Applying a Modified Version of the Prediction of Alcohol Withdrawal Severity Scale in a Canadian Community Withdrawal Management Setting

Introduction

Severe alcohol withdrawal syndrome (SAWS) can lead to significant morbidity and mortality. The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) has been validated in general acute care environments, but its efficacy in withdrawal management settings remains underexplored. This study aimed to assess the utility of a modified PAWSS and identify appropriate cutoff scores in a community withdrawal management setting in Vancouver, Canada.

Methods

From October 2019 to September 2022, we reviewed charts at Vancouver Detox Centre. Modified PAWSS versions replaced question 9 on the original PAWSS with: (i) breath analysis readings; (ii) alcohol consumption in the previous 24 h; and (iii) clinical assessments. We performed receiver operating characteristic analysis and used Youden's index to determine modified PAWSS' diagnostic accuracy against SAWS presentation, defined by a score of 15 or greater on the Clinical Institute Withdrawal Assessment Alcohol, Revised, seizures or delirium tremens and/or benzodiazepine administration.

Results

Among 228 individuals (165 male, 63 female), 175 (75%) met SAWS criteria during admission. For breath analysis readings, an optimal PAWSS cutoff score had 55% sensitivity (95% confidence interval [CI] 46%–63%) and 74% specificity (95% CI 54%–87%). For alcohol consumption in the last 24 h, a cutoff score of 7 had 44% sensitivity (95% CI 36%–51%) and 85% specificity (95% CI 70%–93%). For clinical assessment, a cutoff score of 6 had 53% sensitivity (95% CI 45%–61%) and 71% specificity (95% CI 58%–85%).

Discussion and Conclusions

Within a community withdrawal setting, the prevalence of SAWS was high, rendering the modified PAWSS less valuable. Although higher cutoff scores improved specificity, poor sensitivity hindered identification of low-risk SAWS individuals.