Context Alcohol use disorders (AUDs) are reported in 10-32% of hospitalized medical
patients [Nielsen et al. 1994; Smothers et al. 2004; Dolman and Hawkes 2005;
Doering-Silveira et al. 2014], in 23 % of hospitalized medical patients and in 25-50% of
hospitalized psychiatric patients in France [Paille & Reynaud 2015]. A hospital admission
may result in an abrupt cessation of alcohol consumption for individuals with AUD and
thus provide a risk period for alcohol withdrawal syndrome. Even though the majority of
patients at risk of AWS will develop only minor or uncomplicated withdrawal symptoms, up
to 20% of patients develop symptoms associated with complicated alcohol withdrawal,
including withdrawal seizures and delirium tremens [Maldonado et al., 2010]. Complicated
alcohol withdrawal syndrome is associated with increased in-hospital morbidity and
mortality, increased lengths of stay, inflated costs of care, and worsened cognitive
functioning.
Due to lack of any similar previously existing tools, Maldonado et al. developed the
Prediction of Alcohol Withdrawal Severity Scale (PAWSS) [Maldonado et al. 2014, 2015].
The PAWSS scale has excellent psychometric characteristics and predictive value of
complicated alcohol withdrawal among medically ill hospitalized patients using a PAWSS
cutoff of 4, the tool's sensitivity was 93.1% and specificity was 99.5%. The PAWSS scale
is recommended by the American Society of Addiction Medicine for alcohol withdrawal
management, (ASAM 2020, www.asam.org).
There is no scale available to identify the patients at risk of complicated withdrawal In
France. The PAWSS is not a withdrawal severity scale such as the CIWA-AR or Cushman
scale, which are scored during withdrawal, but a scale designed to screen beforehand,
prior to withdrawal, patients at high risk for the most severe complications (Delirium
tremens and seizures), and thus to take appropriate therapeutic measures. It also has the
advantage of being able to guide patients towards the most suitable scheduled withdrawal
modalities for their condition.
The PAWSS can therefore greatly assist clinicians in directing patients to either
outpatient or hospital withdrawal in more or less intensive care, with a minimum of risk.
Its use would allow earlier management to limit the sequelae, especially cognitive and
those related to seizures.
The PAWSS scale includes an initial screener question and can be used with patients who
are not currently exhibiting signs of withdrawal. If a patient does indeed endorse recent
intake of alcohol, this must be followed by 10 questions contained in the second part of
PAWSS, assessing known risk factors for withdrawal and current clinical status. The PAWSS
is heavily based on self-report of alcohol intake and history provided by patients, as
the literature suggests that interviews by clinicians can provide the most accurate
information on alcohol abuse and relapse, as compared to collateral information or
selected laboratory data.
Objectives The primary objective is to validate the French version of the PAWSS scale
(PRSAC) in a population of patients with AUD.
The secondary objectives are 1) to confirm the optimal cut-off score of 4 for the PRSAC
scale, 2) to evaluate PRSAC scale reproducibility in predicting the risk of complicated
alcohol withdrawal syndrome and 3) to identify an optimal strategy for benzodiazepine use
following the application of PRSAC scale.
Hypothesis Are the psychometric properties of the French version of the PAWSS scale
(PRSAC) comparable to those of the English version in a population of alcohol use
disorders subjects?
Methods This study is a multicentric non-interventional prospective cohort study. Subject
evaluation included during 3 days.
Day 1: Collection of consent and clinical data, DSM-5 criterion for alcohol use
disorders, AUDIT, PRSAC scale (twice by two investigators), and CIWA-AR scale every 8
hours.
Day 2 and Day 3: administration of CIWA-AR scale every 8 hours.
Inclusion criteria Male or female, aged 18 to 60 years Subjects with DSM-5 criteria for
moderate to severe alcohol use disorders (AUD) Subjects hospitalized for AUD or another
condition with AUD. Subjects who understand French and affiliated to the social security
system
Non-inclusion criteria Subject with a neurological disorder, impairing cognition
(epilepsy, dementia,...) Subjects unable to understand the questionnaire and to give
consent or not volunteering for the study Subject under guardianship or curatorship
Study location
Academic substance abuse treatment and Psychiatry departments of:
Barthélemy Durand Hospital at Etampes, France Paul Brousse hospital in Villejuif, France
Rouen university hospital, France Caen university hospital, France Martinique university
hospital, France
Results & Outcome Confirmation of the psychometric qualities of the French version of the
PAWSS scale.