ABPN Addiction Psychiatry common mistakes
ABPN Addiction Psychiatry · Understand the traps and how to avoid them.
Selects "legal problems" as a DSM-5 criterion, or diagnoses a mild substance use disorder from tolerance plus withdrawal alone.
DSM-IV criteria and everyday teaching persist in memory; tolerance and withdrawal feel like the definition of addiction, and patients on prescribed opioids or benzodiazepines often have both without compulsive use.
What to do instead
Recite the 11 DSM-5 criteria in four groups (impaired control, social impairment, risky use, pharmacologic) and require at least 2; remember legal problems was removed and tolerance/withdrawal count only toward the total.
Predicts alcohol withdrawal seizures at 3–5 days and delirium tremens at 6–12 hours, then under-monitors or over-sedates at the wrong times.
Timelines for alcohol, benzodiazepine, and opioid withdrawal blur together; vignettes emphasize onset timing, and fear of missing DTs drives early aggressive dosing.
What to do instead
Memorize: tremulousness 6–24 h, seizures 12–48 h, alcoholic hallucinosis 12–24 h, DTs 48–96 h; benzodiazepine withdrawal later (2–4 days to weeks); opioid withdrawal 6–12 h with peak 36–72 h. Use CIWA-Ar symptom-triggered dosing.
Starts oral naltrexone 24–48 hours after the last opioid dose.
The 7–10 day opioid-free requirement is confused with buprenorphine's shorter window, and clinicians want to begin maintenance quickly.
What to do instead
Wait at least 7–10 days after short-acting opioids and 10–14 days after methadone or buprenorphine; consider a naloxone challenge if unclear; obtain baseline LFTs.
Induces buprenorphine while the patient still has full agonist on board or only 6 hours after the last short-acting opioid.
Buprenorphine's high affinity displaces full agonists; the need for moderate withdrawal (COWS ≥8–12) is forgotten under time pressure.
What to do instead
Confirm COWS ≥8–12 and 12–24 h since short-acting opioid (36–72 h for methadone); use low-dose induction if needed; observe for precipitated withdrawal.
Describes acamprosate as an opioid antagonist or naltrexone as an anti-craving glutamate modulator, and monitors the wrong laboratory test.
Both are oral relapse-prevention drugs with similar trial evidence; the names are learned as a pair without mechanism.
What to do instead
Anchor: naltrexone = μ-opioid antagonist, blocks reward, monitor LFTs, contraindicated with opioids; acamprosate = NMDA/glutamate modulator, restores balance, renal dosing, no liver monitoring.
Reads a positive immunoassay urine drug screen as confirmation of the named drug and acts on it without confirmatory testing.
Rapid point-of-care results feel definitive; cross-reactivity (pseudoephedrine, bupropion, poppy seeds, quetiapine) is not front of mind.
What to do instead
Treat immunoassay as screening only; confirm positives with GC-MS/LC-MS; know common false positives and metabolites (benzoylecgonine, EDDP, oxycodone versus heroin).
Recommends medication taper to abstinence for a pregnant patient with opioid use disorder.
Detoxification is the intuitive "clean" option and withdrawal risk to the fetus is overestimated relative to relapse risk.
What to do instead
Offer methadone or buprenorphine maintenance; untreated OUD carries higher risk of relapse, overdose, preterm birth, and fetal loss; coordinate with obstetric and addiction care.
Attributes depressive, anxious, or psychotic symptoms entirely to intoxication/withdrawal and defers assessment of comorbidity.
Substance-induced symptoms are common and resolving them takes weeks; the exam rewards recognizing that many persist.
What to do instead
Screen and reassess after 2–4 weeks of abstinence; treat comorbid disorders concurrently; do not withhold psychotropics solely because of a substance use disorder.
Uses benzodiazepines as maintenance therapy for opioid use disorder or as monotherapy for opioid withdrawal.
Benzodiazepines are the reflex drug for withdrawal and anxiety; the respiratory depression risk with opioids is underweighted.
What to do instead
Use buprenorphine or methadone for opioid withdrawal and maintenance; avoid chronic benzodiazepines; if co-prescribed, document risk and monitor.
Applies adult AUDIT-C or CAGE cutoffs to adolescents or older adults, or skips CRAFFT entirely.
Adult screening tools are memorized; age-specific tools and lower thresholds for older adults are less familiar.
What to do instead
Use CRAFFT for adolescents (score ≥2), lower cutoffs and shorter recall for older adults, and confirm positive screens with DSM-5 criteria.