CARN cheat sheet

Biopsychosocial model: addiction arises from interacting biological, psychological, and social factors; treatment should address all three.

Disease model (Jellinek): addiction is a chronic, progressive, relapsing brain disease; abstinence is the goal.

Moral model: addiction is a moral failing; leads to stigma and punishment rather than treatment.

Social learning theory (Bandura): substance use is learned through modeling, reinforcement, and expectancies; self-efficacy predicts relapse.

Stage of Change model (Prochaska & DiClemente): precontemplation, contemplation, preparation, action, maintenance, termination; relapse is a stage, not a failure.

Harm reduction: accepts that drug use occurs; aims to reduce negative consequences without requiring abstinence.

Recovery capital: total resources (social, physical, human, cultural) that support recovery; higher capital predicts sustained recovery.

Twelve-step facilitation: mutual-help groups (AA/NA) as a recovery pathway; spiritual component is not required for benefit.

Mesolimbic dopamine pathway (VTA to nucleus accumbens) is the primary reward circuit; all addictive drugs increase dopamine here.

Drug half-life determines dosing frequency and withdrawal onset; shorter half-life (e.g., heroin) produces faster, more intense withdrawal.

Agonist: binds and activates receptor (e.g., methadone at mu-opioid receptor); antagonist: blocks receptor (e.g., naltrexone); partial agonist: activates but with ceiling effect (e.g., buprenorphine).

Alcohol enhances GABA-A (inhibitory) and inhibits NMDA (excitatory) receptors; chronic use leads to GABA downregulation and NMDA upregulation, causing withdrawal hyperexcitability.

Opioid withdrawal symptoms: yawning, lacrimation, rhinorrhea, piloerection, diarrhea, mydriasis, muscle cramps; not life-threatening.

Alcohol withdrawal: tremor, anxiety, insomnia, seizures (6-48 h), delirium tremens (48-96 h); can be fatal.

Benzodiazepine withdrawal: anxiety, insomnia, seizures; risk increased with abrupt cessation of short-acting agents.

Stimulant (cocaine, methamphetamine) intoxication: tachycardia, hypertension, mydriasis, agitation; overdose may cause hyperthermia, seizures, myocardial infarction.

AUDIT-C: 3-item alcohol screen; score ≥4 for men, ≥3 for women indicates hazardous drinking.

CAGE: 4 yes/no questions; ≥2 positive suggests alcohol problem; less sensitive than AUDIT.

DSM-5 substance use disorder: ≥2 of 11 criteria in 12 months; severity: mild (2-3), moderate (4-5), severe (≥6).

Withdrawal is a DSM-5 criterion for most substances except hallucinogens and inhalants.

SBIRT: Screening, Brief Intervention, and Referral to Treatment; brief intervention uses motivational interviewing.

Assessment domains: substance use history, medical/psychiatric history, social/legal, readiness to change, and collateral information when possible.

Urine drug screen (UDS): detection windows vary; e.g., cannabis up to 30 days in chronic users, cocaine 2-4 days.

Differential diagnosis: distinguish substance-induced disorders from independent psychiatric disorders; temporal relationship is key.

Detoxification is not treatment; it is medically managed withdrawal followed by ongoing treatment.

Alcohol withdrawal: use CIWA-Ar to assess severity; benzodiazepines (e.g., diazepam, lorazepam) are first-line for symptom-triggered or fixed-dose regimens.

Thiamine (vitamin B1) before or with glucose in alcohol withdrawal to prevent Wernicke's encephalopathy.

Opioid withdrawal: symptomatic treatment with clonidine (alpha-2 agonist), antiemetics, antidiarrheals; buprenorphine can be used for withdrawal management.

Benzodiazepine withdrawal: gradual taper (e.g., 10-25% dose reduction every 2 weeks) to prevent seizures; abrupt discontinuation is dangerous.

Delirium tremens (DTs): severe agitation, confusion, hallucinations, autonomic instability; medical emergency requiring ICU-level care.

Withdrawal management settings: outpatient for mild, residential for moderate, inpatient for severe or high-risk patients.

ASAM Criteria: six dimensions (intoxication/withdrawal, medical, emotional/behavioral, readiness, relapse potential, recovery environment) determine level of care.

Levels of care: 1 (outpatient), 2 (intensive outpatient/partial hospitalization), 3 (residential), 4 (medically managed inpatient).

Motivational interviewing: collaborative, goal-oriented style; uses open questions, affirmations, reflections, summaries (OARS).

Cognitive behavioral therapy (CBT): identifies and modifies maladaptive thoughts and behaviors related to substance use.

Contingency management: provides tangible rewards for verified abstinence; effective for stimulant use disorder.

Twelve-step programs: AA/NA; spiritual basis, but secular alternatives (SMART Recovery, LifeRing) exist.

Medication-assisted treatment (MAT) combined with counseling is superior to either alone for opioid use disorder.

Opioid use disorder (OUD) medications: methadone (full agonist), buprenorphine (partial agonist), naltrexone (antagonist).

Methadone: only dispensed through SAMHSA-certified opioid treatment programs (OTPs); risk of QT prolongation and respiratory depression.

Buprenorphine: ceiling effect on respiratory depression; can be prescribed in office-based settings (with waiver or via special registration).

Naltrexone: requires opioid-free period (7-10 days) to avoid precipitated withdrawal; also used for alcohol use disorder (oral or long-acting injectable).

Alcohol use disorder medications: naltrexone (first-line), acamprosate (maintains abstinence), disulfiram (aversive; requires supervision).

Acamprosate: dosing 666 mg three times daily; renal impairment requires dose adjustment; no liver metabolism.

Disulfiram: inhibits aldehyde dehydrogenase; causes acetaldehyde accumulation with alcohol; contraindicated in severe cardiac disease.

Nicotine replacement therapy (NRT): patch, gum, lozenge, inhaler, nasal spray; varenicline and bupropion are non-nicotine options.

Integrated treatment for co-occurring disorders (COD): simultaneous treatment of substance use and mental health disorders by the same team.

Common co-occurring disorders: depression, anxiety, PTSD, ADHD, bipolar disorder, schizophrenia.

Substance-induced disorders: symptoms resolve with abstinence; independent disorders persist beyond withdrawal.

Medical complications: alcohol-liver disease, pancreatitis, cardiomyopathy; opioids-constipation, respiratory depression, infectious diseases (HIV, HCV).

Injection drug use: risk of endocarditis, abscesses, cellulitis, and blood-borne infections; harm reduction (needle exchange) reduces transmission.

Psychiatric medications: avoid benzodiazepines in patients with substance use disorder when possible due to misuse risk.

Suicide risk is elevated in substance use disorders; screen regularly and refer for safety planning.

Relapse prevention model: identify high-risk situations, develop coping skills, and enhance self-efficacy.

Marlatt's relapse prevention: relapse is a process; a lapse can be managed to prevent escalation (abstinence violation effect).

Continuing care: ongoing monitoring and support after initial treatment; includes outpatient counseling, mutual-help groups, and recovery coaching.

Recovery-oriented systems of care (ROSC): community-based networks that support long-term recovery.

Peer recovery support services: provided by trained peers with lived experience; improve engagement and retention.

Sobriety sampling: a time-limited abstinence trial to assess control and build motivation.

Relapse triggers: negative emotional states, social pressure, interpersonal conflict, and positive emotional states (celebration).

Family systems theory: substance use affects the entire family; treatment should involve family members.

Codependency: maladaptive caregiving patterns that enable substance use; addressed in family therapy.

Community reinforcement and family training (CRAFT): teaches family members to change contingencies to encourage treatment entry.

Group therapy: provides peer support, universality, and interpersonal learning; effective in early recovery.

Mutual-help groups: AA, NA, SMART Recovery, Al-Anon (for families), Nar-Anon; complementary to professional treatment.

Community-based prevention: environmental strategies (policy, enforcement) combined with individual interventions.

Cultural competence: interventions should be tailored to the community's cultural values and norms.

42 CFR Part 2: federal confidentiality rule for substance use disorder records; stricter than HIPAA; requires written consent for disclosure.

HIPAA: protects health information; does not apply to substance use records covered by 42 CFR Part 2.

Mandated reporting: child abuse/neglect, elder abuse, and imminent danger to self or others; confidentiality may be breached.

Informed consent: must be obtained before treatment, including risks and benefits of medications.

Duty to warn/protect: if a client threatens serious harm to an identifiable person, confidentiality may be breached.

Scope of practice: professionals must practice within their training and licensure; refer when outside competence.

Ethical principles: autonomy, beneficence, nonmaleficence, justice, fidelity; apply to all clinical decisions.

Prevention levels: universal (whole population), selective (at-risk groups), indicated (individuals with early signs).

Harm reduction strategies: needle exchange programs, naloxone distribution, supervised consumption sites, drug checking.

Naloxone: opioid antagonist that reverses overdose; administer intranasally or intramuscularly; repeat as needed.

Fentanyl test strips: allow detection of fentanyl in drug supply; a harm reduction tool.

Health promotion: education on safe use, vaccination (hepatitis A/B), and screening for infectious diseases.

Policy interventions: alcohol taxes, minimum legal drinking age, and restrictions on marketing reduce harm.

Screening and brief intervention (SBI) in primary care: reduces hazardous drinking.