Withdrawal scales for alcohol and opioids
What the Alcohol Withdrawal Scale, CIWA-Ar, COWS and SOWS measure, how to score and act on them with worked examples, and when a score misleads (delirium, sepsis, beta-blockers, non-English speakers).
Tier 1Medical sciences concept
Written with AI assistance and fact-checked against the sources below. For exam study, not clinical decisions. How notes are made
At a glance
- Withdrawal scales turn symptoms and signs into a number that guides symptom-triggered dosing and the frequency of review.
- Alcohol: the Alcohol Withdrawal Scale (AWS) is used in most Australian hospitals; CIWA-Ar is used internationally and in many Australian units. The Australian alcohol guidelines (4th edition, 2021) support either with symptom-triggered diazepam.
- Opioids: the COWS (clinician-rated) and SOWS (self-rated) measure withdrawal; COWS guides when to start buprenorphine.
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Sources
- Guidelines for the Treatment of Alcohol Problems (Haber PS, Riordan BC, eds), 4th editionAU/NZUniversity of Sydney for the Australian Government Department of Health, 2021 (no newer edition found November 2026)
- National Guidelines for Medication-Assisted Treatment of Opioid Dependence (Gowing L et al.)AU/NZAustralian Government Department of Health, 2014
- High potency synthetic opioids: consensus guidance. Managing opioid withdrawal and opioid dependence treatmentAU/NZNSW Health, current as at October 2026
- FitzGerald G et al. The management of withdrawal from alcohol and other drugs in Australian custodial settings: a consensus statement. Med J Aust 2026;224(6):e70225AU/NZMedical Journal of Australia, 2026
- Sullivan JT et al. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). Br J Addict 1989;84:1353-7British Journal of Addiction, 1989
- Wesson DR, Ling W. The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs 2003;35:253-9Journal of Psychoactive Drugs, 2003
- Last updated
- 14 November 2026
What changed
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