NCRS cheat sheet

DSM-5-TR substance use disorder severity is counted from 11 criteria: mild = 2-3, moderate = 4-5, severe = 6 or more, within a 12-month period.

Tolerance and withdrawal are not counted toward the 11 criteria for sedative, stimulant, and opioid use disorders when the substance is taken only under appropriate medical supervision.

Caffeine and hallucinogen use disorders in DSM-5-TR carry no withdrawal criterion; cannabis withdrawal and caffeine withdrawal are recognized criteria.

A diagnosis of substance use disorder requires clinically significant impairment or distress; mere use or legal consequences alone do not meet threshold.

The AUDIT-C screens with 3 items (score 0-12); a score of 4 or more in men and 3 or more in women is a positive screen for unhealthy alcohol use.

The CAGE has 4 yes/no items; 2 or more affirmative answers suggests probable alcohol problem, but it detects only later-stage problems, not risky use.

The CIWA-Ar has 10 items scored 0-7 (total 0-67); scores of 8-15 suggest mild withdrawal, and scores above 15 indicate risk of severe withdrawal requiring medical management.

The COWS has 11 items scored 0-5 (total 0-48); a score of 13 or higher generally indicates sufficient opioid withdrawal to consider buprenorphine induction.

The Clinical Opiate Withdrawal Scale, CIWA-Ar, and CINA scale are observer-rated; the AUDIT, DAST-10, and CRAFFT are self-report screening instruments.

Motivational interviewing rests on four processes: engaging, focusing, evoking, and planning; the spirit is partnership, acceptance, compassion, and evocation.

The stages of change are precontemplation, contemplation, preparation, action, maintenance, and (for some models) termination; relapse is treated as a stage, not a failure.

In motivational interviewing, change talk (desire, ability, reasons, need, commitment, activation, taking steps) is reflected and elicited; sustain talk is reflected without confrontation.

Cognitive behavioral relapse prevention distinguishes a lapse (single use) from a relapse (return to prior pattern), and uses high-risk situation analysis, coping skills, and lifestyle balance.

Contingency management gives tangible reinforcers for verified abstinence; evidence is strongest for stimulant use disorder, where no FDA-approved pharmacotherapy exists.

Twelve-step facilitation is a manualized, clinician-delivered approach that actively introduces clients to AA/NA; it outperformed cognitive behavioral therapy in Project MATCH outpatients at 1-year follow-up.

Medication for opioid use disorder: methadone requires an opioid treatment program, buprenorphine can be prescribed by any DEA-registered practitioner (no X-waiver since 2023), and naltrexone requires 7-10 days opioid-free.

Alcohol pharmacotherapy: naltrexone reduces heavy drinking, acamprosate supports abstinence and is renally cleared, and disulfiram is a second-line aversive agent requiring supervised adherence.

A written treatment plan should specify problems, goals, measurable objectives, interventions, responsible clinician, and a review date; it is updated when goals change or at defined intervals.

Confidentiality for substance use disorder records is governed by 42 CFR Part 2, which is stricter than HIPAA; written consent must specify the recipient, purpose, and expiration or event.

A subpoena alone does not authorize release of Part 2 records; a court order meeting Part 2 requirements (or valid consent) is generally needed.

Mandatory child abuse and neglect reporting overrides confidentiality; the clinician reports to the designated state authority and does not need to investigate first.

Informed consent requires disclosure of the nature of services, risks, benefits, alternatives, fees, and limits of confidentiality, documented in the record.

Dual relationships should be avoided when they risk exploitation or impaired judgment; not all multiple relationships are unethical, but the burden is on the clinician to justify.

The duty to protect (Tarasoff-type) applies when a client poses serious danger to an identifiable person; actions may include warning, notifying police, or hospitalization per state law.

Scope of practice: a counselor must practice within training and licensure; referring out or seeking supervision is required when a client's needs exceed competence.

Documentation should be timely, objective, and behaviorally specific; records are legal documents and may be reviewed by courts, licensing boards, and payers.

Termination requires advance notice, a written summary when appropriate, referral options, and no abandonment; abandonment is terminating without adequate referral or notice.

The Institute of Medicine prevention continuum: universal (whole population), selective (at-risk groups), and indicated (individuals with early signs but no diagnosis).

Recovery is defined as a process of improved health, wellness, and quality of life, often supported by four dimensions: health, home, purpose, and community.

Recovery capital includes social, physical, human, and cultural resources; assessment of recovery capital guides support planning beyond abstinence.

Peer recovery support specialists use lived experience; they are not clinicians and require role clarity, supervision, and boundaries.

Medication for opioid use disorder reduces overdose mortality; retention on methadone or buprenorphine is associated with substantially lower all-cause mortality than no medication.

Naloxone reverses opioid overdose by competitive antagonism; it has no effect on non-opioid overdose and may precipitate withdrawal in dependent individuals.

Relapse prevention includes identifying high-risk situations, building coping and refusal skills, and planning for lapses; recovery is nonlinear and re-engagement is a support task.

Screening, Brief Intervention, and Referral to Treatment (SBIRT) targets risky use before dependence; brief intervention is typically 5-15 minutes using motivational approaches.

Mutual-help groups differ: AA/NA are abstinence-based 12-step programs, SMART Recovery uses cognitive behavioral tools, and moderation management targets reduced drinking.

Co-occurring disorder means at least one substance use disorder plus at least one mental health disorder; either may be primary, and integrated treatment is the evidence-based approach.

Integrated treatment delivers both disorder treatments in the same setting by the same team with a unified plan; sequential and parallel models have weaker outcomes.

Dual diagnosis capability is often described on a four-quadrant model based on severity of mental illness and severity of substance use, guiding service intensity.

Withdrawal risks: alcohol and benzodiazepine withdrawal can be fatal (seizure, delirium tremens); opioid withdrawal is extremely uncomfortable but rarely life-threatening.

Adolescents: the CRAFFT screen has 6 items; 2 or more yes answers indicates high risk, and confidentiality and parental consent rules vary by state.

Pregnant women with opioid use disorder should be offered methadone or buprenorphine; untreated opioid use disorder carries higher maternal and fetal risk than medication.

Older adults metabolize alcohol and drugs more slowly and are more sensitive to benzodiazepines and opioids; screening should account for polypharmacy and falls.

Trauma-informed care assumes widespread trauma, prioritizes safety, trustworthiness, choice, collaboration, and empowerment, and avoids re-traumatization.

For clients with serious mental illness and substance use, assertive community treatment and long-acting injectable antipsychotics improve engagement and reduce relapse.