood swings
• Anxiety: Although a sedative that can help put drinkers at ease, alcohol, as we know, disrupts the natural process of chemicals in the brain (which is why that first drink can lead to a chilled out feeling.) Alcohol-related anxiety is all about the way in which the body and brain is processing the unnatural chemicals that alcohol releases. When the effects of alcohol wear off after prolonged abuse (which is what the detoxification period is), the brain still thinks it ought to produce enough neurotransmitters to account for the alcohol. The shakes, confusion, and anxiety are all to do with the body no longer feeling the relaxed and sedative effects of alcohol
• Grand mal seizures: During alcohol addiction, the body becomes dependent on a synthetic drug that affects the brain, and after prolonged abuse, believes it needs this toxin to survive. When this toxin is suddenly removed, the body goes into shock. Grand mal seizures relate to a chemical dysfunction on both sides of the brain due to a sudden cessation of alcohol. These parts are responsible for sending messages to the muscles, glands, and nerves. Disruption to this process can cause the brain to tell the body’s functions to go into overdrive, resulting in extreme muscular contractions – also known as seizures

What is the purpose of the CIWA Score?

The CIWA score makes it possible for clinicians to determine the degree of alcohol withdrawal a person is most likely to go through and the speed at which it is expected to progress. This makes treatment much easier to determine and set in place.

In treatments, the goal is to give the least amount of medication over the shortest time possible, which will decrease the likelihood that the patient will become addicted to the medication being used to assist with the detox.

How has the CIWA-Ar score improved from the original test?

To expedite treatment and ensure reproducibility, the CIWA was revised to the Clinical Institute Withdrawal Assessment-Alcohol-revised (CIWA-Ar), which is a shortened version of the scale.

Instead of thirty different signs, the revised version only has ten symptoms and can be used to determine the development of alcohol withdrawal syndrome.

This makes it faster and easier to use, and the revised version is popular in detox units, hospitals, and clinics. The CIWA-Ar has also been more useful in being able to correctly determine which detoxing individuals will be more likely to suffer from hallucinations and seizures, which makes it very useful for doctors and nurses in the field.

How withdrawal symptoms can be treated using the CIWA-Ar score

The revised scale is incredibly useful in determining how severe the symptoms are likely to be as the detox progresses.

Through use of the CIWA-Ar score, doctors and nurses are more likely to know if they will need to provide additional IV fluids or nutrition based on whether or not the patient will be experiencing severe sweating, vomiting, or other symptoms that may lead to dehydration.

Multivitamins, magnesium sulphate, thiamine, and glucose are all things regularly administered to assist someone through detox to help their system return to its natural balance as quickly as possible. The specific score returned by the CIWA-Ar scale will help doctors to know what they may need to prescribe.

What are the limitations of the CIWA-Ar scale?

There are two fundamental limitations to the CIWA-Ar scale. One, it is subjective in terms of what information is provided to the doctor. They must rely on the patient’s word for determining the score, which will be the basis of the entire treatment plan.

The second, related, limitation is the fact that if someone is already experiencing alcohol withdrawal symptoms, they will most likely have an impaired ability to communicate.

Whatever responses they give may be tainted by their deteriorating mental and physical state. Also, there is the chance that there might be a language barrier, and translations will not be as accurate, especially if the person answering the questions is already suffering from symptoms.

Examples of alcohol detoxification protocol

An example of a case using detoxification protocols that include CIWA-Ar would look something like the following. Each step followed up by professionals.

• CIWA questions given at initial assessment and then every eight hours after that for the first full day
• Vital signs checked regularly
• Drug screen is taken
• Glucose, thiamine, or other substances supplied on an as-needed basis
• Provide medication when CIWA responses reach critical levels
• Call a medical doctor as required to provide additional drugs to abate symptoms
• Continue CIWA until answers are below a score of three for three consecutive rounds of questions

How effective is the CIWA-Ar score in treating alcohol withdrawal?

Multiple studies have shown that when CIWA-Ar is used to score patients coming into medical centres for alcohol detox, it leads to better outcomes. There were shorter inpatient stays, fewer uses of restraints, and less of a chance they would end up in the ICU.

Also, when CIWA-Ar was used, it more accurately identified which people would end up suffering from delirium tremens, which made it easier to treat proactively.

The importance of patient follow-up after using the CIWA-Ar score

No matter what treatment plan is used or which protocol is used to determine that plan, follow-up is very important. It will be a way for the patient to get support, resources, and encouragement.

Without a follow-up, the patient might return to their addiction, and the resulting detoxes afterwards will be all the worse for it. People are more likely to relapse if they do not have a steady support system in place after detoxification.

These support systems include twelve-step programmes, cognitive-behavioural therapy, family therapy, and regular doctor visits to check on their overall health.