Biopsychosocial SUD Assessment
15%of exam
Acute Care Needs
20%of exam
Individualized Plan of Care
15%of exam
Educate + Behavior Change
15%of exam
Care Management Through Recovery
35%of exam
Quick Facts
- Exam
- CARN
- Credential
- Certified Addictions Registered Nurse
- Items
- 150 (about 25 pilot)
- Time
- 3 hours
- Pass
- 75% of scored items
- Standard
- Angoff-set, no scaled score
- Delivery
- PSI test centers
- Applications
- C-NET, online only
- Fee
- $300; $250 member
- Eligibility
- RN + 2,000 hours
- CE
- 30 hours; 51% addictions
- Window
- 90-day testing window
- Retake
- 30 days after attempt
- Validity
- 4 years
- Pass rate
- 70% in 2025
- Blueprint
- Implemented 2026
CAGE
Cut down, Annoyed, Guilty, Eye-opener
2+ is a positive screenLifetime, not currentPair with AUDIT-C
Tolerance vs Dependence
Tolerance
- Needs more for effect
- Receptor adaptation
- Occurs on prescribed opioids
Dependence
- Withdrawal on stopping
- Physiologic adaptation
- Not addiction by itself
Neither alone means addiction
Patient Problem Weights
- Opioid
- 27% of items40-42
- Alcohol
- 25% of items37-39
- Stimulant
- 15% of items22-24
- Co-occurring
- 12% of items19-21
- Medication misuse
- 10% of items15-17
- Cannabinoids
- 6% of items9-11
- Tobacco
- 5% of items7-9
CRAFFT
Car, Relax, Alone, Forget, Friends, Trouble
Ages 12-21Score 2+ is positiveAlcohol and drugs together
Screening Tools + Cut-offs
- AUDIT
- 10 items; 8+ is positive
- AUDIT-C
- 3 items; 4+ men, 3+ women
- CAGE
- 4 items; 2+ significant
- DAST-10
- 3-5 moderate; 6-8 substantial
- CRAFFT
- Ages 12-21; 2+ positive
- ASSIST
- 4-26 moderate; 27+ high
- CUDIT-R
- 8+ hazardous; 12+ likely disorder
- SBIRT
- Screen, brief intervene, refer
- Screen vs diagnose
- Screens stratify risk only
DSM-5-TR SUD Criteria
- Criteria count
- 11 within 12 months
- Mild
- 2-3 criteria
- Moderate
- 4-5 criteria
- Severe
- 6+ criteria
- Four clusters
- Control, social, risky, pharmacologic
- Prescribed opioid
- Tolerance, withdrawal excluded
- Craving
- Strong desire to use
- Substance-induced
- Clears after acute withdrawal
- Independent disorder
- Persists roughly one month
Alcohol Withdrawal Clock
6-12 tremor, 12-48 seizure, 48-72 DTs
Hallucinosis 12-24 hoursSensorium clear in hallucinosisDTs are a medical emergency
CIWA-Ar vs COWS
CIWA-Ar
- Alcohol withdrawal
- 10 items, max 67
- Needs reliable self-report
COWS
- Opioid withdrawal
- 11 items, 0-48
- Observer-rated signs
Alcohol self-report vs opioid signs
Withdrawal Management Picker
- Alcohol, CIWA-Ar 8+→Symptom-triggered benzodiazepine(Reassess hourly)
- Alcohol plus liver disease→Lorazepam or oxazepam(No active metabolites)
- Patient cannot self-report→Fixed-schedule dosing(CIWA-Ar invalid)
- Opioid withdrawal, COWS 8+→Start buprenorphine(Avoids precipitated withdrawal)
- Wants methadone maintenance→Refer to OTP(Federally regulated dispensing)
- Long-term benzodiazepine use→Slow taper, never abrupt(5-10% every 1-4 weeks)
- Stimulant crash→Support, screen suicidality(No titration scale exists)
- Inpatient smoker admitted→Offer NRT early(Peaks days 2-3)
- Neonate showing withdrawal→Eat, Sleep, Console(Rooming-in before medication)
CIWA-Ar + COWS Bands
- CIWA-Ar
- 10 items; max 67
- CIWA-Ar treat
- Benzodiazepine at 8-10
- CIWA-Ar invalid
- Cannot self-report reliably
- COWS
- 11 items; 0-48
- COWS 5-12
- Mild withdrawal
- COWS 13-24
- Moderate withdrawal
- COWS 25-36
- Moderately severe withdrawal
- COWS 37+
- Severe withdrawal
- Buprenorphine gate
- COWS 8+ before dosing
- Trend rule
- Serial scores beat one
Withdrawal Timelines
- Alcohol tremor
- 6-12 hours after last drink
- Alcoholic hallucinosis
- 12-24 hours; sensorium clear
- Withdrawal seizures
- 12-48 hours
- Delirium tremens
- 48-72 hours; clouded consciousness
- Short-acting opioids
- Onset 8-12 hours
- Methadone withdrawal
- Onset 24-48 hours; prolonged
- Nicotine withdrawal
- Peaks days 2-3
- Cannabis withdrawal
- Peaks first week
- Stimulant crash
- Dysphoria, fatigue, vivid dreams
Overdose + Emergency Rules
- Opioid overdose triad
- Coma, pinpoint pupils, apnea
- Naloxone nasal
- 4 mg; repeat 2-3 minutes
- Naloxone duration
- 30-90 minutes; observe after
- Xylazine
- Alpha-2 agonist; naloxone cannot reverse
- Stimulant agitation
- Benzodiazepine first-line
- Flumazenil
- Avoid; can precipitate seizures
- Thiamine timing
- Before or with glucose
- Fever plus injection
- Rule out infective endocarditis
- Cocaethylene
- Cocaine plus alcohol; cardiotoxic
- Gabapentinoid plus opioid
- Additive respiratory depression
ASAM Six Dimensions
Intox, Bio, Psych, Risk, Environment, Person
Fourth edition, 2023Readiness folded into risksLeast intensive safe level
Buprenorphine vs Methadone
Buprenorphine
- Partial agonist
- Ceiling on respiration
- Office-based prescribing
Methadone
- Full agonist
- No ceiling effect
- OTP dispensing only
Partial office vs full OTP
Level of Care Picker
- Emergent medical instability→Level 4(Hospital inpatient)
- Acute psychiatric emergency→Level 4 Psychiatric(Skilled psychiatric management)
- Needs IV fluids, wound care→Level 3.7 BIO(Biomedical capability added)
- Needs 24-hour withdrawal nursing→Level 3.7(Medically managed residential)
- Unsafe home, needs containment→Level 3.5(High-intensity residential)
- Housing gap, clinically stable→Level 3.1(Low-intensity residential)
- Needs near-daily structure→Level 2.5(High-intensity outpatient)
- Structured groups, sleeps home→Level 2.1(Intensive outpatient)
- Stable, weekly therapy→Level 1.5(Outpatient therapy)
- Stable on medication alone→Level 1.0(Long-term remission monitoring)
MOUD Agents + Rules
- Methadone
- Full agonist; OTP only
- Methadone first day
- Up to 50 mg
- Buprenorphine
- Partial agonist; high affinity
- Buprenorphine prescriber
- DEA Schedule III authority
- X-waiver
- Eliminated by 2023 law
- XR-naltrexone
- Antagonist; 380 mg monthly
- Naltrexone washout
- 7-10 opioid-free days
- Best outcome measure
- Retention in treatment
- Telehealth start
- Permitted; methadone needs audio-visual
Naltrexone vs Naloxone
Naltrexone
- Long-acting antagonist
- Treatment, not rescue
- Oral or monthly injection
Naloxone
- Short-acting antagonist
- Overdose rescue only
- Lasts 30-90 minutes
Maintenance vs rescue
MOUD Selection Picker
- Severe OUD, wants structure→Methadone(Daily OTP dosing)
- Wants office-based flexibility→Buprenorphine(Any Schedule III prescriber)
- Committed to full abstinence→XR-naltrexone(7-10 opioid-free days first)
- Pregnant with OUD→Methadone or buprenorphine(Continue through postpartum)
- Leaving jail or detox→Start before discharge(Tolerance already lost)
- Urine positive during treatment→Intensify support(Do not discharge)
- Surgery or analgesia planned→Avoid naltrexone(Blocks opioid analgesia)
AUD + Tobacco Medications
- Naltrexone AUD
- 50 mg oral daily
- Acamprosate
- 666 mg three times daily
- Renal vs hepatic
- Acamprosate renal, naltrexone hepatic
- Disulfiram
- Blocks aldehyde dehydrogenase
- Disulfiram reaction
- Flushing, vomiting, tachycardia, hypotension
- Hidden alcohol
- Mouthwash, cough syrup, sauces
- Varenicline
- Most effective single agent
- Combination NRT
- Patch plus short-acting form
- Nicotine patch steps
- 21, 14, 7 mg
- Bupropion SR
- Begin before quit date
ASAM Fourth Edition Levels
- Level 1.0
- Long-term remission monitoring
- Level 1.5
- Outpatient therapy
- Level 1.7
- Medically managed outpatient
- Level 2.1
- Intensive outpatient
- Level 2.5
- High-intensity outpatient
- Level 2.7
- Medically managed intensive outpatient
- Level 3.1
- Low-intensity residential
- Level 3.5
- High-intensity residential
- Level 3.7
- Medically managed residential
- Level 4
- Medically managed inpatient
- COE tag
- Co-occurring enhanced program
- BIO tag
- Added biomedical capability
- Level 0.5
- Removed in fourth edition
ASAM Six Dimensions
- Dimension 1
- Intoxication, withdrawal, addiction medications
- Dimension 2
- Biomedical conditions
- Dimension 3
- Psychiatric and cognitive conditions
- Dimension 4
- Substance use-related risks
- Dimension 5
- Recovery environment interactions
- Dimension 6
- Person-centered considerations
- Readiness to change
- No longer a dimension
- Placement rule
- Least intensive safe level
OARS
Open, Affirm, Reflect, Summarize
Engage, focus, evoke, planResist the righting reflexPlanning comes last
Precontemplation vs Contemplation
Precontemplation
- No problem seen
- Not considering change
- Raise awareness only
Contemplation
- Ambivalent about change
- Weighing pros and cons
- Explore, do not push
Unaware vs ambivalent
Behavior Change Picker
- Sees no problem→Raise awareness gently(Precontemplation)
- Ambivalent about quitting→Explore both sides(Contemplation)
- Ready within one month→Build a concrete plan(Preparation)
- Recently stopped using→Reinforce skills, monitor closely(Action)
- Six months abstinent→Build recovery capital(Maintenance)
- Declines all treatment→Offer harm reduction(Keep the door open)
MI + Stages of Change
- OARS
- Open, affirm, reflect, summarize
- MI processes
- Engage, focus, evoke, plan
- Righting reflex
- Resist arguing for change
- Precontemplation
- No problem recognized
- Contemplation
- Ambivalent, weighing change
- Preparation
- Intends change within month
- Action
- Changed under six months
- Maintenance
- Sustained beyond six months
- Rulers
- Rate importance and confidence
- Change talk
- Reflect and reinforce it
Stages of Change
Pre, Contemplation, Preparation, Action, Maintenance
Match intervention to stageDo not skip aheadRelapse is a recycle
Harm Reduction Essentials
- Naloxone access
- Nasal spray sold over-the-counter
- Fentanyl test strips
- Detect fentanyl before use
- Syringe services
- Cut HIV and hepatitis
- Never use alone
- Overdose needs a witness
- Highest overdose risk
- After jail, detox, hospital
- Tolerance loss
- Former dose now lethal
- Standard drink
- 14 grams pure alcohol
- Binge drinking
- 4 women, 5 men
- Heavy drinking
- 8 women, 15 men weekly
- Hepatitis C
- Treat despite active use
Methadone Take-Home Ladder
7 days, then 14 days, then 28 days
Days 1-14: up to 7Day 15+: up to 14Day 31+: up to 28Ceilings, not entitlements
Lapse vs Relapse
Lapse
- Single use event
- Has a learnable trigger
- Reframe and plan ahead
Relapse
- Return to prior pattern
- Follows the guilt spiral
- Needs plan revision
One slip is not failure
Pregnancy + Neonatal Rules
- OUD in pregnancy
- Continue methadone or buprenorphine
- Supervised withdrawal
- Not recommended during pregnancy
- Third trimester
- Dose often must rise
- NOWS
- Neonatal opioid withdrawal syndrome
- Eat Sleep Console
- Function-based, non-drug first
- Finnegan
- Symptom-count neonatal scoring tool
- Breastfeeding
- Encouraged unless contraindicated
- Older adults
- Avoid benzodiazepines and Z-drugs
- Safer benzodiazepines
- Lorazepam, oxazepam, temazepam
Part 2 vs HIPAA
42 CFR Part 2
- SUD program records
- Blocks legal use
- One consent since 2024
HIPAA
- All health records
- Broad treatment disclosure
- No court-order shield
Extra shield for SUD records
42 CFR Part 2 + Ethics
- Part 2 scope
- Federally assisted SUD programs
- 2024 final rule
- Aligns Part 2 with HIPAA
- Compliance date
- February 16, 2026
- Single consent
- Covers treatment, payment, operations
- Legal proceedings
- Needs consent or court order
- Part 8
- Governs opioid treatment programs
- Person-first language
- Person with substance use disorder
- Avoid these words
- Addict, abuser, clean, dirty
Relapse Prevention + Support
- Lapse
- Single discrete use event
- Relapse
- Return to prior pattern
- Abstinence violation effect
- Guilt drives full return
- Urge surfing
- Ride craving without acting
- Recovery capital
- Resources sustaining long-term recovery
- AA
- Twelve steps, sponsor, spirituality
- SMART Recovery
- Secular, cognitive-behavioral, four points
- Contingency management
- Best for stimulant disorder
- Integrated care
- One team, both conditions
Common Traps
Naloxone vs naltrexone
Naloxone reverses acute overdose ≠ Naltrexone maintains ongoing abstinence
Screen vs diagnose
AUDIT and DAST screen risk ≠ DSM-5-TR criteria diagnose
Dependence vs addiction
Dependence is physiologic adaptation ≠ Addiction adds compulsive harmful use
Early buprenorphine dosing
Waiting prevents precipitated withdrawal ≠ Dose only at COWS 8+
Reversal reflex
Opioid overdose gets naloxone ≠ Benzodiazepine overdose gets airway support
Glucose before thiamine
Thiamine first or together ≠ Glucose alone precipitates Wernicke
Positive urine screen
Not a discharge trigger ≠ Intensify support and monitoring
Stimulant withdrawal scale
No CIWA-Ar equivalent exists ≠ Screen suicidality during crash
Detox equals treatment
Withdrawal management only stabilizes ≠ Medication and care must follow
Last Minute
- 1.Care management domain is 35%
- 2.Acute care needs domain is 20%
- 3.Opioid 27%, alcohol 25% of items
- 4.CIWA-Ar is alcohol; COWS is opioid
- 5.Buprenorphine only when COWS 8+
- 6.Naltrexone needs 7-10 opioid-free days
- 7.Thiamine before or with glucose
- 8.Naloxone wears off before fentanyl
- 9.Sedative withdrawal can be fatal
- 10.Contingency management for stimulant disorder
- 11.Retention on MOUD is the outcome
- 12.Pregnancy: continue methadone or buprenorphine
- 13.Pick the least intensive safe level
- 14.Part 2 shields SUD treatment records
- 15.Person-first language on every item
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