Alcohol Withdrawal

A 45 year old man comes to the office because he wants to quit drinking alcohol. He reports that he drinks about 12 to 15 beers daily and the occasional cup of wine with dinner. His last drink of alcohol was yesterday, about 24 hours ago. He tells you he feels odd and thinks he has been hearing voices. On exam, his pulse and heart rate are elevated (100 bpm, 160/100 mmHg) and he has a visible tremor, mild diaphoresis and appears agitated. You administer the clinical institute withdrawal assessment scale for alcohol, revised (CIWA-Ar score). His score is 18.

A 45 year old man is brought to the emergency department after having a seizure. He is a chronic alcoholic who had not had a drink for more than 24 hours. He is given IV lorazepam.

A 40 year old man in the hospital who is 3 days post-op is found to be agitated, anxious, sweating, and has an elevated heart rate and blood pressure.


Benzodiazepines are used to prevent alcohol withdrawal seizures. They are given using a fixed-dose or symptom-based schedule. Examples of commonly used benzodiazepines for alcohol withdrawal include: Lorazepam (Ativan), Chlordiazepoxide (Librium) and Diazepam (Valium).

CIWA-Ar score

A pdf of the CIWA-Ar score is available from the journal of the college of family physicians of Canada (here). Below is the image from there:

A score >15 is considered severe alcohol withdrawal. A score of 10-15 is moderate and a score <10 is mild.

SAWS Score

The Short Alcohol Withdrawal Scale (SAWS) is a validated question based assessment for alcohol withdrawal. However, unlike the CIWA-Ar, it is completed by the patient and was validated for the outpatient setting.

Item None (0 points) Mild (1 point) Moderate (2 points) Severe (3 points)
Feeling confused
Problems with memory
Tremor (shakes)
Heart pounding
Sleep disturbance


American Academy of Family Physicians (AAFP.org) – article on outpatient management of alcohol withdrawal syndrome – available online here, and as a pdf here.

Journal of the College of Physicians of Canada (CFP.ca) – article: Clinical Institute Withdrawal Assessment for Alcohol–Revised might be an unreliable tool in the management of alcohol withdrawal. Available here, and as a pdf here.