The Alcohol Withdrawal CIWA Protocol

CIWA Protocol

Alcohol withdrawal symptoms can range from mild sleeplessness and shaky conduct to more serious ones like delirium tremens. Although a person’s medical history and a physical exam are usually enough to make a diagnosis, CIWA protocol makes the treatment process even more efficient. CIWA, which stands for Clinical Institute Withdrawal Assessment Protocol, gives doctors a way to objectively measure how bad a patient’s alcohol withdrawal is likely to be.

What is the CIWA Protocol? 

The CIWA Protocol is a scale that measures the symptoms used to evaluate and treat people trying to quit drinking. Each symptom on the scale has its score, and when you add up all the scores, physicians get an overall value that shows how bad alcohol withdrawal is. The score for nine of these symptoms is between 0 and 7, and the score for orientation is between 0 and 4. This makes figuring out how to treat the patient more effective.

CIWA Protocol Scoring for Alcohol Withdrawal Symptoms Treatment

We initially mentioned that the CIWA Protocol has a scoring system for ten symptoms of alcohol withdrawal. These symptoms have a related question that the therapist asks to determine the requisite point. The point between 0 to 7 for the first nine questions and 0 to 4 for orientation is based on the patient’s response. Let’s check out the Questions, the scoring for responses, and how experts use them to determine the next steps for treatment. 

High Pulse Rate and Sweating

Alcohol affects the CNS and circulation, increasing heart rate and dilating skin blood vessels. Hence, Alcohol withdrawal causes the body’s sweat glands to work overtime and cause ‘night sweats.’ These symptoms are observed and scored based on the CIWA scale below:

  • 0 means Sweating is not evident
  • 1 represents very light perspiration, wet palms
  • 2,3, and 4 are points for dripping sweat on the forehead.
  • Five, six, and seven are points for sweaty pangs.

Tremors in the Hands

This symptom of alcohol withdrawal is a common sign of alcoholism. This symptom often emerges less than 6 hours after drinking alcohol. Alcohol depresses the CNS and causes the brain to release more neurotransmitters than usual. When alcohol use is abruptly interrupted, the brain still believes it should generate enough neurotransmitters for the alcohol it’s accustomed to. This causes hand tremors. Here, Clinicians observe by asking the patient to stretch their hands forward. Points for observations are:

Lack of Sleep or Insomnia

Alcohol impairs the brain’s natural mechanism for determining the sleep duration required every night based on active periods. Alcohol’s diuretic nature increases the desire to use the toilet at night and affects sleep quality. To ascertain this symptom, the Clinician observes the patients.

Nausea and Vomiting

Alcohol withdrawal causes nausea for several reasons. Alcohol dehydrates the body. It also increases urine production and causes dehydration. 

Alcohol irritates the stomach and intestinal lining to cause vomiting. First, nausea from stomach muscles contracting causes alcohol-induced vomiting. Second, ‘dry heaves’ cause the stomach’s biggest section to spasm. Then, the Small intestine’s contents are expelled through the mouth. To ascertain this condition, The Physician asks, “Is your stomach aching or making you want to vomit?”. Your response determines your points on the CIWA Scale. Here,

  • 0 points for not nauseating or vomiting symptoms.
  • 1 for very minimal vomiting.
  • 2,3 and 4 for consistent nausea and dry heaves.
  • 5,6, and 7 for more continuous nausea, vomiting, and dry heaves.


This symptom is often called ‘delirium Tremens’ which is the medical name for withdrawal-induced hallucinations. This usually happens on the second to third day after withdrawal. The Physician asks here, “Is there anything you’re seeing that makes you uncomfortable? Do you have an uncanny ability to perceive things that aren’t there?”

  • 0 means no presence of hallucinations.
  • 1,2, 3, and 4 represent moderate to light sensitivity 
  • 5 represents terrible hallucinations
  • 6 means Intense hallucinations
  • 7 is the point for Constantly hallucinating 


Although sedating, alcohol disturbs the brain’s normal chemical process. How the body and brain handle alcohol’s abnormal compounds cause alcohol-related anxiety. After extended alcohol consumption, the brain thinks it should manufacture sufficient neurotransmitters to compensate for the consumed alcohol. Experts often ask a question to grade this symptom: “Do you have a heightened sense of anxiety?”. The response is graded as follows:

  • 0 means the patient is at ease.
  • 1 means the patient is moderately anxious.
  • 2,3 and 4 mean the Client is somewhat apprehensive
  • 5,6, and 7 represent chronic states caused by schizophrenia or delirium tremens.


Alcohol changes brain chemistry by reducing serotonin levels, which govern memory, sleep, and mood. Low amounts of this substance cause poor sleep, cognitive problems, and mood changes. This symptom is assessed by observation. Here are the points for each:

  • 0 signifies a normal level of activity.
  • 1 represents a little more than the usual activity
  • 2,3,4 represents moderate agitation and restlessness
  • 5,6,7 are scores consistent pacing and thrashing

Grand Mal Seizures

During alcoholism, the body relies on a brain-affecting synthetic chemical and feels it requires it to live. This poison causes shock when removed rapidly. Grand mal seizures are caused by abruptly stopping alcohol use. These convey signals to muscles, nerves, and glands. Disrupting this mechanism may lead the brain to instruct the body’s processes to escalate performance and cause seizures.

Here the Physician asks, “Do you feel any numbness, prickling, burning, itching, or the feeling that something is creeping underneath your skin?” 

  • 0 signifies the absence of any unpleasant sensations
  • 1 signifies a minor itch, tingling, numbness, or burning sensation
  • 2 signifies itching, burning, pins & needles, or numbness.
  • 3 signifies Mild irritation, stinging, and numbness
  • 4 represents mild to moderate hallucinations
  • 5 represents terrible hallucinations
  • 6 stands for Intense hallucinations
  • 7 stands for a pattern of persistent, disturbing delusions

The CIWA score helps doctors determine how bad and fast alcohol withdrawal will be. This makes it easier to plan treatments. In treatments, the goal is to give as little medicine as possible in as little time as possible. This makes an effort to reduce the chance that patient’s become dependent on the detox medicine. Clinicians will be able to use the CIWA-Ar scale to decide which magnesium sulfate, Multivitamins, thiamine, IV fluids, and glucose to provide.

CIWA Protocol

How Successful is the CIWA Protocol in the Treatment of Alcohol Withdrawal?

Using CIWA-Ar to rate individuals entering medical facilities for alcohol detox has improved results. More patients got discharged from detox centers and hospitals after shorter stays and less usage of shackles.

It was also simpler to treat delirium tremens proactively whenever CIWA-Ar was used since it was more accurate at predicting who would develop the condition.

Alcohol Addiction Treatment in The San Francisco Bay Area

 If you’re seeking alcohol addiction treatment in San Francisco Bay Area, our team at Silicon Valley Recovery can help. We’re highly experienced in using the CIWA Protocol to safely and effectively treat alcohol withdrawal symptoms. Contact us today by calling 408-547-4089 to learn more about our program and how we can help you or your loved one get on the road to recovery.

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