Brief Alcohol Withdrawal Scale (BAWS)

What led to the development of the Brief Alcohol Withdrawal Score? Was there a particular clinical experience or patient encounter that inspired your research? 

We found that we had difficulty with treating patients with alcohol withdrawal and that the CIWA was cumbersome to use, particularly on units were nurses had limited experience with it.  Many of the items in CIWA are subjective (anxiety, headache) and the scoring is broad (1 to 7 for most items) and vague (e.g., “moderate visual hallucinations” vs “moderately severe visual hallucinations”).  We were interested in developing a scale that was simpler to use, based more on observation and had clearer scoring.

How does this tool change clinical care for patients?

It has decreased the time it takes to assess patients and has made it possible for us to implement symptom-triggered treatment in a wide variety of settings.

What pearls, pitfalls and/or tips do you have for users of this tool? 

Withdrawal scales are intended to help with treatment, but should only be used in the appropriate clinical context and are not a substitute for clinical judgement.  A delirious patient who is not experiencing alcohol withdrawal can have a high score on this (and other) scales and this may lead to inappropriate administration of benzodiazepines.

What recommendations do you have for doctors and clinical staff once they have calculated the BAWS?

We have a simple protocol that we use that ties the scale to benzodiazepine dosing and assessment intervals.  We prefer to use diazepam because it is long-acting and a rapid onset of action; it can also be given intravenously.

Are there any adjustments or updates you would make to the score based on new data or practice changes?

We have used this at the two main Hopkins Hospitals for over 6 years and it has performed well.  We are considering making some changes to the treatment protocol that is tied to the scale: 1. Including the option of a loading-dose of diazepam 10-20 mg for high-risk patients before they have significant withdrawal, and 2. Removing the requirement for an initial 10 mg dose of diazepam (instead of 20 mg) with a BAWS 6-8 if the patient has not received any benzodiazepines.

Any other research in the pipeline that you’re particularly excited about?

Not at this time.

Anything else you want clinicians to know?

Most patients with alcohol withdrawal or at risk for withdrawal do well with simple assessment scales and treatment protocols. Some try to make this more complicated than it needs to be.

Darius A. Rastegar, MD, is an associate professor of medicine at Johns Hopkins University and the program director for the Johns Hopkins Addiction Medicine Fellowship. Dr. Rastegar completed his undergraduate studies at the University of Wisconsin, Madison, received his MD from the University of Pennsylvania, and trained in internal medicine at Johns Hopkins Bayview Medical Center.