1. Appraisal of Alcohol Withdrawal in Native Americans with the Clinical Institute Withdrawal Assessment of Alcohol Revised Scale. Paul Saladino MS, William Adamas-Rappaport MD Results Background The Clinical Institute Withdrawal Assessment of Alcohol revised (CIWA-Ar) scale has been commonly used to assess the severity of alcohol withdrawal syndrome in the acute setting. The CIWA-Ar scale has been validated in the general population but the ethnicities of these populations has not been documented. Previous studies by Rappaport et. al 1 have called into question the validity of this scoring system in Native-American populations. In a sample size of 201 individuals, approximately ¼ of whom were Native American, these authors showed that Native Americans had consistently lower CIWA-Ar scores at 0,2,4 and 6 hours and were admitted to the hospital less often than Hispanic or Caucasian patients (p<0.002 and p<0.001, respectively). Hypothesis The current CIWA-Ar scale does not include objective physiologic parameters such as systolic blood pressure, diastolic pressure or pulse as indicators of withdrawal severity. We hypothesize that in our study population of Caucasian and Hispanic individuals these parameters will correlate with CIWA-Ar scoring and may be applied to the scoring of Native Americans assessed for alcohol withdrawal, in whom CIWA-Ar scoring does not seem to be an adequate assessment. Methods A case series of patients seen for alcohol withdrawal at an Acute Drug and Alcohol Detoxification facility was conducted from June 1, 2011, until January 1, 2014. The CIWA-Ar scores were recorded by trained nursing staff on presentation and every 2 hours thereafter. At our institution, a score of 10 or greater indicates the need for inpatient hospital admission and treatment. Ethnicity was self-reported. Age, sex, blood alcohol concentration, blood pressure, and pulse were recorded on presentation and vital signs repeated every 2 hours. Patients were excluded from the study if other drug use was noted by history or initial urine drug screen. Caucasian and Hispanic patients were divided into groups with and without evidence of withdrawal: CIWA-Ar>=5 at any time during observation and CIWA -Ar<5, respectively. T-tests comparing systolic and diastolic blood pressure and pulses between the two groups were conducted at 0,2,4 and 6 hours to assess for statistically significant differences. Discussion Future directions References A total of 141 Caucasians, 51 Hispanics, and 49 Native Americans were included in the analysis. Time (hours)0246 p value0.003420.000110.000443.83E-08 Time (hours)0246 p value0.000033.42E-070.000144.50E-08 Time (hours)0246 p value0.001940.003110.001551.44983E-09 As noted previously, CIWA-Ar scoring does not adequately assess alcohol withdrawal severity or need for hospitalization in Native Americans. Illustrated in the graphs to the left of the results section is evidence from our cohort of patients that despite good correlation between trends in systolic blood pressure, diastolic blood pressure and pulse among races, Native Americans consistently score lower on CIWA, a difference which has previously been found to be statistically significant (p<.002). We hypothesized that with this apparent inadequacy of CIWA-Ar scoring in Native Americans, objective parameters such as blood pressure and pulse (not previously included in CIWA-Ar scoring) might also qualify alcohol withdrawal in Caucasian and Hispanic populations and be useful as adjunctive indices in Native Americans. The graphs to the right of the results section illustrate that when Caucasian and Hispanic populations are stratified by CIWA-Ar score >=5 and <5, statistically significant differences in all three physiologic parameters can be identified at all time points. We believe these findings provide evidence that these parameters correlate with alcohol withdrawal and provide objective measures which may be used in Native Americans. With these findings in mind, we plan to continue this study by developing a scoring system for alcohol withdrawal in Native Americans which incorporates these three physiologic parameters. This scoring system will then be tested in the Acute Drug and Alcohol Detoxification facility setting for validity in qualifying severity of withdrawal and need for hospitalization in this population. 1. Rappaport D, Chuu A, Hulllet C, Nematollahi S, Teeple M, Honkanen I, Bunyan N, Adamas-Rappaport WJ, Sanders A. Assessment of alcohol withdrawal in Native American patients utilizing the Clinical Institute Withdrawal Assessment of Alcohol Revised Scale. J Addict Med. 2013 May- Jun;7(3):196-9.