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The Association of Alcohol Withdrawal Severity Scales that Incorporate Vital Signs and Withdrawal Outcomes: A Multicenter Cohort Study
Journal article   Peer reviewed

The Association of Alcohol Withdrawal Severity Scales that Incorporate Vital Signs and Withdrawal Outcomes: A Multicenter Cohort Study

Andrea E Roberts, Peter Yarbrough, Jaclyn Vargas, Matthew Tuck, Meredith Trubitt, Andrea Smeraglio, Meghna N Shah, Richard Rose, Matthew Ronan, Benjamin A Rodwin, …
Journal of addiction medicine
04/17/2026
DOI: 10.1097/ADM.0000000000001698
PMID: 42360115

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Abstract

Guidelines recommend symptom-triggered therapy for the management of alcohol withdrawal, and the most commonly used assessment scale is the Clinical Institute Withdrawal Assessment, Revised (CIWA-Ar). CIWA-Ar has been criticized, however, for relying on patient self-report, and numerous alternative scales have been developed that incorporate vital signs to be more objective. Few studies compare alcohol withdrawal outcomes based on the type of assessment scale.OBJECTIVESGuidelines recommend symptom-triggered therapy for the management of alcohol withdrawal, and the most commonly used assessment scale is the Clinical Institute Withdrawal Assessment, Revised (CIWA-Ar). CIWA-Ar has been criticized, however, for relying on patient self-report, and numerous alternative scales have been developed that incorporate vital signs to be more objective. Few studies compare alcohol withdrawal outcomes based on the type of assessment scale.We conducted a retrospective cohort study of patients hospitalized with alcohol withdrawal on medical wards in 19 Veteran Health Administration (VHA) hospitals between October 1, 2018, and September 30, 2019. Hospital outcomes, including treatment duration and the occurrence of complicated withdrawal were analyzed based on the use of CIWA-Ar compared with withdrawal scales that incorporated vital signs.METHODSWe conducted a retrospective cohort study of patients hospitalized with alcohol withdrawal on medical wards in 19 Veteran Health Administration (VHA) hospitals between October 1, 2018, and September 30, 2019. Hospital outcomes, including treatment duration and the occurrence of complicated withdrawal were analyzed based on the use of CIWA-Ar compared with withdrawal scales that incorporated vital signs.In total, 461 (78%) patients were managed using CIWA-Ar, and 127 (22%) patients were managed using symptom scales that included vital signs. The mean duration of treatment was 3.4 days (SD, 2.0) for patients managed with CIWA compared with 3.9 days (SD, 2.0) for patients managed with scales incorporating vital signs (P=0.007). In multivariable analysis, duration of treatment remained longer using scales with vital signs (RR 1.30, 95% CI, 1.15-1.48). There was no difference in rates of complicated withdrawal (OR 1.00, 95% CI, 0.41-2.46).RESULTSIn total, 461 (78%) patients were managed using CIWA-Ar, and 127 (22%) patients were managed using symptom scales that included vital signs. The mean duration of treatment was 3.4 days (SD, 2.0) for patients managed with CIWA compared with 3.9 days (SD, 2.0) for patients managed with scales incorporating vital signs (P=0.007). In multivariable analysis, duration of treatment remained longer using scales with vital signs (RR 1.30, 95% CI, 1.15-1.48). There was no difference in rates of complicated withdrawal (OR 1.00, 95% CI, 0.41-2.46).Our results indicate that the use of alcohol withdrawal scales that incorporate vital signs are associated with increased treatment duration and no difference in rates of complicated withdrawal. Randomized clinical trials are needed to ascertain which assessment scale is best.CONCLUSIONSOur results indicate that the use of alcohol withdrawal scales that incorporate vital signs are associated with increased treatment duration and no difference in rates of complicated withdrawal. Randomized clinical trials are needed to ascertain which assessment scale is best.

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