Alcohol withdrawal
PAWSS to predict complicated withdrawal, a full CIWA-Ar scorer with ASAM severity bands, RASS for the patient who cannot self-report, the withdrawal timeline, and ASAM 2020 treatment pathways — benzodiazepines, phenobarbital, thiamine, adjuncts and ICU triggers.
1Context
2PAWSS — risk of complicated withdrawal
Part A threshold must be met before scoring. 1 point per item; max 10.
Part B — interview
Part C — clinical evidence
3CIWA-Ar — current severity
CIWA-Ar relies on self-report; not valid in delirium or when critically ill.
4Complications & sedation
5Safety modifiers
Phenobarbital contraindications (label)
How it works
Severity bands and what they trigger (ASAM 2020)
| Severity | CIWA-Ar | Picture |
|---|---|---|
| Mild | <10 | Mild–moderate anxiety, sweating, insomnia; no tremor |
| Moderate | 10–18 | Moderate anxiety, sweating, insomnia, mild tremor |
| Severe | ≥19 | Severe anxiety, moderate–severe tremor; no confusion, hallucinations or seizure |
| Complicated | ≥19 or any | Seizure, delirium (cannot follow instructions, clouded sensorium) or new hallucinations |
ASAM notes the cut-points vary in the literature and are examples, not rules. The original CIWA-Ar form states that patients scoring under 10 do not usually need additional medication. Maximum score 67.
Severe (≥19): treat in the ED or inpatient; front-loading with diazepam or chlordiazepoxide is recommended. Moderate: benzodiazepines first-line. Mild with low risk: supportive care, or carbamazepine/gabapentin/benzodiazepine.
CIWA-Ar limitations
- Not diagnostic. It grades severity “once a diagnosis has been made” (ASAM). Hypoglycemia, DKA, sepsis, other sedative withdrawal and essential tremor can mimic withdrawal.
- Needs a communicative patient. Nausea, anxiety, tactile, auditory, visual disturbances and headache are self-reported. Do not use it in delirium (ASAM VI.9) — use RASS, CAM-ICU, DDS or MINDS.
- Confounded: falsely high with fever/infection or other withdrawal; falsely low on beta-blockers or other sympatholytics. In medical/surgical patients low scores are reassuring; interpret high scores with caution.
- Short-acting agents with CIWA-Ar: reassess promptly — delayed scoring has led to breakthrough seizures.
PAWSS items and cutoff
Threshold: any alcohol in the past 30 days or a positive blood alcohol on admission. Then 1 point each: recent intoxication (30 days), AUD treatment ever, previous withdrawal, blackouts, withdrawal seizures, delirium tremens, alcohol with benzodiazepines/barbiturates (90 days), alcohol with other substances (90 days), BAL ≥200 on presentation, autonomic hyperactivity.
≥4 = high risk of moderate–severe (complicated) withdrawal; prophylaxis and/or treatment may be indicated. In the 403-patient validation (medically ill inpatients), cutoff 4 gave sensitivity 93.1%, specificity 99.5%. It is a screening tool, usable before any withdrawal signs appear.
Timeline after the last drink (ASAM)
- Early symptoms: begin 6–24 h — anxiety, insomnia, tremor, nausea, tachycardia, sweating, hypertension.
- Seizures: from as early as 8 h up to 48 h; peak around 24 h.
- Hallucinations: develop within 12–24 h; usually resolve within 24–48 h if delirium does not emerge. Persisting beyond 72 h suggests alcohol-induced psychotic disorder.
- Withdrawal delirium (DTs): onset typically 72–96 h (ASAM §II); ASAM §I also describes onset at 24–48 h and as late as 3–5 days. Lasts hours to usually 2–3 days.
Stages are not always sequential — a seizure can occur without other prominent signs, and older adults can follow a different course.
ASAM Appendix V sample regimens
| Drug / approach | Example |
|---|---|
| Chlordiazepoxide, single dose | Mild 25–50 mg PO · moderate 50–100 mg · severe 75–100 mg |
| Chlordiazepoxide, symptom-triggered | 25–100 mg PO q4–6h when CIWA-Ar ≥10; extra doses PRN |
| Chlordiazepoxide, fixed taper | Day 1 25–100 mg q4–6h · day 2 q6–8h · day 3 q8–12h · day 4 at bedtime · (day 5 optional); cut daily total 25–50%/day; extra doses PRN |
| Front-loading | Chlordiazepoxide 50–100 mg PO q1–2h until CIWA-Ar <10, or q1–2h × 3 doses. Text examples: diazepam 20 mg q1h until CIWA-Ar <10; 10 mg PO q1h while CIWA-Ar ≥10; 20 mg PO q2h × 3 |
| Oxazepam, score-graded | 15 mg for CIWA-Ar 8–15, 30 mg for >15 (text example) |
| Phenobarbital | 10 mg/kg IV over 30 min (single adjunct, ED) · ICU monotherapy 130 mg IV q30min to RASS 0 to −1 · ED fixed 260 mg IV then 130 mg IV q30min · ICU escalating adjunct after diazepam 120 mg: 60 → 120 → 240 mg IV q30min to RASS 0 to −2 |
| Carbamazepine | Mono 600–800 mg/day tapered to 200–400 mg/day over 4–9 days · adjunct 200 mg q8h or 400 mg q12h |
| Gabapentin | Mono: load 1200 mg then 600 mg q6h day 1, or 1200 mg/day × 1–3 days, taper to 300–600 mg/day by day 4–7 · adjunct 400 mg q6–8h |
| Valproic acid | Adjunct 300–500 mg q6–8h (not monotherapy; not in liver disease or childbearing potential) |
Why lorazepam or oxazepam in liver disease
ASAM: with signs of significant liver disease, reduce the dose or use a benzodiazepine with less hepatic metabolism. Lorazepam and oxazepam are cleared by glucuronidation to inactive glucuronides (product labels). Diazepam is oxidized by CYP3A4/2C19 to active metabolites (desmethyldiazepam half-life up to 100 h); its half-life rises 2–5-fold in cirrhosis. Chlordiazepoxide also has long-acting active metabolites. Any benzodiazepine can worsen hepatic encephalopathy.
Sources
- The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management. J Addict Med 2020;14(3S Suppl 1):1–72. Adopted by the ASAM Board January 23, 2020. Table 1 (severity), Appendix III (scales), Appendix V (sample medication regimens), Recommendations II, V, VI, VII.
- Maldonado JR, Sher Y, Das S, et al. Prospective validation study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in medically ill inpatients: a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol Alcohol 2015;50(5):509–18. doi:10.1093/alcalc/agv043
- Maldonado JR, Sher Y, Ashouri JF, et al. The “Prediction of Alcohol Withdrawal Severity Scale” (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol 2014;48(4):375–90.
- 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):1353–7. doi:10.1111/j.1360-0443.1989.tb00737.x (form reproduced in ASAM News 2001;16(1); not copyrighted).
- Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation–Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002;166(10):1338–44. doi:10.1164/rccm.2107138
- Rosenson J, Clements C, Simon B, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo-controlled study. J Emerg Med 2013;44(3):592–8. doi:10.1016/j.jemermed.2012.07.056
- D’Onofrio G, Rathlev NK, Ulrich AS, Fish SS, Freedland ES. Lorazepam for the prevention of recurrent seizures related to alcohol. N Engl J Med 1999;340(12):915–9. doi:10.1056/NEJM199903253401203
- Galvin R, Bråthen G, Ivashynka A, et al. EFNS guidelines for diagnosis, therapy and prevention of Wernicke encephalopathy. Eur J Neurol 2010;17(12):1408–18. doi:10.1111/j.1468-1331.2010.03153.x
- Phenobarbital sodium injection, prescribing information (Hikma, rev. 2020; DailyMed) — contraindications, IV rate ≤60 mg/min. Lorazepam, oxazepam and diazepam prescribing information (DailyMed) — metabolism.
Educational reference only — not a substitute for clinical judgment, institutional protocols, or specialist advice. Calculations run in your browser; nothing you enter is sent or stored.