VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders

Stabilization Pocket Card 

1 

Stabilization Algorithm
2 

Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar)

Patient and Time Information

Name, date, time, pulse or heart rate taken for one minute, and blood pressure

Items

Nausea and vomiting: Ask, "Do you feel sick to your 

stomach? Have you vomited?" Observation.

0: No nausea and no vomiting

1: Mild nausea with no vomiting

2 

3 

4: Intermittent nausea with dry heaves

5 

6 

7: Constant nausea, frequent dry heaves and vomiting

Tactile disturbances: Ask, "Have you had any itching, 

pins and needles sensations, any burning, any 

numbness, or do you feel bugs crawling on or under 

your skin?" Observation.

0: None

1: Very mild itching, pins and needles, burning or 

numbness

2: Mild itching, pins and needles, burning or numbness

3: Moderate itching, pins and needles, burning or 

numbness

4: Moderately severe hallucinations

5: Severe hallucinations

6: Extremely severe hallucinations

7: Continuous hallucinations

Tremor: Arms extended and fingers spread apart.

Observation.

0: No tremor

1: Not visible, but can be felt fingertip to fingertip

2 

3 

4: Moderate, with patient's arms extended

5 

6 

7: Severe, even with arms not extended

Auditory disturbances: Ask, "Are you more aware of 

sounds around you? Are they harsh? Do they frighten 

you? Are you hearing anything that is disturbing to you? 

Are you hearing things you know are not there?" 

Observation.

0: Not present

1: Very mild harshness or ability to frighten

2: Mild harshness or ability to frighten

3: Moderate harshness or ability to frighten

4: Moderately severe hallucinations

5: Severe hallucinations

6: Extremely severe hallucinations

7: Continuous hallucinations

Paroxysmal sweats: Observation.

0: No sweat visible

1: Barely perceptible sweating, palms moist

2 

3 

4: Beads of sweat obvious on forehead

5 

6 

7: Drenching sweats

Visual disturbances: Ask, "Does the light appear to be 

too bright? Is its color different? Does it hurt your eyes? 

Are you seeing anything that is disturbing to you? Are 

you seeing things you know are not there?" 

Observation.

0: Not present

1: Very mild sensitivity

2: Mild sensitivity

3: Moderate sensitivity

4: Moderately severe hallucinations

5: Severe hallucinations

6: Extremely severe hallucinations

7: Continuous hallucinations
3 

Clinical Institute Withdrawal Assessment of Alcohol (CIWA-Ar)

Anxiety: Ask, "Do you feel nervous?" Observation.

0: No anxiety, at ease

1: Mild anxious

2 

3 

4: Moderately anxious, or guarded, so anxiety is inferred

5 

6 

7: Equivalent to acute panic states as seen in severe 

delirium or acute schizophrenic reactions

Headache, fullness in head: Ask, "Does your head feel 

different? Does it feel like there is a band around your 

head?" Do not rate for dizziness or lightheadedness. 

Otherwise, rate severity.

0: Not present

1: Very mild

2: Mild

3: Moderate

4: Moderately severe

5: Severe

6: Very severe

7: Extremely severe

Agitation: Observation.

0: Normal activity

1: Somewhat more than normal activity

2 

3 

4: Moderately fidgety and restless

5 

6 

7: Paces back and forth during most of the interview, or 

constantly thrashes about

Orientation and clouding of sensorium: Ask, "What day 

is this? Where are you? Who am I?"

0: Oriented and can do serial additions

1: Cannot do serial additions or is uncertain about date

2: Disoriented for date by no more than 2 calendar days

3: Disoriented for date by more than 2 calendar days

4: Disoriented for place/or person

Scoring

Total CIWA-Ar Score ______

Rater's Initials ______

Maximum Possible Score: 67

Interpret sum of total scores as follows:

 Minimal or absent withdrawal: ≤9 

 Mild to moderate withdrawal: 10-19

 Severe withdrawal: ≥20
4 

Clinical Opiate Withdrawal Scale (COWS)

Patient and Time Information

Name, date, time, reason for this assessment

Items

Pulse Rate: Record Beats per Minute

Measured after patient is sitting or lying for one minute

0: Pulse rate 80 or below

1: Pulse rate 81-100

2: Pulse rate 101-120

4: Pulse rate greater than 120

Gastrointestinal Upset: Over Last 1/2 Hour

0: No gastrointestinal symptoms

1: Stomach cramps

2: Nausea or loose stool

3: Vomiting or diarrhea

5: Multiple episodes of diarrhea or vomiting

Sweating: Over Past 1/2 Hour not Accounted for by 

Room Temperature or Patient Activity

0: No report of chills or flushing

1: Subjective report of chills or flushing

2: Flushed or observable moistness on face

3: Beads of sweat on brow or face

4: Sweat streaming off face

Tremor Observation of Outstretched Hands

0: No tremor

1: Tremor can be felt, but not observed

2: Slight tremor observable

4: Gross tremor or muscle twitching

Restlessness Observation During Assessment

0: Able to sit still

1: Reports difficulty sitting still, but is able to do so 

3: Frequent shifting or extraneous movements of 

legs/arms

5: Unable to sit still for more than a few seconds

Yawning Observation During Assessment

0: No yawning

1: Yawning once or twice during assessment

2: Yawning three or more times during assessment

4: Yawning several times/minute

Pupil Size

0: Pupils pinned or normal size for room light

1: Pupils possibly larger than normal for room light

2: Pupils moderately dilated

5: Pupils so dilated that only the rim of the iris is visible

Anxiety or Irritability

0: None

1: Patient reports increasing irritability or anxiousness

2: Patient obviously irritable/anxious

4: Patient so irritable or anxious that participation

in the assessment is difficult

Bone or Joint Aches if Patient was Having Pain 

Previously, only the Additional Component Attributed 

to Opiate Withdrawal is Scored

0: Not present

1: Mild diffuse discomfort

2: Patient reports severe diffuse aching of 

joints/muscles

4: Patient is rubbing joints or muscles and is unable to sit 

still because of discomfort

Gooseflesh Skin

0: Skin is smooth

3: Piloerection of skin can be felt or hairs standing up on 

arms

5: Prominent piloerection

Runny Nose or Tearing Not Accounted for by Cold 

Symptoms or Allergies

0: Not present

1: Nasal stuffiness or unusually moist eyes

2: Nose running or tearing

4: Nose constantly running or tears streaming down 

cheeks
5 

Clinical Opiate Withdrawal Scale (COWS)

Scoring

Total COWS Score ______

Rater's Initials ______

Maximum Possible Score: 48

Interpret sum of total scores as follows:

 Mild withdrawal: 5-12

 Moderate withdrawal: 13-24

 Moderately severe withdrawal: 25-36

 Severe withdrawal: >36

Patients Appropriate for Inpatient Medically Supervised Withdrawal Management

Patients for Whom Inpatient Medically 

Supervised Withdrawal Management is 

Recommended

Patients for Whom Inpatient Medically 

Supervised Withdrawal Management is 

Suggested

Patients with any of the following conditions:

 History of delirium tremens or withdrawal seizures 

 Inability to tolerate oral medication

 Co-occurring medical conditions that would pose 

serious risk for ambulatory withdrawal management 

(e.g., severe coronary artery disease, congestive 

heart failure, liver cirrhosis)

 Severe alcohol withdrawal (i.e., CIWA-Ar score ≥20)

 Risk of withdrawal from other substances in addition 

to alcohol (e.g., sedative hypnotics)

Patients with at least moderate alcohol withdrawal (i.e., 

CIWA-Ar score ≥10 and any of the following conditions:

 Recurrent unsuccessful attempts at ambulatory 

withdrawal management

 Reasonable likelihood that the patient will not 

complete ambulatory withdrawal management (e.g., 

due to homelessness) 

 Active psychosis or severe cognitive impairment 

 Medical conditions that could make ambulatory 

withdrawal management problematic (e.g., 

pregnancy, nephrotic syndrome, cardiovascular 

disease, lack of medical support system)

Abbreviation: CIWA-Ar: Clinical Institute Withdrawal Assessment for Alcohol (revised version)
6 

Sedative-hypnotic Conversion Table

Generic Name 

Approximate 

Equivalents to 

Diazepam 10 mg or

Phenobarbital 30 mg1

Time to Peak 

Plasma level

(in Hours)

Half-life

Parent Drug

(in Hours)2

Metabolite 

Activity

(Maximal Half-life 

in Hours)3

Alprazolam 1 mg 1-2 12 ± 2 Inactive

Chlordiazepoxide 25 mg 1-4 10 ± 3.4 Active (up to 120)

Clonazepam 1 mg 1-4 23 ± 5 Inactive

Clorazepate 15 mg Variable 2 ± 0.9 Active (up to 120)

Diazepam 10 mg 1-2 43 ± 13 Active (up to 120)

Estazolam 1 mg 0.5-0.6 10-24 Inactive

Flurazepam 15 mg 0.5-1.0 74 ± 24 Active (up to 100)

Lorazepam 2 mg 2-4 14 ± 5 Inactive

Oxazepam 30 mg 2-3 8.0 ± 2 Inactive

Quazepam 10 mg 1.5 39 Active (up to 75)

Temazepam 15 mg 2.5 11 ± 6 Inactive

Triazolam 0.25 mg 1-2 2.9 ± 1.0 Inactive

Eszopiclone 15 mg 1 6 Active (<parent)

Zaleplon 20 mg 1 1 Inactive

Zolpidem 20 mg 1.6 2 Inactive

Butalbital 50 mg 1-2 35 Inactive

Pentobarbital 100 mg 0.5-1 15-50 Inactive

Phenobarbital 30 mg 1+ 53-140 Inactive

Meprobamate 400 mg 2-3 10 Inactive

Carisoprodol 350 mg 1-3 2 Active (see 

Meprobamate)

Choral hydrate 250 mg 0.5 <1 Active (up to 94)

Abbreviation: mg: milligrams

 

1 Withdrawal doses of diazepam or phenobarbital are those sufficient to suppress most withdrawal symptoms and 

may not reflect therapeutic dose equivalency. 2 Half-life of active metabolite(s) may differ. 3 Primary route of barbiturate elimination is renal excretion.