Free CARN Exam Flashcards

No. DSM-5-TR excludes tolerance and withdrawal as criteria when an opioid is taken as prescribed under medical supervision. Base the diagnosis on the other nine criteria, such as craving, loss of control, failure to meet obligations, and continued use despite harm.

A previous non-fatal overdose. Other high-risk markers are recent loss of tolerance after incarceration, detoxification or hospitalization, concurrent benzodiazepine, alcohol or gabapentinoid use, injection use, and using alone. Any of these should trigger take-home naloxone and overdose education.

AUDIT has 10 items scored 0 to 40, and a total of 8 or more suggests hazardous or harmful drinking. AUDIT-C uses only the first three consumption items, scored 0 to 12, with a positive screen at 4 or more for men and 3 or more for women.

Two or more yes answers to Cut down, Annoyed, Guilty and Eye-opener is clinically significant and warrants full assessment. CAGE screens for lifetime alcohol problems only. It does not quantify current intake or identify hazardous drinking levels, so pair it with a consumption measure.

The exact agent, total daily dose, duration of continuous use, and every other sedating substance the patient takes. Withdrawal risk rises with dose and duration. The FDA's 2020 class-wide boxed warning covers abuse, misuse, addiction, physical dependence and withdrawal reactions, which occur even at prescribed doses.

By persistence. Substance-induced symptoms clear as intoxication and acute withdrawal resolve. Symptoms that continue for a substantial period, roughly one month, after acute withdrawal ends, or that clearly predate substance use, indicate an independent psychiatric disorder that needs its own treatment plan.

Stimulant withdrawal is not autonomically dangerous, so no titration scale exists. Assess the DSM-5-TR features: dysphoric mood plus fatigue, vivid unpleasant dreams, insomnia or hypersomnia, increased appetite, and psychomotor change. The priority risk during the crash is suicidality, so screen for it directly and repeatedly.

The Cannabis Use Disorder Identification Test-Revised has 8 items scored 0 to 32. A score of 8 or more indicates hazardous cannabis use, and 12 or more suggests a possible cannabis use disorder warranting full diagnostic assessment. It is a screening tool, never a diagnosis on its own.

The Clinical Opiate Withdrawal Scale has 11 items scored 0 to 48: 5 to 12 is mild, 13 to 24 moderate, 25 to 36 moderately severe, and 37 or more severe. Repeat the score at each reassessment; the trend across scores, not a single number, guides medication decisions.

Buprenorphine is a partial agonist with very high mu-opioid receptor affinity. Given while a full agonist still occupies receptors, it displaces that agonist and swaps full activation for partial activation, causing abrupt severe withdrawal. Prevent it by waiting for objective withdrawal signs, typically COWS 8 or higher.

Naloxone acts for roughly 30 to 90 minutes, shorter than fentanyl, methadone and extended-release opioids. Re-sedation and respiratory depression can return once it wears off. Keep the patient under observation, be prepared to repeat dosing, and never judge safety from a single response.

Ten items scored to a maximum of 67. Most protocols give a benzodiazepine at 8 to 10 or higher and reassess hourly. CIWA-Ar depends on patient self-report, so it is invalid for anyone who cannot communicate reliably, including intubated, severely delirious or acutely intoxicated patients.

Tremor, anxiety and autonomic arousal begin 6 to 12 hours after the last drink. Alcoholic hallucinosis appears at 12 to 24 hours with an intact sensorium. Withdrawal seizures cluster at 12 to 48 hours. Delirium tremens, with clouded consciousness and instability, starts at 48 to 72 hours.

Glucose metabolism consumes thiamine and can precipitate Wernicke encephalopathy in a depleted patient. Give parenteral thiamine first or simultaneously. The classic triad of confusion, ocular findings and ataxia appears in only a minority of cases, so treat on suspicion rather than waiting for all three signs.

It reverses benzodiazepine effects abruptly and can precipitate seizures or status epilepticus in a physically dependent patient, especially alongside a co-ingested proconvulsant. Unlike opioid withdrawal, sedative withdrawal can be fatal. Support the airway and ventilation, then taper, rather than reversing.

Infective endocarditis. Fever plus injection drug use is endocarditis until proven otherwise. Draw multiple sets of blood cultures before antibiotics, examine for murmur, septic emboli and skin findings, and arrange echocardiography. Also assess for skin and soft tissue infection, osteomyelitis, HIV and hepatitis C.

A benzodiazepine. It reduces agitation, heart rate, blood pressure and temperature together. Antipsychotics alone can worsen hyperthermia and lower the seizure threshold. Cool hyperthermia actively, and avoid prolonged physical restraint, which raises temperature and the risk of rhabdomyolysis.

Symptoms start within 24 hours, peak at 2 to 3 days, and largely settle over 2 to 4 weeks. Irritability, anxiety, poor concentration, restlessness and increased appetite are often misread as anxiety or non-adherence. Offer nicotine replacement early in the admission rather than waiting to be asked.

A six-dimension assessment. The ASAM Criteria 4th edition (2023) dimensions are intoxication, withdrawal and addiction medications; biomedical and physical functioning; psychiatric and cognitive functioning; substance use-related risks; recovery environment interactions; and person-centered considerations. Readiness to change is no longer a separate dimension. Recommend the least intensive level that safely meets the needs found across all six.

Seven to ten days. Naltrexone is a full opioid antagonist, so giving it while opioids still occupy receptors precipitates severe withdrawal. Confirm abstinence by history, urine testing and, where protocol allows, a naloxone challenge. This waiting period is a common reason patients start buprenorphine instead.

Naltrexone and acamprosate. Naltrexone is metabolized hepatically and blocks opioid receptors, so it is avoided with current opioid use or planned opioid analgesia. Acamprosate is cleared renally, making it safer in significant liver disease but requiring dose reduction or avoidance in renal impairment.

Disulfiram blocks aldehyde dehydrogenase, so drinking causes flushing, throbbing headache, nausea, vomiting, tachycardia and hypotension. It requires abstinence before the first dose and strong motivation, ideally with supervised dosing. Warn about hidden alcohol in mouthwash, cough syrup, sauces and topical preparations.

Gradually and by agreement, commonly reducing 5 to 10 percent of the dose every one to four weeks and slowing further near the end. Consider converting to a longer-acting agent for steadier levels. Do not begin a taper during an acute crisis, and never stop abruptly.

Integrated. One team treats both conditions at the same time, in the same setting, under a single plan. Sequential care that requires stabilizing one problem first, and parallel care in unlinked systems, both produce dropout and worse outcomes. Integrated treatment is the SAMHSA standard.

Contingency management, which provides escalating tangible incentives for objectively verified stimulant-negative results. No medication is FDA-approved for cocaine or methamphetamine use disorder. Combine contingency management with cognitive behavioral therapy or the Matrix Model, and treat co-occurring conditions alongside it.

Recognize the signs: unresponsiveness, slow or absent breathing, blue lips. Call 911, give naloxone, provide rescue breaths, repeat the dose after 2 to 3 minutes if there is no response, place the person on their side, and stay until help arrives. Nasal naloxone is available over the counter.

Opioid tolerance falls within days of abstinence while the familiar dose does not change. Returning to a pre-abstinence amount then causes fatal respiratory depression. Teach that the old dose is no longer safe, start medication for opioid use disorder before discharge, and send naloxone home.

Fourteen grams of pure alcohol. That equals 12 ounces of regular beer at about 5 percent, 5 ounces of table wine at about 12 percent, or 1.5 ounces of 80-proof spirits at 40 percent. Craft beers, large pours and mixed drinks often contain several standard drinks each.

Binge drinking brings blood alcohol to about 0.08 percent, typically 4 or more drinks for women and 5 or more for men within about 2 hours. Heavy drinking is 4 or more per day or 8 or more per week for women, and 5 per day or 15 per week for men.

Open questions, Affirmations, Reflective listening, Summaries. Resist the righting reflex of arguing for change. Explore ambivalence, reflect change talk when it appears, and use importance and confidence rulers. Motivational interviewing moves through engaging, focusing, evoking and planning, so planning comes last.

Stay engaged rather than closing the conversation. Offer harm reduction now: safer-use supplies, fentanyl test strips, naloxone, hydration, sleep, wound and dental care, and HIV and hepatitis C testing. Ask permission before giving information, and leave the door open. Engagement predicts later treatment entry.

This pattern suggests cannabinoid hyperemesis syndrome. Topical capsaicin and antipsychotics such as haloperidol or droperidol relieve acute episodes better than standard antiemetics. The only definitive treatment is stopping cannabis; symptoms usually settle within days to weeks and return if use resumes. Compulsive hot bathing is a diagnostic clue, not a cure.

Up to 7 take-home doses during days 1 to 14, up to 14 doses from day 15, and up to 28 doses from day 31. The 2024 final rule made the COVID-era flexibilities permanent. Within each ceiling the number is the practitioner's documented clinical judgment, not a fixed entitlement.

Any clinician holding a DEA registration that includes Schedule III authority. The Consolidated Appropriations Act of 2023 eliminated the DATA 2000 X-waiver and its patient caps. A one-time eight-hour training on treating substance use disorders is now attached to DEA registration and renewal instead.

A function-based assessment asking whether the infant can eat, sleep and be consoled, prioritizing rooming-in, breastfeeding when not contraindicated, low stimulation and parent presence before medication. In the multicenter ESC-NOW trial, infants were medically ready for discharge about 6.7 days sooner than with Finnegan-based usual care.

With methadone or buprenorphine, continued throughout pregnancy and postpartum. Medically supervised withdrawal is not recommended because return to use is common and carries overdose and fetal risk. Doses often need to rise in the third trimester. Expected neonatal withdrawal is not a reason to stop treatment.

Retention in treatment. Time on methadone or buprenorphine roughly halves all-cause and overdose mortality, and risk climbs sharply in the weeks after stopping. Judge progress by continued engagement and function, and treat a positive urine screen as a reason to intensify support, not to discharge.

Symptom-triggered dosing guided by repeated CIWA-Ar scores. It uses less total benzodiazepine and shortens treatment compared with fixed schedules, without losing safety. Fixed dosing still has a role when reliable scoring is impossible, such as an intubated patient or one with a withdrawal seizure history.

Lorazepam, oxazepam and temazepam. These three are cleared by glucuronidation alone, with no oxidative phase-one metabolism and no active metabolites, so they do not accumulate when hepatic function is impaired. Long-acting chlordiazepoxide and diazepam can build up dangerously in the same patients.

In Marlatt's relapse prevention model, one lapse triggers guilt and a belief that the failure is total and personal, which drives a full return to use. Reframe the lapse as a discrete situational event with a learnable trigger, then rehearse a concrete plan for the next high-risk situation.

AA is a peer fellowship built on twelve steps, sponsorship and reliance on a higher power as each member understands it. SMART Recovery is secular and uses cognitive behavioral and motivational tools in a four-point program. Offer both, and match options to the patient's beliefs rather than assuming.

Gabapentin and pregabalin add central nervous system and respiratory depression to opioid effects, and the combination is associated with higher opioid-related mortality. They are also misused to potentiate opioids. Several states have scheduled gabapentin as a controlled substance and require prescription monitoring reporting.

Avoid them. Older adults are more sensitive and clear these drugs more slowly, and both classes raise the risk of falls, fractures, delirium and motor vehicle crashes. Z-drugs such as zolpidem carry similar risks without better outcomes. Prefer cognitive behavioral therapy for insomnia.

No. AASLD and IDSA guidance recommends treating everyone with hepatitis C, including people who currently inject drugs. Direct-acting antivirals cure well over 95 percent in 8 to 12 weeks, reinfection is manageable, and treating this group also reduces onward transmission. Pair treatment with syringe services.

Part 2 gives added protection to records from federally assisted substance use disorder programs. The 2024 final rule, with compliance required from February 16, 2026, aligns it with HIPAA: one written consent can cover all future treatment, payment and health care operations, and HIPAA-covered recipients may redisclose under HIPAA. Records still cannot be used against the patient in legal proceedings without consent or a court order.

When cocaine and alcohol are used together, the liver forms cocaethylene, an active metabolite with a longer half-life than cocaine and greater cardiotoxicity. The combination raises the risk of myocardial infarction, arrhythmia and sudden death. Always ask about alcohol when assessing cocaine use.

Methamphetamine-associated cardiomyopathy and pulmonary hypertension, which can present as fatigue, breathlessness or edema in a young patient and warrant echocardiography. Also monitor severe dental disease, weight loss, skin-picking lesions, cognitive impairment, and psychosis that persists after use stops.

Xylazine is an alpha-2 agonist, not an opioid, so naloxone cannot reverse its sedation. Give naloxone anyway, because fentanyl is almost always present too, then support ventilation until the person recovers. Xylazine also causes severe necrotic wounds away from injection sites that need active wound care.

Yes. After heavy prolonged use stops, symptoms appear within about a week: irritability or anger, nervousness, sleep difficulty with vivid dreams, decreased appetite, restlessness, depressed mood, and a physical symptom such as abdominal pain, tremor, sweating, fever, chills or headache. It peaks in the first week.

Varenicline is the most effective single agent. Combination nicotine replacement, a patch plus a short-acting form such as gum or lozenge, beats single-form NRT and performs about as well as varenicline. The FDA removed varenicline's boxed warning for serious neuropsychiatric events in December 2016 after the EAGLES trial found no significant excess risk.