RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL 1

Recommendations for Alcohol Withdrawal

Andrew Reiter, Steve Erikson, Kalsang Wangdu, Ken Koslowski

Bethel University

Evidenced-Based Practice

NURS 430

Kristen Sandau PhD, RN

November 29, 2015

2RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL

Recommendations for Alcohol Withdrawal

Introduction

Chronic alcohol consumption and dependency has been linked to several diagnoses

requiring admission to the acute care setting including seizures, delirium, tremors, and increased

risk for myocardial infarction. “8.2 million Americans suffer from alcohol dependency and

account for twenty percent of hospital admissions contributing to a two hundred billion dollars a

year in care cost” (Perry, 2014, p. 402). The common need for this patient population is

supplementation with a chemical sedative such as a benzodiazepine to offset the symptoms of

withdrawal from alcohol dependency. Our concern for patient safety has given me the

opportunity to pose the population intervention comparison outcome (PICO) question. In adult

inpatients receiving treatment for chemical dependency withdrawal, is the Clinical Institute

Withdrawal Assessment for Alcohol (CIWA-Ar) safe and effective for basing benzodiazepine

administration in comparison to fixed rate dosing protocol?

Critique of studies

Methods

Becker and Semrow (2006) and Melson, Kane, Mooney, McWilliams, and Horton,

(2014) are performing primary studies on the implementation of the CIWA-Ar assessment

protocol. This tool is approved by the Centers for Disease Control for the treatment of alcohol

withdrawal. These are quasi-experimental studies using systematic review of patient charts.

This would be stage two evidence according to John Hopkins evidence based practice model. 

The patient chart represents a legal record of the patient’s care. Recorded treatment,

3RECOMMENDATIONS FOR ALCOHOL WITHDRAWALassessments, and results are considered a valid source of data. Both studies are limited to both

short and long acting benzodiazepines as a general category of medication because there is no

specific medication due to physician preference. The third article also uses a systematic review

of charts in a quasi- experimental pre and post intervention analysis. It compared fixed rate

combined with symptom based versus just symptom based. The average dose and duration of

benzodiazepines was then compared using Mann-Whitney U test. This was also a stage two

experimental quasi-experimental study and it provided more rigorous quality assurance and

validity in the research analysis. A key flaw in the study was the vast amount of physicians

charting and placing orders (Ng, Dahri, Chow & Legal, 2011). The last article is a double blind

randomized control trial directly comparing fixed dosing to symptom based dosing using CIWA-

Ar. “The fixed-schedule regimen was determined according to the guidelines of the American

Society of Addiction Medicine (30 mg every 6 hours for 4 doses, then 15 mg every 6 hours for 8

doses” (Daeppen, et al. 2002, p.1118). See the matrix grid for more details.

Sample

All of the articles sample groups meet the criteria of the PICO question. They are all

conducted in acute care hospitals on adult patients suffering alcohol withdrawal. Becker &

Semrow (2006) limit their study groups to two participating hospitals in Wisconsin and are

generalizable to people in their area. The sample included 63 patients discharged with a

diagnosis of acute alcohol withdrawal syndrome over a period of ten months. Melson, et al.

(2014) limit their study subjects to patients receiving treatment within the Christina Health care

system of Delaware. The location of study was limited. There was a total of 1053 total charts

reviewed over a period of 21 months. The large sample size improves the weak generalizability

4RECOMMENDATIONS FOR ALCOHOL WITHDRAWALof the study. Ng et al. (2011) conducted study at the University of British Columbia Hospital in

patients 18 years of age or older and 159 patients met the inclusion criteria, and 71 charts were studied

pre-implementation and 72 post-implementations. The single location lacks diversity but an adequate

number of patients were compared. Daeppen et al. (2002) used a double blind randomized

controlled trial to select two groups. 56 were treated with benzodiazepines based on symptoms using

CIWA-Ar. The other group had 61 on fixed scheduled dosing. The study was conducted at two

university hospitals increasing the population demographic covered in their research.

Instrument

Instrument Used

The instrument used in these articles is the Clinical Institute Withdrawal Assessment for

Alcohol Withdrawal Syndrome (CIWA-ar) is the most commonly used withdrawal assessment

tool for clinical inpatients that exhibit symptoms of acute alcohol withdrawal. The CIWA-ar

addresses ten separate symptoms that are commonly associated with acute alcohol withdrawal

symptoms. These symptoms include nausea/vomiting, tremors, anxiety, agitation, paroxysmal

sweats, orientation including clouding of the sensorium, tactile disturbances, auditory

disturbances, visual disturbances and headache. The user or care provider rate the severity of

symptoms on a one to seven or one to four-point quantified scale. Each point in the scale is

associated to a descriptor that staff will use to determine the final CIWA-ar score. The score is

then used to determine the amount and frequency of benzodiazepine administration and

frequency that which the assessment should be completed.

Reliability and Validity of Instrument

Williams, Lewis and McBride (2001) state that there were more than 30 different rating

scales for alcohol withdrawal syndrome between the years 1973 and 1997. They were able to

5RECOMMENDATIONS FOR ALCOHOL WITHDRAWALnarrow these down to 16 similar scales. Various clinical sites developed assessment tools that

tracked symptoms they believed were clinically significant indicators for medication

administration. According to Williams et al. (2001) The Clinical Institute Withdrawal

Assessment CIWA-Ar scale evolved from the Total Severity Assessment Scale (TSA) and

Selective Symptom Assessment scale. CIWA-Ar allowed the assessment to be completed more

frequently. The CIWA-Ar consisted of a fifteen-point scale designed by Sullivan, Swift, and

Lewis in 1991. This was later reduced to a ten-point scale by Metcalfe, Sobers, and Dewey in

1995. Metcalfe et al. (1995) stated that the CIWA-Ar scale could be complete accurately with

consistent inter-rater reliability in under a minute. It is regarded as a safe and consistent tool for

administration of benzodiazepines.

Statistical significance

Though Melson et al. (2014) state that there was measured improvement in the first three

months after implementation of the CIWA-Ar protocol. The p number was p = 0.5. This means

there was no significant improvement after one year.  Three years after implementation of the

intervention the number of negative outcomes remained below the pre-implementation levels.

Overall improvement of patient outcomes was observed. Becker and Semrow (2006) did not

have many statistical references but they did indicate staff were surveyed post implementation.

Results showed fifty percent being comfortable with protocol and fifty percent being somewhat

comfortable. This indicates that further training regarding protocol is required. Daeppen et al.

(2002) reported average benzodiazepine dose administered in the symptom-triggered group was

37.5 mg compared with 231.4 mg in the fixed-schedule group (P<.001). They also showed

evidence of reduced duration of use compared to fixed rate dosing. Ng et al. (2011) contradicts

6RECOMMENDATIONS FOR ALCOHOL WITHDRAWALthese findings but discrepancies in pre and post protocol implementation showed increased

addiction amongst patient groups.

Discussion of researcher’s conclusions

 The CIWA-Ar scale works when used properly by trained registered nurses. A

combination of scheduled and symptom based dosing of benzodiazepines as mentioned in Ng et

al. (2011) as being the preferred protocol. The article is a good alternative but not optimal since

it increased the chances of over sedation and administered unneeded doses which increases cost.

CIWA-Ar is the most widely used tool that care providers utilize for inpatient withdrawal and

according to Melson, et al. (2014) is proven to reduce inpatient transfers to intensive care unit,

related to the severity of symptoms. As a result, withdrawal has been manageable on most

medical or mental health inpatient units. Some patients who are at the upper end of the abuse

spectrum at the most risk for acute and severe withdrawal symptoms will still require ICU for

withdrawal. As Becker and Semrow (2006) stated Early detection with use of CAGE and

CIWA-ar combine with proper administration of medications reduced ICU transfers and

improved patient withdrawal experience.  Care providers should be trained in proper use of the

CIWA-ar and assessing the withdrawal symptoms. For example, some patients may not be

agitated because of withdrawal, a sweaty person could be result of the room being too hot. A

combination of symptoms and the patient’s reaction to their environment must be considered by

the professional rater. There is also the possibility of patients who seek sedative medications

such as benzodiazepines and play up withdrawal symptoms. Nurses in the emergency

department as well as inpatient units should be aware of signs and symptoms of chronic alcohol

abuse related to patients whom deny alcohol dependence out of embarrassment or ignorance that

7RECOMMENDATIONS FOR ALCOHOL WITHDRAWALwithdrawal may be a problem. Patients in alcohol withdrawal do not fit any one specific

stereotypical profile men, women and young people from all ethnic backgrounds are at risk for

substandard care due to care providers not recognizing withdrawal.

Expert Analysis and Professional Guidelines

 Melson et al. (2014) state that initiation of the CIWA-Ar algorithm decreased symptom

progression into delirium tremens and other severe consequences of withdrawal. Using this tool

decreases risks of delirium tremens, restraints, physical assaults, and transfers to the intensive

care unit (Melson et al. 2014). In many cases it has been found that implementation of such

protocol may show minor improvement in patient outcomes though there is a definite gap in

inter-rater reliability that may stem from insufficient user training and overall lack of expertise.

Registered nurses Kathy Becker and Sue Semrow (2006) agree that standardizing the assessment

process and treatment plan would improve patient outcomes by allowing for a clear

communication pathway between the care team.    “A thorough alcohol consumption history

should be recorded that includes consumption, volume, routine, preferred drink, and last drink”

(Perry, 2014, p. 402).  Early assessment on admission allows for prevention and will alert the

care team to anticipate potential severity and patient need.    A barrier to this assessment is that

many of the patients who do present with alcohol withdrawal are unresponsive or incoherent and

information may be skewed.

Regions Hospital, a level one trauma center in Saint Paul, Minnesota uses CIWA-Ar

protocol and order sets for patients suspected of and or admitted to the hospital for alcohol

withdrawal.  Current guidelines for policy and procedure are located in the Regions Hospital

online employee competencies database.  Clinical competencies are continuously managed by

8RECOMMENDATIONS FOR ALCOHOL WITHDRAWALthe Regions Hospital patient safety committee and the administrative board of directors.  CIWA-

Ar scoring is followed to gauge appropriate treatment needs and treatment location.  If a patient

score is 20 or above two times within two hours they will be transported to intensive care where

the patient can be closely monitored and put on a benzodiazepine drip. This is a sound protocol

and is accepted because it provides education to the user, oversight, and measures to address

emergency situations. The current protocol does not require nurses to complete a CIWA-Ar

assessment during bedside shift report. This may lead to a gap in inter-rater reliability and over

or under sedation and needs to be addressed.

The National Institute of Health subdivision of the National Institute on Alcohol Abuse

and Alcoholism is a United States government office that collects, analyzes, and disseminates

information to assist in the identification of health risks.  This is a government office that does

not require membership and provides information as studies become available (National

Institutes of Health, October 14, 2015). Information on chemical dependency and treatment

protocols is given through this organization.

In our clinical judgment the nurse needs to take into account both verbal and nonverbal

indicators during the CIWA-Ar assessment. If a patient is suspected of divulging inaccurate

information. The physician should be notified for possible scheduled benzodiazepine dosing.

Facilities should also provide a specialized in-service to make sure staff nurses are using the

CIWA-Ar appropriately and congruently. Holbrook, Crowther, Lotter, Cheng, King (1999)

completed a meta-analysis of three randomized controlled trials involving the use of

benzodiazepines in conjunction with the CIWA-Ar tool. The authors stated that their analysis of

data determined that benzodiazepines are the preferred central nervous system depressant used in

9RECOMMENDATIONS FOR ALCOHOL WITHDRAWALalcohol withdrawal.   Using the CIWA-Ar to score withdrawal and guide benzodiazepine

administration also showed evidence that patients had a reduced need for pharmacological

sedation within two days. This provided safe patient outcomes in addition to shorter hospital

stay. We feel that fixed scheduled dosing is potentially hazardous and in many cases unneeded

sedation hurts rapport with patients.

Patient Preferences and Values

Patients treated with benzodiazepines using the CIWA-Ar assessment tool had decreased

severity of withdrawal symptoms, including a reduction in hallucinations (Becker, & Semrow,

2006). There was also no difference in comfort and wellbeing between fixed dose group and

symptom based group (Daeppen et al., 2002). Keeping the patient alert and oriented is

something that is important to them and their family members. Reducing unnecessary doses that

can cause too much sedation is appreciated by both the patient and their loved ones as long as

they are comfortable. Being active participants in their care plan by presenting symptoms to the

nurse makes them feel like they have a voice in their treatment.

Change Theory and Quality Improvement

After reviewing evidence based practice on alcohol withdrawal. Symptom based dosing

of benzodiazepines using CIWA-Ar assessment tool has been found to be an effective change

agent compared to previous fixed scheduled dosing. Kurt Lewin identified three stages of

implementing a change agent into practice. To implement a change agent into practice the

protocol requires unfreezing, change or moving, and refreezing (Dulaney, & Stanley, 2005).

During the unfreezing stage the fixed scheduled dosing causing unnecessary sedation is

identified as a protocol that has flaws. This may adversely affect attitudes of staff members who

10RECOMMENDATIONS FOR ALCOHOL WITHDRAWALimplemented the fixed scheduled dosing. A comprehensive analysis of staff members affected

by the change should be evaluated during the unfreezing stage as it can be detrimental to

introducing the CIWA-Ar assessment tool into practice. During the change stage training and

support for staff members on CIWA-Ar is important so that staff members feel confident and

comfortable in their ability to properly administer on their patients. The refreezing stage

includes providing data on effectiveness of CIWA-Ar with outcomes conveyed to all staff. As

this becomes common practice re-education should be provided for any regression or

inconsistencies to help cement this change agent into practice.

To improve the quality of this change agent adverse events of alcohol withdrawal patients

should be conducted on facility charts quarterly by a quality improvement specialist. The data

should include seizures, physical harm to staff or self, restraint use, over sedation requiring

intervention, tremors, and other complications associated with alcohol withdrawal. Once data is

collected information should be given to the unit nursing director and results posted in work area.

This will let staff know the effectiveness of the CIWA-Ar protocol and areas needing

improvement. The safety coordinator and quality specialist should identify any facility gaps in

patient outcomes and education and training provided to units of concern. It is important that

these units are not chastised for negative outcome results. Becker and Semrow (2006) indicate

creating a safety interdisciplinary group that meets bi-weekly would provide other staff members

support that is needed. A collaborative educational in-service with interdisciplinary involvement

should encourage concerns of staff members to identify any barriers in quality improvement.

11RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL

Conclusion

After systematic review of the use of the CIWA-Ar for acute alcohol withdrawal in the

acute care setting. We were able to determine that when used consistently the CIWA-Ar is a safe

and effective tool for administering benzodiazepines to the adult population.   The protocol

reduced the amount of benzodiazepines given and the duration of use compared to fixed rate

protocol. The duration of hospitalization also decreased. Reducing length of stay and

medication cost using this symptom based protocol is beneficial to the healthcare system and the

patient. However, facilities with a high volume of patients and untrained staff members may

want to implement fixed rate dosing in addition to CIWA-Ar protocol until staff are familiar with

the tool. Education and regular audits should be performed on staff members to assess inter-rater

reliability and the need for additional training. Studies reveal an overall improvement in patient

outcomes as a total reduction in severity of symptoms.

12RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL

EVIDENCE-BASED MATRIX GRID

PICO Question: In adult inpatients receiving treatment for chemical dependency withdrawal, is the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) safe and effective for basing benzodiazepine administration in comparison to fixed rate dosing protocol?

Student Name, Citation in APA

Purpose of Study

Sample/Setting Design Results Recommendations for Practice Change

Methodology

Instruments (include

reliability& validity)

#1 Kalsung Wangdu

Becker, K., & Semrow, S., (2006). Standardizing the care of detox patients to achieve quality outcomes: professionals from many disciplines come together to focus on the patient and improve care. Journal of Psychosocial Nursing & Mental Health Services, 44(3), 33 - 38.

Using a multidisciplinary performance improvement team to review evidence based practice and initiate the AWA protocol for safe administration of sedatives for improved patient outcomes.

This study occurred at two hospitals. The first was Waukesha Memorial Hospital, a 300-bed tertiary community hospital. The second was Oconomowoc Memorial Hospital, a 72-bed community hospital. The sample reviewed 45 patients of unknown race or gender with alcohol withdrawal.

Retrospective review of the literature with a multidisciplinary team.

1. Symptom triggered administration

2. scheduled administration

3. combination of 1&2

1 -3 using CIWA-Ar AWA protocol. And early detection using CAGE tool. When used correctly these scales are considered valid assessment tools. A core group of nurses received hands-on training at ProHealth Care’s inpatient/outpatient substance abuse treatment facility. This would facilitate other nurses on best protocol.

Improved staff education and comfortable and consistent use of AWA tool between staff members along with early detection resulted and improved patient outcomes. Overall reduction in DT, MI and seizure. Increased referrals for outpatient management.

1. A well-organized protocol to manage ETOH dependent patients in acute care setting.2. Standardized protocol for identifying and treating patients at risk for ETOH withdrawal.3. Special project team to review literature, provide education to support consistent use of AWA tool.

13RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL

#2 Andrew Reiter

Melson, J., Kane, M., Mooney, R., McWilliams, J., & Horton, T. (2014). Improving Alcohol Withdrawal Outcomes in Acute Care. The Permanente Journal, 18(2), 141 - 145

CIWA implementation study for the reduction in incidents of ETOH withdrawal advancing to DT use of restraints and subsequent patient transfer from acute care to intensive care.

Retrospective review of existing data sets of patients of the Christiana Care Health System of Delaware. for a period of 21 months in the acute care and intensive care setting.

Quarterly retrospective data analysis of information extracted from existing data sources of patients discharged with a dx of acute alcohol withdrawal. 9 months prior to implementation and quarterly for 12 months after. Screening of all inpatients for risk of AWS and using symptom triggered management using CIWA-ar and AUDIT-PC for patient that score at treatable.

There was a measurable reduction in patients experiencing DT, requiring restraint or transfer to ICU in the first quarter after implementation. Though over the course of the study r = 0.5 and finding were not significant. Though results remained below reimplementation levels by conclusion of the study.

Recommend repeating the study with a control group. Recommend that physicians be able to track patients detox history starting in the ED in order to better gage dosages by implementing patient tracking including previous visits and CIWA-Ar scores.

#3 Steve Erikson

Ng, K., Dahri, K., Chow, I., & Legal, M. (2011). Evaluation of an Alcohol Withdrawal Protocol and a Preprinted Order Set at a Tertiary Care Hospital. The Canadian Journal of Hospital Pharmacy, 64(6), 436–445.

To evaluate efficiency and safety of a combination fixed-scheduledosing and symptom-triggered benzodiazepine dosing protocol for alcohol withdrawal.

This study took place at the University of British Columbia Hospital in patients 18 years of age or older. 159 patients met the inclusion criteria. 71 charts were studied pre-implementation and 72 post-implementations. Anyone with seizures unrelated to alcohol withdrawal and

Patients were placed on 1 of 4 scheduled benzodiazepine protocols in addition to symptom based administration using CIWA-Ar. Nurses had specialized educational course in CIWA-Ar tool. Data collection was entered in Microsoft Excel using SPSS and Predictive Analytic SoftwareWare to analyze data. The average length of benzodiazepine treatment and the average total benzodiazepine dose for withdrawal were

Average length of stay was 5.6 days pre-implementation and 3.5 days post-implementation. The patients receiving both protocols had higher doses for decreased duration.

Using a fixed schedule dosing as well as symptom related dosing with the CIWA-Ar tool may lead to additional doses that are not required causing oversedation. However, this may be beneficial in a high volume work environment where assessments may not be accurate and staff are not thoroughly trained using the CIWA-Ar tool for symptom based dosing..

14RECOMMENDATIONS FOR ALCOHOL WITHDRAWAL

current benzodiazepine use were excluded.

compared using the Mann–Whitney U test.

#4 Ken Koslowski

Daeppen, J., Gache, P., Landry, U., Sekera, E., Schweizer, V., Gloor, S., Yersin, B. (2002). Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: A randomized treatment trial. Archives of Internal Medicine, 162(10), 1117-1121

Fixed doses of benzodiazepines primary course of action in alcohol withdrawal. This article explores benefits of symptom specific benzodiazepine administration using CIWA-Ar assessment tool and the length of its use after initiation of treatment.

This study evaluated 117 patients with alcohol withdrawal. Participants were enrolled in treatment programs at both the Lausanne and Geneva University Hospitals, in Switzerland. Patients were randomized into 2 groups: 56 were treated with benzodiazepines based on symptoms using CIWA-Ar. 61 were treated with benzodiazepines every 6 hours with additional doses as needed (fixed-schedule).

This was a randomized control trial of 117 chemically dependent patients. A full medical history and exam with blood tests for γ-glutamyltransferase, red blood cell volume, and blood alcohol concentration were obtained at admission. Patients were interviewed by trained research assistants to assess their demographic characteristics and medical comorbidities using the Charlson Scale. Those with withdrawal medication use in the last 30 days, illegal drug use, and mental disorders were excluded. Comfort and well-being were evaluated day three using the Medical Outcomes Study 36-Item Short-Form Health Survey (MOS-SF-36) questionnaire.

The average dose given in the symptom-triggered group was 37.5 mg compared with 231.4 mg in the fixed-schedule group (P<.001). The average duration of treatment was 20.0 hours in the symptom-triggered group vs 62.7 hours in the fixed-schedule group (P<.001). Withdrawal reactions consisted of a single episode of seizures in the symptom-triggered group.

Following the CIWA-Ar assessment tool in the treatment of alcohol withdrawal provided decreased benzodiazepine dosages and reduced duration of treatment. This had no effect on the patient's’ comfort or well-being. This also improved cost of care due to the reduction in pharmaceutical interventions.

References

15RECOMMENDATIONS FOR ALCOHOL WITHDRAWALBecker, K., & Semrow, S. (March 26, 2006). Standardizing the care of detox patients to achieve

quality outcomes: professionals from many disciplines come together to focus on the

patient and improve care. Journal of Psychosocial Nursing & Mental Health Services,

44(3), 33 - 38. Retrieved from http://web.a.ebscohost.com.ezproxy.bethel.edu

/ehost/detail/detail?sid=ec64312a-f3d8-4f84-a243-d05e9c59b73a%40sessionmgr4005&

vid=0&hid=4209&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=106444

870&db=ccm

Daeppen, J., Gache, P., Landry, U., Sekera, E., Schweizer, V., Gloor, S., Yersin, B. (2002).

Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: A

randomized treatment trial. Archives of Internal Medicine, 162(10), 1117-1121.

Dulaney, P., & Stanley, K. (2005). Accomplishing change in treatment strategies. Journal Of

Addictions Nursing (Taylor & Francis Ltd), 16(4), 163-167 5p.

Holbrook, A. M., Crowther, R., Lotter, A., Cheng, C., & King, D. (1999). Meta‐analysis of

benzodiazepine use in the treatment of acute alcohol withdrawal (structured abstract).

Canadian Medical Association Journal, 160, 649-655.

Melson, J., Kane, M., Mooney, R., McWilliams, J., & Horton, T. (2014). Improving alcohol

withdrawal outcomes in acute care. The Permanente Journal, 18(2), 141-145.

http://dx.doi.org/doi: 10.7812/TPP/13-099

Metcalfe, P., Sobers, M., & Dewey, M. (1995). The windsor clinic alcohol withdrawal

assessment scale (wcawas): Investigation of factors associated with complicated

withdrawals. Alcohol & Alcoholism, 30, 367-372.

16RECOMMENDATIONS FOR ALCOHOL WITHDRAWALNational Institute on Alcohol Abuse and Alcoholism (NIAAA). (October 14, 2015). Retrieved

November 2, 2015, from

http://www.nih.gov/about-nih/what-we-do/nih-almanac/national-institute-alcohol-abuse-

alcoholism-niaaa#mission

Ng, K., Dahri, K., Chow, I., & Legal, M. (2011). Evaluation of an alcohol withdrawal protocol

and a preprinted order set at a tertiary care hospital. The Canadian Journal Hospital

Pharmacy, 64(6), 436–445.

Perry, E. C. (April 30, 2014). Inpatient management of acute alcohol withdrawal syndrome. CNS

Drugs , 28, 401 -410. http://dx.doi.org/DOI 10.1007/s40263-014-0163-5

Williams, D., Lewis, J., & McBride, A. (2001). A comparison of rating scales for the alcohol-

withdrawal syndrome. Alcohol & Alcoholism, 36, 104-108. http://dx.doi.org/doi:

10.1093/alcalc/36.2.104