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PAWSS Explained: Alcohol Withdrawal Risk Assessment

Medical Providers:
Dr. Michael Vines, MD
Alex Spritzer, FNP, CARN-AP, PMHNP
Clinical Providers:
Natalie Foster, LPC-S, MS
Last Updated: February 6, 2026

Alcohol withdrawal syndrome can turn serious fast, especially for people who drink heavily and then suddenly stop drinking. What begins as shakiness, anxiety, or nausea can escalate into unstable blood pressure, a rapid heart rate, confusion, or seizures—sometimes within a day. That’s why detox programs don’t rely on “wait and see.” They screen for risk early.

The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) was designed for that exact moment: the first clinical conversation, when symptoms of alcohol withdrawal may not be fully present yet. It helps teams identify who may be at high risk for complicated alcohol withdrawal, so care can be matched to the real level of danger—not guesswork. It also helps clarify how it differs from a symptom tool like CIWA, which is used after withdrawal begins.

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Alcohol Withdrawal Overview

Alcohol withdrawal occurs when someone with a pattern of regular or binge drinking abruptly reduces intake or stops drinking altogether. Over time, the brain adapts to alcohol’s effects. When alcohol is removed, the nervous system can swing into overdrive as it tries to rebalance.

That reaction is why alcohol withdrawal syndrome can look so different from person to person. Some experience mild symptoms—sweating, tremors, irritability, poor sleep. Others develop spikes in blood pressure, a fast heart rate, hallucinations, seizures, or delirium tremens. The risk rises in people who drink larger amounts of alcohol, have had withdrawal before, or have co-existing health conditions.

In a clinical setting, the goal is not only comfort. It’s safety. Early screening allows teams to prevent withdrawal from becoming life threatening during alcohol detox.

When Does Alcohol Withdrawal Start?

A common question is: when does alcohol withdrawal start? For many people, symptoms begin within 6 to 12 hours after the last drink, especially if the person drinks daily or has recently been drinking heavily.

Early signs may include anxiety, tremors, nausea, sweating, headache, and a noticeable increase in heart rate. As the body progresses through withdrawal, symptoms can intensify. The 24 to 48 hours window is often when risk is highest for seizures and other forms of complicated alcohol withdrawal.

It’s also worth noting that timing isn’t only about the clock. It’s influenced by the effect of alcohol on the body over months or years—how often someone drinks, the amount of alcohol they consume, and whether they stop drinking abruptly or taper gradually. Because withdrawal can shift quickly, medical oversight matters.

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Understanding PAWSS

PAWSS exists for one reason: prediction. It helps clinicians spot high-risk withdrawal before severe symptoms start, so the treatment plan can be proactive rather than reactive.

In many real-world scenarios, a person arrives to detox feeling “okay,” but their history suggests otherwise. Maybe they’ve had withdrawal seizures, needed hospitalization, or mixed alcohol with other sedatives in the past. PAWSS helps surface those details in a structured way, which is especially useful in busy treatment programs where decisions have to be made quickly and safely.

 

What is the PAWSS Assessment Tool?

Short for the Prediction of Alcohol Withdrawal Severity Scale—is used by medical professionals to estimate the likelihood of severe alcohol withdrawal syndrome.

Instead of rating current symptoms, it focuses on risk markers such as:

  • Prior withdrawal complications (including seizures or delirium)
  • Recent heavy drinking alcohol patterns
  • Co-occurring medical conditions that raise risk
  • Psychiatric or mental health concerns that can complicate detox
  • Signs of autonomic instability, such as elevated blood pressure or heart rate

Because it does not require someone to already be in active withdrawal, it’s often used early—during intake, triage, or the first hours after someone stops drinking.

Benefit of Using the PAWSS Alcohol Withdrawal Scale

The PAWSS scale offers several benefits in the management of alcohol withdrawal:

Early Identification of High-Risk Patients

PAWSS helps identify who may deteriorate even if they currently look stable. That early warning allows staff to increase monitoring, address vital signs, and begin appropriate medications before withdrawal becomes dangerous.

Improved Patient Outcomes

When care is matched to risk, people tend to have fewer complications. Severe symptoms may be prevented, and detox can be safer and more manageable—especially during the vulnerable first 12 hours and the 24 to 48 hour window.

Resource Allocation

Not everyone needs the same intensity of care. PAWSS helps treatment programs decide who needs inpatient monitoring, who might require more frequent vitals (blood pressure and heart rate checks), and who may need rapid escalation if symptoms appear.

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PAWSS vs. CIWA

PAWSS

PAWSS is a predictive tool. It estimates the likelihood of severe withdrawal before symptoms fully develop. Its purpose is prevention—spotting high risk early.

CIWA

CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol) is a symptom tool. It tracks symptoms of alcohol withdrawal after withdrawal has started, helping clinicians adjust medication and monitor progression.

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Finding Help for Alcohol Abuse

If you or someone close to you stops drinking and begins to feel unwell—shaking, sweating, elevated blood pressure, racing heart rate, confusion, or severe anxiety—it’s not something to “push through.” Alcohol withdrawal syndrome can become life threatening, and the safest option is medically supervised alcohol detox.

Scottsdale Detox provides structured detox treatment in Arizona with clinical screening, monitoring, and individualized care plans. Using tools like PAWSS alongside real-time observation, the goal is to prevent complicated alcohol withdrawal and support safe stabilization—so the next steps in recovery are built on a medically solid foundation.

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