Scientific Principles & Co-Occurring
25%of exam
Evidence-Based Screening & Assessment
20%of exam
Treatment, Counseling & Referral
30%of exam
Motivational InterviewingStages of ChangeMAT MedicationsTreatment PlanningDischarge PlanningRecovery Pathways
Professional, Ethical & Legal
25%of exam
Quick Facts
- Questions
- 150 (125 scored, 25 pretest)
- Time Limit
- 3 hours
- Pass Score
- 500 scaled (200-800)
- Domains
- 4 (25/20/30/25%)
- Retake Wait
- 90 days minimum
- Delivery
- Prometric CBT or remote
- Blueprint
- November 2022 edition
Dependence vs Addiction
Physical Dependence
- Withdrawal on stopping
- Can occur with prescribed meds
Addiction
- Compulsive use despite harm
- Loss of control
Withdrawal alone isn't addiction
Drug Classes
- CNS Depressants
- Alcohol, benzos, barbiturates
- Opioids
- Pain relief; overdose risk
- Stimulants
- Cocaine, methamphetamine
- Hallucinogens
- Low dependence potential
- Cannabis
- Low acute lethality
- Inhalants
- Rapid onset; organ damage
Withdrawal Signs
- Alcohol Withdrawal
- Tremor; seizures day 1-2
- Delirium Tremens
- Life-threatening; later onset
- Opioid Withdrawal
- Flu-like; not life-threatening
- Benzo Withdrawal
- Seizure risk like alcohol
- Stimulant Crash
- Fatigue, low mood, cravings
- Opioid Overdose
- Pinpoint pupils, slow breathing
Neurobiology & Risk Factors
- Disease Model
- Chronic brain condition
- Reward Pathway
- VTA to nucleus accumbens
- Tolerance
- Need more for effect
- Physical Dependence
- Withdrawal on stopping
- Cross-Tolerance
- Tolerance carries to similar drugs
- Top Risk Factors
- Trauma, family history, early use
ASAM Dimensions 1 to 6
D1→D6: Intox-Bio-Psych-Risk-Env-Person
D1: Intoxication, withdrawal, medsD2: Biomedical conditionsD3: Psychiatric, cognitive conditionsD4: Substance use risksD5: Recovery environmentD6: Person-centered considerations
CAGE-AID vs ASI
CAGE-AID
- 4-item brief screen
- 2+ yes flags risk
ASI
- 7-domain severity interview
- Guides treatment planning
Screen vs comprehensive assessment
Level of Care Picker
- Mild withdrawal, stable support→Level 1(Outpatient)
- Moderate symptoms, some risk→Level 2(Intensive outpatient)
- Needs 24-hour structure→Level 3(Residential)
- Severe withdrawal risk→Level 3.7(Medically managed residential)
- Life-threatening instability→Level 4(Medically managed inpatient)
- Sustained remission, monitoring only→Level 1.0(Long-term monitoring)
Screening Tools
- CAGE-AID
- 4-item; 2+ yes flags
- ASI
- 7-domain severity interview
- SASSI
- Self-report; detects defensiveness
- ACE
- Adverse childhood experiences score
- AUDIT
- Alcohol-specific screening tool
- DAST
- Drug-specific screening tool
DSM-5-TR SUD Criteria
- Criteria Count
- 11 total; need 2+
- Mild
- 2-3 criteria
- Moderate
- 4-5 criteria
- Severe
- 6 or more criteria
- Prescribed Meds
- Tolerance/withdrawal don't count
ASAM Six Dimensions
- Dimension 1
- Intoxication/withdrawal/addiction medications
- Dimension 2
- Biomedical conditions
- Dimension 3
- Psychiatric, cognitive conditions
- Dimension 4
- Substance use-related risks
- Dimension 5
- Recovery environment interactions
- Dimension 6
- Person-centered considerations
ASAM Levels of Care
- Level 1
- Outpatient care
- Level 2
- Intensive outpatient
- Level 3
- Residential care
- Level 4
- Medically managed inpatient
- Level 0.5
- Removed in 4th edition
- Decimals
- Mark gradation within level
OARS Micro-Skills
Open, Affirm, Reflect, Summarize
Open-ended questionsAffirmationsReflective listeningSummaries
Methadone vs Buprenorphine
Methadone
- Full agonist
- OTP dispensing only
- QTc monitoring needed
Buprenorphine
- Partial agonist
- Ceiling effect
- Any qualified prescriber
Full agonist vs ceiling effect
MAT Medication Picker
- Active opioid use, OTP access→Methadone(Full agonist)
- Office-based opioid treatment→Buprenorphine(Partial agonist)
- Opioid-free 7-10 days→Naltrexone(Antagonist)
- Alcohol use disorder, adherent→Acamprosate(Renal dosing)
- Alcohol use, needs deterrent→Disulfiram(Aversive reaction)
- Pregnant with opioid use disorder→Methadone or buprenorphine(Preferred over withdrawal)
Motivational Interviewing
- OARS
- Open, Affirm, Reflect, Summarize
- Change Talk
- Reinforce statements favoring change
- Sustain Talk
- Reflect; don't argue against
- Spirit
- Partnership, acceptance, compassion, evocation
- Ambivalence
- Normal; not resistance
Stages of Change Order
Precontemplation -> Contemplation -> Preparation -> Action -> Maintenance
Precontemp: not consideringContemplation: weighing pros/consPreparation: planning to actAction: actively changingMaintenance: sustaining change
Goals vs Objectives
Goals
- Broad desired outcome
- Long-term direction
Objectives
- Specific measurable steps
- Time-limited and trackable
Broad vs specific and measurable
Stages of Change
- Precontemplation
- Not considering change
- Contemplation
- Weighing pros and cons
- Preparation
- Planning to act soon
- Action
- Actively changing behavior
- Maintenance
- Sustaining the change
MAT Medication Memory Line
Methadone full | Bupe partial | Naltrexone blocks
Methadone: full agonist, OTPBuprenorphine: partial agonist, ceilingNaltrexone: antagonist, needs opioid-free
Lapse vs Relapse
Lapse
- Single use event
- Can be learned from
Relapse
- Return to full use pattern
- Often follows abstinence violation effect
One slip vs full return
MAT Medications
- Methadone
- Full agonist; OTP-only
- Buprenorphine
- Partial agonist; ceiling effect
- X-Waiver
- Eliminated 2023 (CAA)
- Naltrexone
- Antagonist; needs opioid-free days
- Vivitrol Wait
- 7-10 opioid-free days minimum
- Acamprosate
- Renal dosing; three times daily
- Disulfiram
- Aversive; blocks alcohol metabolism
Domain Weight Order
25-20-30-25 percent, I to IV
Domain I: 25%Domain II: 20%Domain III: 30%Domain IV: 25%
Treatment Planning & Process
- Goals
- Broad desired outcome
- Objectives
- Specific, measurable, time-limited steps
- Tuckman Stages
- Form, storm, norm, perform
- Relapse Triggers
- Emotions, conflict, social pressure
- Abstinence Violation
- Guilt after single lapse
- Warm Handoff
- Direct provider-to-provider connection
Discharge & Recovery Pathways
- Discharge Elements
- Aftercare, relapse plan, referrals
- 12-Step
- Mutual-aid fellowship model
- SMART Recovery
- Secular, CBT-based mutual aid
- Harm Reduction
- Reduces risk without abstinence
- Multiple Pathways
- No single model fits all
Consultation vs Supervision
Consultation
- Informal peer exchange
- Case-specific question
Supervision
- Ongoing formal oversight
- Tracks skill development
Informal vs ongoing oversight
42 CFR Part 2 Disclosure Picker
- Routine treatment, payment, operations→Single TPO consent(2024 final rule)
- Bona fide medical emergency→Disclose without consent(Document the emergency)
- Law enforcement has subpoena only→Still need consent(Subpoena alone insufficient)
- Court orders Subpart E hearing→Disclosure permitted(Good-cause hearing required)
- Subcontractor needs client data→QSOA required(Qualified service agreement)
- Suspected child abuse, initial report→State law applies(Initial report exception)
Boundaries & Self-Disclosure
- Dual Relationship
- Another role with client
- Self-Disclosure Rule
- Serves client; stays brief
- Scope of Practice
- Set by training, credential
- Conflict of Interest
- Disclose; step back
Court Order vs Subpoena
Court Order
- Subpart E hearing required
- Permits Part 2 disclosure
Subpoena Alone
- Not sufficient alone
- No disclosure without order
Order compels; subpoena doesn't
42 CFR Part 2
- 2026 Compliance
- Required by Feb 16 2026
- Single TPO Consent
- Covers treatment, payment, operations
- SUD Notes
- Still need separate consent
- Court Order
- Subpart E hearing; not subpoena
- QSOA
- Qualified service organization agreement
- Medical Emergency
- Bona fide exception; no consent
Informed Consent & Rights
- Informed Consent
- Purpose, risks, benefits, alternatives
- Voluntary
- No coercion; can withdraw
- Client Rights
- Dignity, refuse care, grievance
- Grievance Process
- No retaliation; documented response
Supervision & Documentation
- Supervision
- Ongoing oversight of casework
- Consultation
- Informal case discussion
- Documentation Standard
- Objective, timely, specific
- Record Security
- Limited access; written policy
- Cultural Humility
- Ongoing self-reflection; not checklist
Common Traps
Tolerance ≠ Addiction
Tolerance is pharmacological need ≠ Addiction adds compulsive harmful use
Lapse ≠ Relapse
Lapse is one slip ≠ Relapse is sustained return
Consultation ≠ Supervision
Consultation is informal peer input ≠ Supervision is ongoing formal oversight
Subpoena ≠ Court Order
Subpoena alone is insufficient ≠ Court order needs Subpart E hearing
CAGE-AID ≠ Diagnosis
CAGE-AID only screens risk ≠ DSM-5-TR criteria give diagnosis
Readiness ≠ Standalone Dimension
4th edition assesses readiness everywhere ≠ Dimension 4 now substance use risks
Methadone ≠ Buprenorphine
Methadone is full agonist ≠ Buprenorphine is partial with ceiling
Last Minute
- 1.Weights: 25-20-30-25 percent
- 2.150 questions; 125 scored only
- 3.Pass is 500 scaled score
- 4.90-day minimum wait to retake
- 5.4 failed attempts trigger remediation
- 6.ASAM 4th edition: six dimensions
- 7.Part 2 compliance due Feb 2026
- 8.Single consent now covers TPO
- 9.Naltrexone needs 7-10 opioid-free days
- 10.Buprenorphine needs no federal X-waiver
- 11.OARS = core MI skills
- 12.DSM-5-TR severe means 6+ criteria
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