Discharge Criteria for Substance Withdrawal

Alcohol Withdrawal Discharge Criteria

The American College of Medical Toxicology recommends that patients with alcohol withdrawal can be safely discharged when CIWA-Ar scores remain consistently below 8, indicating minimal to mild withdrawal that does not require pharmacological treatment 1
Patients with CIWA-Ar scores ≥8-10 indicate moderate withdrawal requiring benzodiazepine treatment and continued monitoring 1
Patients with CIWA-Ar scores ≥15 indicate severe withdrawal with significantly increased risk of complications and absolutely require inpatient management 2
The American Society of Addiction Medicine suggests that patients must meet all of the following criteria before discharge: CIWA-Ar scores consistently <8 for at least 8-12 hours without additional benzodiazepine dosing, no evidence of autonomic instability, and adequate social support and follow-up arrangements in place 3

The American College of Emergency Physicians recommends that patients with opioid withdrawal can be safely discharged when COWS scores are <8, indicating mild or no withdrawal, and buprenorphine is not indicated for treatment 4
Patients with COWS scores >8 indicate moderate to severe withdrawal requiring buprenorphine treatment 4
The Society for Academic Emergency Medicine suggests that the COWS scoring ranges are: 5-12 (mild), 13-24 (moderate), 25-36 (moderately severe), >36 (severe) 5, 6
The American Academy of Addiction Psychiatry recommends that patients should be re-assessed 30-60 minutes after initial buprenorphine dose and target total dose of 16 mg sublingual buprenorphine for most patients before discharge 4

The American Medical Association suggests that assessments should be performed every 1-2 hours initially during active withdrawal, then extended to every 4-8 hours as symptoms stabilize 1
The American Society of Addiction Medicine recommends that benzodiazepines should not be discontinued prematurely based on day of admission alone—treat until symptom resolution 3
The National Institute on Drug Abuse suggests that more than 70% of cirrhotic patients may not require pharmacological treatment, but when symptoms are present, continue dosing until resolution 3
The Substance Abuse and Mental Health Services Administration recommends that patients should be provided with overdose prevention education and take-home naloxone kit 4
The American College of Physicians suggests that arrangement for follow-up for medication-assisted treatment continuation is essential, as this approach demonstrates better short-term improvement in treatment and reduced illicit opioid use compared to referral only 4