Alcohol withdrawal management protocol page 2 of 2. To provide guidelines for safe and consistent management of uncomplicated alcohol withdrawal, which is usually completed in 4896 hours. The recommended goal is to achieve light somnolence or to achieve minimal to moderate sedation. Scores of less than 8 to 10 indicate minimal to mild withdrawal. Development of a new benzodiazepine hypnotics withdrawal. The objective, sensitive, and reliable quantitation of withdrawal symptoms is essential to assess physical dependence on drugs. Clinician downloads primary care behavioral health. A scale comprising six items from the clinical institute withdrawal assessment scalebenzodiazepines ciwab was used to measure withdrawal symptoms. May wake patient to perform assessments as ordered. Outpatient management of alcohol withdrawal syndrome. Phenobarbital in severe alcohol withdrawal syndrome. Which specific scales to use are at program medical director discretion, as long as they are objective and validated. The patients were asked to fill a questionnaire that was developed by selecting questions from benzodiazepine withdrawal symptom questionnaire bwsq and clinical institute withdrawal assessment for benzodiazepines ciwa b on the basis of the symptoms triggered by reduction or abrupt cessation of the intake of hypnotics. Veileder for bruk av clinical withdrawal assessment scale for.
Clinical institute withdrawal assessment for alcohol. Two forms available, one to assess any history of bzd withdrawal symptoms and the. Can be used objectively to assess for the development of aws validated objective scale has a list of 10 signs and symptoms quick, easy to use, useful. Alcohol withdrawal is commonly encountered in general hospital settings. The ciwab is a 22item instrument that monitors type and severity of. Follow your hospitals own alcohol withdrawal protocol. Patients scoring less than 10 do not usually need additional medication for withdrawal.
Benzodiazepine withdrawal symptom questionnaire each moderate score is given a rating of 1 and each severe score a rating of 2. Withdrawal, as manifested by either of the following. Benzodiazepine withdrawal management withdrawal syndrome. Recommend an hourly symptombased regimen, using the clinical institute withdrawal assessment for alcohol ciwa ar score or the short scale of withdrawal severity shot to assess medication initiationcontinuation. The ciwa b is a 22item instrument that monitors type and severity of benzodiazepine withdrawal symptoms such as irritability, fatigue, appetite, and sleeplessness. Clinical institute withdrawal assessment of alcohol scale. A clinical scale to assess benzodiazepine withdrawal. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. Alcohol withdrawal severity is decreased by symptom. Clinicians often use the symptomtriggered clinical institute withdrawal assessment for alcohol scale, revised ciwa ar1 to assess patients risk for alcohol withdrawal because it has welldocumented reliability, reproducibility, and validity based on comparison with ratings by expert clinicians. Safer use of benzodiazepines for alcohol detoxification. Clinical institute withdrawal assessment scale benzodiazepines. A scale modeled after the wellvalidated ciwa ar for alcohol withdrawal is currently being tested for widespread use.
For prevention and early detection of dependence on hypnotics such as benzodiazepines bzds or its agonists, a withdrawal symptom scale specialized for this kind of drug has long been sought. Patients are at risk for withdrawal when abru ptly reducing or stopping alcohol intake. Ciwa b clinical institute withdrawal assessment scale benzodiazepines cm contingency management cns central nervous system cpr cardiopulmonary resuscitation crw community residential withdrawal cwas cannabis withdrawal assessment scale dacas drug and alcohol clinical advisory services damec drug and alcohol multicultural education centre. Objective assessment of sweating, restlessness pacing, and. The maximum score possible is 40, unless of course additional symptoms are included. Management of substance withdrawal in acutely ill medical patients. Guidance on medical protocols for withdrawal management. Journal of clinical psychopharmacology, 9 6, 412416. Alcohol withdrawal management guide withdrawal symptoms may begin within 6 to 12 hours after the last drink symptoms can occur in heavy drinkers who still have detectable alcohol levels in their blood. The ambulatory detox program adp is a voluntary program to meet the detoxification needs of adult kaiser perma nente members who are actively abusing andor are dependent on alcohol, opiates heroin and prescription narcotics, and benzodiazepines. Clinical institute withdrawal assessment scale benzodiazepines ciwa b insight 2019. Withdrawal scales benzodiazepine withdrawal symptom questionnaire. This tool can be used in both inpatient and outpatient settings to reproducibly rate common signs and symptoms of opiate withdrawal and monitor these symptoms over time. These guidelines were developed through an intensive collaborative effort by physicians and nurses representing all medical and surgical subspecialties within the institution.
Clinical opiate withdrawal scale introduction the clinical opiate withdrawal scale cows is an 11item scale designed to be administered by a clinician. A new rating scale for the quantitative assessment of the alcohol withdrawal syndrome aws was developed from the ciwa a scale by item analysis based on the data from 2 alcoholic patients. Note also whether the symptoms occurred when the tablets were reduced or stopped, or if the. Alcohol withdrawal severity is decreased by symptomorientated adjusted bolus therapy. The objective, sensitive, and reliable quantitation of withdrawal symptoms is. Veileder for bruk av clinical withdrawal assessment. It forms a major part of referrals received by a consultationliaison psychiatrist.
Management of substance withdrawal in acutely ill medical. The onset and duration of symptoms varies depending on the particular benzodiazepine s taken as there is a wide variation in halflife and some benzodiazepines have active metabolites. Clinical institute withdrawal assessment of alcohol scale, revised ciwa ar the ciwa ar scale can measure 10 symptoms. A symptomtriggered benzodiazepine protocol utilizing sas. Perhaps the most widely used bzd withdrawal scale in the published literature completed by a trained clinician. Management of alcohol withdrawal in critically ill patients. An important advance in the last 3 decades has been the use of benzodiazepines to treat alcohol withdrawal. Diazepam valium, lorazepam ativan, and chlordiazepoxide librium are the most frequently used benzodiazepines. Psychometric properties of the revised clinical institute. For the purpose of this withdrawal protocol they can be treated as benzodiazepines. Pdf a new rating scale for the assessment of the alcohol.
Drug and alcohol withdrawal clinical practice guidelines nsw summary to provide the most uptodate knowledge and current level of best practice for the treatment of withdrawal from alcohol and other drugs such as heroin, and other opioids, benzodiazepines, cannabis and psychostimulants. These questions refer to how the person is feeling. Implementation of a symptomtriggered benzodiazepine protocol for alcohol withdrawal the a mount of alcohol intake and the duration of a patients recent drinking habit. Ciwa ar scores, combined with a history of withdrawal seizures or delirium gamma hydroxybutyrate ghb withdrawal and dependence view in chinese benzodiazepine withdrawal have not been validated specifically for ghb withdrawal, both objective ciwa. Benzodiazepine withdrawal symptom questionnaire bwsq provides the only specific self report measure of bzd withdrawal.
Notify provider of any new onset delirium andor hallucinations. Ciwa ar clinical institute withdrawal assessment for alcohol scale revised ten symptoms assessed, maximum score 67 studied primarily in specialized alcohol treatment programs and medical detoxification facilities has not been validated in the ed gray, s. The clinical institute withdrawal assessment scale benzodiazepines ciwa b. The ciwa ar is not ed and may be reproduced freely. The clinical institute withdrawal assessment for alcohol, commonly abbreviated as ciwa or ciwa ar revised version, is a 10item scale used in the assessment and management of alcohol withdrawal.
In the late 1960s, the comparison of chlordiazepoxide with placebo and 3 other drugs established the therapeutic efficacy of benzodiazepines for alcohol withdrawal. Patient has received 6 mg lorazepam in 1 hour but still has rass 3 known history of difficult to manage aws. Clinical institute withdrawal assessment scale benzodiazepines ciwab insight 2019. Drug and alcohol withdrawal clinical practice guidelines nsw. Clinical protocols for detoxification in hospitals and. Scores of 8 to 15 indicate moderate withdrawal marked autonomic arousal. University of michigan alcohol withdrawal guidelines overview the following document contains the university of michigan alcohol withdrawal guidelines. From these 22 symptoms, we constructed the ciwa b, a scale of 20 fivepoint items and two additional values. The citap benzodiazepine withdrawal protocol stage one preparing to reduce withdrawing from benzodiazepines safely is a long and slow process and it is important to choose a suitable time and situation in which to begin this. This study measured the diagnostic characteristics of the revised clinical institute withdrawal alcohol assessment ciwa ar and the brief alcohol withdrawal scale baws compared with a reference standard in patients with psychiatric illness and evaluated their administration time. The selfcompleted, 10item saws short alcohol withdrawal scale. Each item on the scale is scored independently, and the summation of the scores yields an aggregate value that correlates to the severity of alcohol withdrawal, with ranges of scores designed to. Guide to the use of the clinical withdrawal assessment scale for. The clinical institute withdrawal assessment scale.
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