Predicting Severity of Alcohol Withdrawal

In this week’s pearl we will discuss how to predict severity of alcohol withdrawal (AWS)

Introduction

• Predicting a patients risk of complicated withdrawal can help determine the level of care needed to adequately treat a patient presenting with AWS.

• Complicated withdrawal is characterized as having AWS induced seizures and delirium tremens.

• Patient’s at high risk of complicated withdrawal should be monitored in an inpatient care setting such as the hospital or residential withdrawal management facility.

• patients with low risk of complicated withdrawal can be considered for residential management facility or outpatient care.

The Predicting Alcohol Withdrawal Severity Scale (PAWSS)

Maldonado JR, Sher Y, Ashouri JF, et al. The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol. 2014;48(4):375-390. doi:10.1016/j.alcohol.2014.01.004

• Max score is 10

• A score of 4 or more suggests high risk for moderate to severe AWS (likelihood ratio (LR) of 174 for severe or complicated AWS, while a score ≤ 3 has a LR of 0.07)

High Risk Features

• Drinking 17 or more standard drinks/day

• History of withdrawal seizures or delirium (i.e. complicated AWS)

• Recent Severe AWS (< 1 year ago)

• Concurrent benzodiazepine dependence

• Withdrawing with a (+) blood alcohol level

Standard Drink Reference

Centers for Disease Control and Prevention. (2024, May 15). Standard drink sizes. U.S. Department of Health and Human Services. https://www.cdc.gov/alcohol/standard-drink-sizes/index.html

References

1. Maldonado JR, Sher Y, Ashouri JF, et al. The "Prediction of Alcohol Withdrawal Severity Scale" (PAWSS): systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol. 2014;48(4):375-390. doi:10.1016/j.alcohol.2014.01.004

2. Centers for Disease Control and Prevention. (2024, May 15). Standard drink sizes. U.S. Department of Health and Human Services. https://www.cdc.gov/alcohol/standard-drink-sizes/index.html

3. ASAM 2020 AWS CPG 

4. Canadian 2023 AUD CPG  

5. ED Management of AWS White Paper, Strayer 2023 

6. UpToDate Ambulatory Management of Alcohol Withdrawal, Holt S 2022 

7. The Addiction Medicine Curbsiders Episode #2