Key takeaway
CIWA-Ar is a ten-item scale clinicians use to rate alcohol withdrawal. Nine items run from 0 to 7, and orientation from 0 to 4, for a maximum of 67. A 2001 sheet ties higher scores to more severe withdrawal. A low number is not clearance to stop drinking alone.
Last updated: Mon Oct 05 2026 00:00:00 GMT+0000 (Coordinated Universal Time)
You want a clock: which hour the shaking starts, which hour it should be over. Clinicians use a different tool. The Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, or CIWA-Ar, is a short rating scale. A trained person scores what they see and what the patient reports. It is not a schedule you follow at home, and it is not a worksheet for the kitchen.
If someone is seizing, will not wake, or cannot breathe, call 911. Do not pause to add a column of numbers. For a mental health crisis, call or text 988.
Ten items, and a maximum of 67
A 2001 supplement to ASAM News reprints the CIWA-Ar and says the revised scale measures 10 symptoms. It was cut down from a longer list of 30 signs and symptoms. The sheet says the assessment takes about two minutes.
Nine categories are scored from 0 to 7:
- Nausea and vomiting
- Tremor
- Paroxysmal sweats
- Anxiety
- Agitation
- Tactile disturbances
- Auditory disturbances
- Visual disturbances
- Headache, or fullness in the head
Orientation and clouding of sensorium is scored from 0 to 4. The questions on the form ask what day it is, where the person is, and who the rater is. The total of all ten items has a maximum of 67.
The rater is supposed to look, not only to take the patient's word. Tremor is checked with the arms extended. Sweat is checked by looking at the skin. Agitation is checked by watching whether the person can sit still. The headache item says not to rate dizziness or lightheadedness. Those rules are why a self-score is a different instrument. You cannot watch your own tremor the way the form asks, and you should not try while you are the person in withdrawal.
The sheet says no single withdrawal scale is clearly better than the others. It also says there is a clinical point to using one: staff can see withdrawal before it becomes more advanced, including delirium tremens, and can avoid both overtreatment and undertreatment. High scores, it says, predict seizures and delirium as well as mark severe withdrawal. That sentence cites older studies. It is not a prediction for one person.
What the bands mean, and what they do not clear
The same sheet gives bands. Scores of less than 8 to 10 indicate minimal to mild withdrawal. Scores of 8 to 15 indicate moderate withdrawal, which it describes as marked autonomic arousal. Scores of 15 or more indicate severe withdrawal, and the sheet's phrase is impending delirium tremens.
A note at the bottom of the form says patients scoring less than 10 do not usually need additional medication for withdrawal. Read the next finding before you treat that note as a green light. The sheet cites a hospital study, Foy and colleagues in 1988, that predicted a higher risk of severe withdrawal when the score was above 15. The relative risk it prints is 3.72, with a 95 percent confidence interval of 2.85 to 4.85. The same note says 6.4 percent of patients still had complications, despite low scores, if they were left untreated. A low score did not mean nobody was harmed. It meant most people in that study were not, and some were.
Those figures describe a hospital study the sheet cites. They are not your risk, and they are not a reason to stay home because you feel "under 10." The symptom guide lists tremor, sweating, seizures, and delirium without turning them into a score. The detox timeline has the hour window from SAMHSA. That clock stays on the timeline.
How a clinic uses the number
SAMHSA's TIP 45 quick guide, reprinted in a later TIP on alcohol medicines, describes symptom-triggered therapy. Medical personnel trained on CIWA-Ar or a similar scale recognize withdrawal, make a rating, and give a benzodiazepine only when the signs reach a threshold. The guide then prints a typical routine, including a drug name and a milligram amount, and says to reassess. The dose stays with the prescriber who can see the patient. Copying a milligram from a clinician's manual is how people get hurt.
The same quick guide warns that benzodiazepines plus alcohol can lead to coma, slowed breathing, poor coordination, and misuse. The FDA boxed warning on benzodiazepines says that stopping them suddenly, or cutting the dose too fast, can cause seizures and can be life-threatening. If someone is already taking that kind of medicine, do not stop it to see a "real" withdrawal score. The benzodiazepine detox guide covers that warning.
The 2001 sheet also says the CIWA-Ar has been adapted into a benzodiazepine withdrawal scale. A similar name is not the same form. Do not use the alcohol total to manage a benzodiazepine stop.
TIP 45's opening principles say detoxification alone is not sufficient treatment. It is evaluation, stabilization, and a step into further care. A score that falls is not the end of treatment. The first-72-hours guide covers what comes after the rating. The home-versus-medical guide covers why an unsupervised stop is the wrong setting when the risk is high.
Call (800) 653-9376 if you need help finding medically monitored alcohol withdrawal care.
Additional Resources
Sources cited on this page:
- Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar), supplement to ASAM News, January-February 2001
- SAMHSA TIP 45 quick guide, excerpted in NCBI Bookshelf (TIP 49, Appendix C)
- FDA: Boxed warning on benzodiazepines
- 988 Suicide & Crisis Lifeline
Common Questions
Can I add up a CIWA-Ar score on myself at home?
No. The scale is built for a rater who watches tremor, sweating, and agitation and asks a set of questions. The 2001 sheet says the check takes about two minutes when a clinician does it. A self-score misses the observation items and can miss a rising risk. The categories are named here. The anchor sheet is not reprinted as a worksheet.
What do the bands on the sheet mean?
The January-February 2001 supplement to ASAM News says scores under 8 to 10 indicate minimal to mild withdrawal, scores of 8 to 15 indicate moderate withdrawal, and scores of 15 or more indicate severe withdrawal. It uses the phrase impending delirium tremens for that top band. Those bands are a clinical shorthand from that sheet. They are not a personal forecast, and they are not permission to wait.
If the number is under 10, is it safe to stay home?
Do not read the form that way. The sheet notes that patients scoring under 10 do not usually need additional withdrawal medication. The same sheet cites a hospital study in which 6.4 percent of patients still had complications despite low scores if they were left untreated. A low number in a clinic is not a home clearance. Stopping heavy drinking suddenly can be life-threatening.
Does the score tell the nurse which pill to give?
SAMHSA's TIP 45 quick guide says trained medical staff can rate withdrawal with CIWA-Ar or a similar scale and give a benzodiazepine only when the score crosses a threshold. The guide prints a sample routine with a drug and a milligram amount. That dose stays in the clinical manual. A prescriber chooses the medicine. Do not take someone else's benzodiazepine because a number looked familiar.
Where is the hour-by-hour timeline?
On the alcohol detox timeline. That page has the 6-to-24-hour window from TIP 45 and the reasons it is not a home schedule. The subject here is only the rating scale. If someone is seizing, will not wake, or cannot breathe, call 911. Do not finish a score first. For a mental health crisis, call or text 988.