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substance abuse, addiction treatment & rehab. guide

Alcohol addiction treatment
– alcohol scale

Below, I present clinical institue withdrawal assessment, the so-called 'Alcohol Scale' in its original version. First time we have this interview after 6-24 hours after last alcohol use. Afterwards, interview is repeated (1 test per 1-2 hours) till 8-10 point are achieved.

PATIENT:

Time: _____:_____
(24 hour clock, midnight = 00:00)

Date: _____/_____/_____

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

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

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

Pulse or heart rate, taken for 1 minute: ______. Blood pressure: _____/_____

Tactile disturbances

Ask, "Have you 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

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 that you know aren't 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

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 you? Are you seeing things that you know aren't 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

Anxiety

Ask, "Do you feel nervous?" Observation.

  • 0 — no anxiety, at ease
  • 1 — mildly 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

Agitation

Observation.

  • 0 — normal activity
  • 1 — somewhat more than normal activity
  • 2
  • 3
  • 4 — moderately fi dgety and restless
  • 5
  • 7 — paces back and forth during most of the interview, or constantly thrashes about

Headache, fullness in head

Ask, "Does your head feel different? Does it feel like there is a band around your head?" Do not rate 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

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 certain 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 and/or person

SUMMARY

Total CIWA-A score: _____

Rater's initials: _____

Maximum possible score – 67