CARN Cheat Sheet | ExamFinch

Biopsychosocial SUD Assessment

15% of exam
Screening Tools + Cut-offs DSM-5-TR SUD Criteria Tolerance vs Dependence CAGE CRAFFT

Acute Care Needs

20% of exam
CIWA-Ar + COWS Bands Withdrawal Timelines Overdose + Emergency Rules Withdrawal Management Picker CIWA-Ar vs COWS Alcohol Withdrawal Clock

Individualized Plan of Care

15% of exam
MOUD Agents + Rules AUD + Tobacco Medications ASAM Fourth Edition Levels ASAM Six Dimensions Level of Care Picker MOUD Selection Picker

Educate + Behavior Change

15% of exam
MI + Stages of Change Harm Reduction Essentials Behavior Change Picker OARS Stages of Change

Care Management Through Recovery

35% of exam
Pregnancy + Neonatal Rules 42 CFR Part 2 + Ethics Relapse Prevention + Support Lapse vs Relapse Part 2 vs HIPAA Methadone Take-Home Ladder

Quick Facts

Exam CARN
Credential Certified Addictions Registered Nurse
Items 150 (about 25 pilot)
Time 3 hours
Pass 75% of scored items
Standard Angoff-set, no scaled score
Delivery PSI test centers
Applications C-NET, online only
Fee $300; $250 member
Eligibility RN + 2,000 hours
CE 30 hours; 51% addictions
Window 90-day testing window
Retake 30 days after attempt
Validity 4 years
Pass rate 70% in 2025
Blueprint Implemented 2026

CAGE AS

Cut down, Annoyed, Guilty, Eye-opener
2+ is a positive screen Lifetime, not current Pair with AUDIT-C

Tolerance vs Dependence AS

Tolerance

Needs more for effect
Receptor adaptation
Occurs on prescribed opioids

Dependence

Withdrawal on stopping
Physiologic adaptation
Not addiction by itself
Neither alone means addiction

Patient Problem Weights AS

Opioid 27% of items 40-42
Alcohol 25% of items 37-39
Stimulant 15% of items 22-24
Co-occurring 12% of items 19-21
Medication misuse 10% of items 15-17
Cannabinoids 6% of items 9-11
Tobacco 5% of items 7-9

CRAFFT AS

Car, Relax, Alone, Forget, Friends, Trouble
Ages 12-21 Score 2+ is positive Alcohol and drugs together

Screening Tools + Cut-offs AS

AUDIT 10 items; 8+ is positive
AUDIT-C 3 items; 4+ men, 3+ women
CAGE 4 items; 2+ significant
DAST-10 3-5 moderate; 6-8 substantial
CRAFFT Ages 12-21; 2+ positive
ASSIST 4-26 moderate; 27+ high
CUDIT-R 8+ hazardous; 12+ likely disorder
SBIRT Screen, brief intervene, refer
Screen vs diagnose Screens stratify risk only

DSM-5-TR SUD Criteria AS

Criteria count 11 within 12 months
Mild 2-3 criteria
Moderate 4-5 criteria
Severe 6+ criteria
Four clusters Control, social, risky, pharmacologic
Prescribed opioid Tolerance, withdrawal excluded
Craving Strong desire to use
Substance-induced Clears after acute withdrawal
Independent disorder Persists roughly one month

Alcohol Withdrawal Clock AC

6-12 tremor, 12-48 seizure, 48-72 DTs
Hallucinosis 12-24 hours Sensorium clear in hallucinosis DTs are a medical emergency

CIWA-Ar vs COWS AC

CIWA-Ar

Alcohol withdrawal
10 items, max 67
Needs reliable self-report

COWS

Opioid withdrawal
11 items, 0-48
Observer-rated signs
Alcohol self-report vs opioid signs

Withdrawal Management Picker AC

Alcohol, CIWA-Ar 8+ → Symptom-triggered benzodiazepine ( Reassess hourly )
Alcohol plus liver disease → Lorazepam or oxazepam ( No active metabolites )
Patient cannot self-report → Fixed-schedule dosing ( CIWA-Ar invalid )
Opioid withdrawal, COWS 8+ → Start buprenorphine ( Avoids precipitated withdrawal )
Wants methadone maintenance → Refer to OTP ( Federally regulated dispensing )
Long-term benzodiazepine use → Slow taper, never abrupt ( 5-10% every 1-4 weeks )
Stimulant crash → Support, screen suicidality ( No titration scale exists )
Inpatient smoker admitted → Offer NRT early ( Peaks days 2-3 )
Neonate showing withdrawal → Eat, Sleep, Console ( Rooming-in before medication )

CIWA-Ar + COWS Bands AC

CIWA-Ar 10 items; max 67
CIWA-Ar treat Benzodiazepine at 8-10
CIWA-Ar invalid Cannot self-report reliably
COWS 11 items; 0-48
COWS 5-12 Mild withdrawal
COWS 13-24 Moderate withdrawal
COWS 25-36 Moderately severe withdrawal
COWS 37+ Severe withdrawal
Buprenorphine gate COWS 8+ before dosing
Trend rule Serial scores beat one

Withdrawal Timelines AC

Alcohol tremor 6-12 hours after last drink
Alcoholic hallucinosis 12-24 hours; sensorium clear
Withdrawal seizures 12-48 hours
Delirium tremens 48-72 hours; clouded consciousness
Short-acting opioids Onset 8-12 hours
Methadone withdrawal Onset 24-48 hours; prolonged
Nicotine withdrawal Peaks days 2-3
Cannabis withdrawal Peaks first week
Stimulant crash Dysphoria, fatigue, vivid dreams

Overdose + Emergency Rules AC

Opioid overdose triad Coma, pinpoint pupils, apnea
Naloxone nasal 4 mg; repeat 2-3 minutes
Naloxone duration 30-90 minutes; observe after
Xylazine Alpha-2 agonist; naloxone cannot reverse
Stimulant agitation Benzodiazepine first-line
Flumazenil Avoid; can precipitate seizures
Thiamine timing Before or with glucose
Fever plus injection Rule out infective endocarditis
Cocaethylene Cocaine plus alcohol; cardiotoxic
Gabapentinoid plus opioid Additive respiratory depression

ASAM Six Dimensions PL

Intox, Bio, Psych, Risk, Environment, Person
Fourth edition, 2023 Readiness folded into risks Least intensive safe level

Buprenorphine vs Methadone PL

Buprenorphine

Partial agonist
Ceiling on respiration
Office-based prescribing

Methadone

Full agonist
No ceiling effect
OTP dispensing only
Partial office vs full OTP

Level of Care Picker PL

Emergent medical instability → Level 4 ( Hospital inpatient )
Acute psychiatric emergency → Level 4 Psychiatric ( Skilled psychiatric management )
Needs IV fluids, wound care → Level 3.7 BIO ( Biomedical capability added )
Needs 24-hour withdrawal nursing → Level 3.7 ( Medically managed residential )
Unsafe home, needs containment → Level 3.5 ( High-intensity residential )
Housing gap, clinically stable → Level 3.1 ( Low-intensity residential )
Needs near-daily structure → Level 2.5 ( High-intensity outpatient )
Structured groups, sleeps home → Level 2.1 ( Intensive outpatient )
Stable, weekly therapy → Level 1.5 ( Outpatient therapy )
Stable on medication alone → Level 1.0 ( Long-term remission monitoring )

MOUD Agents + Rules PL

Methadone Full agonist; OTP only
Methadone first day Up to 50 mg
Buprenorphine Partial agonist; high affinity
Buprenorphine prescriber DEA Schedule III authority
X-waiver Eliminated by 2023 law
XR-naltrexone Antagonist; 380 mg monthly
Naltrexone washout 7-10 opioid-free days
Best outcome measure Retention in treatment
Telehealth start Permitted; methadone needs audio-visual

Naltrexone vs Naloxone PL

Naltrexone

Long-acting antagonist
Treatment, not rescue
Oral or monthly injection

Naloxone

Short-acting antagonist
Overdose rescue only
Lasts 30-90 minutes
Maintenance vs rescue

MOUD Selection Picker PL

Severe OUD, wants structure → Methadone ( Daily OTP dosing )
Wants office-based flexibility → Buprenorphine ( Any Schedule III prescriber )
Committed to full abstinence → XR-naltrexone ( 7-10 opioid-free days first )
Pregnant with OUD → Methadone or buprenorphine ( Continue through postpartum )
Leaving jail or detox → Start before discharge ( Tolerance already lost )
Urine positive during treatment → Intensify support ( Do not discharge )
Surgery or analgesia planned → Avoid naltrexone ( Blocks opioid analgesia )

AUD + Tobacco Medications PL

Naltrexone AUD 50 mg oral daily
Acamprosate 666 mg three times daily
Renal vs hepatic Acamprosate renal, naltrexone hepatic
Disulfiram Blocks aldehyde dehydrogenase
Disulfiram reaction Flushing, vomiting, tachycardia, hypotension
Hidden alcohol Mouthwash, cough syrup, sauces
Varenicline Most effective single agent
Combination NRT Patch plus short-acting form
Nicotine patch steps 21, 14, 7 mg
Bupropion SR Begin before quit date

ASAM Fourth Edition Levels PL

Level 1.0 Long-term remission monitoring
Level 1.5 Outpatient therapy
Level 1.7 Medically managed outpatient
Level 2.1 Intensive outpatient
Level 2.5 High-intensity outpatient
Level 2.7 Medically managed intensive outpatient
Level 3.1 Low-intensity residential
Level 3.5 High-intensity residential
Level 3.7 Medically managed residential
Level 4 Medically managed inpatient
COE tag Co-occurring enhanced program
BIO tag Added biomedical capability
Level 0.5 Removed in fourth edition

ASAM Six Dimensions PL

Dimension 1 Intoxication, withdrawal, addiction medications
Dimension 2 Biomedical conditions
Dimension 3 Psychiatric and cognitive conditions
Dimension 4 Substance use-related risks
Dimension 5 Recovery environment interactions
Dimension 6 Person-centered considerations
Readiness to change No longer a dimension
Placement rule Least intensive safe level

OARS ED

Open, Affirm, Reflect, Summarize
Engage, focus, evoke, plan Resist the righting reflex Planning comes last

Precontemplation vs Contemplation ED

Precontemplation

No problem seen
Not considering change
Raise awareness only

Contemplation

Ambivalent about change
Weighing pros and cons
Explore, do not push
Unaware vs ambivalent

Behavior Change Picker ED

Sees no problem → Raise awareness gently ( Precontemplation )
Ambivalent about quitting → Explore both sides ( Contemplation )
Ready within one month → Build a concrete plan ( Preparation )
Recently stopped using → Reinforce skills, monitor closely ( Action )
Six months abstinent → Build recovery capital ( Maintenance )
Declines all treatment → Offer harm reduction ( Keep the door open )

MI + Stages of Change ED

OARS Open, affirm, reflect, summarize
MI processes Engage, focus, evoke, plan
Righting reflex Resist arguing for change
Precontemplation No problem recognized
Contemplation Ambivalent, weighing change
Preparation Intends change within month
Action Changed under six months
Maintenance Sustained beyond six months
Rulers Rate importance and confidence
Change talk Reflect and reinforce it

Stages of Change ED

Pre, Contemplation, Preparation, Action, Maintenance
Match intervention to stage Do not skip ahead Relapse is a recycle

Harm Reduction Essentials ED

Naloxone access Nasal spray sold over-the-counter
Fentanyl test strips Detect fentanyl before use
Syringe services Cut HIV and hepatitis
Never use alone Overdose needs a witness
Highest overdose risk After jail, detox, hospital
Tolerance loss Former dose now lethal
Standard drink 14 grams pure alcohol
Binge drinking 4 women, 5 men
Heavy drinking 8 women, 15 men weekly
Hepatitis C Treat despite active use

Methadone Take-Home Ladder RE

7 days, then 14 days, then 28 days
Days 1-14: up to 7 Day 15+: up to 14 Day 31+: up to 28 Ceilings, not entitlements

Lapse vs Relapse RE

Lapse

Single use event
Has a learnable trigger
Reframe and plan ahead

Relapse

Return to prior pattern
Follows the guilt spiral
Needs plan revision
One slip is not failure

Pregnancy + Neonatal Rules RE

OUD in pregnancy Continue methadone or buprenorphine
Supervised withdrawal Not recommended during pregnancy
Third trimester Dose often must rise
NOWS Neonatal opioid withdrawal syndrome
Eat Sleep Console Function-based, non-drug first
Finnegan Symptom-count neonatal scoring tool
Breastfeeding Encouraged unless contraindicated
Older adults Avoid benzodiazepines and Z-drugs
Safer benzodiazepines Lorazepam, oxazepam, temazepam

Part 2 vs HIPAA RE

42 CFR Part 2

SUD program records
Blocks legal use
One consent since 2024

HIPAA

All health records
Broad treatment disclosure
No court-order shield
Extra shield for SUD records

42 CFR Part 2 + Ethics RE

Part 2 scope Federally assisted SUD programs
2024 final rule Aligns Part 2 with HIPAA
Compliance date February 16, 2026
Single consent Covers treatment, payment, operations
Legal proceedings Needs consent or court order
Part 8 Governs opioid treatment programs
Person-first language Person with substance use disorder
Avoid these words Addict, abuser, clean, dirty

Relapse Prevention + Support RE

Lapse Single discrete use event
Relapse Return to prior pattern
Abstinence violation effect Guilt drives full return
Urge surfing Ride craving without acting
Recovery capital Resources sustaining long-term recovery
AA Twelve steps, sponsor, spirituality
SMART Recovery Secular, cognitive-behavioral, four points
Contingency management Best for stimulant disorder
Integrated care One team, both conditions

Common Traps

Naloxone vs naltrexone

Naloxone reverses acute overdose ≠ Naltrexone maintains ongoing abstinence

Screen vs diagnose

AUDIT and DAST screen risk ≠ DSM-5-TR criteria diagnose

Dependence vs addiction

Dependence is physiologic adaptation ≠ Addiction adds compulsive harmful use

Early buprenorphine dosing

Waiting prevents precipitated withdrawal ≠ Dose only at COWS 8+

Reversal reflex

Opioid overdose gets naloxone ≠ Benzodiazepine overdose gets airway support

Glucose before thiamine

Thiamine first or together ≠ Glucose alone precipitates Wernicke

Positive urine screen

Not a discharge trigger ≠ Intensify support and monitoring

Stimulant withdrawal scale

No CIWA-Ar equivalent exists ≠ Screen suicidality during crash

Detox equals treatment

Withdrawal management only stabilizes ≠ Medication and care must follow

Last Minute

1. Care management domain is 35%
2. Acute care needs domain is 20%
3. Opioid 27%, alcohol 25% of items
4. CIWA-Ar is alcohol; COWS is opioid
5. Buprenorphine only when COWS 8+
6. Naltrexone needs 7-10 opioid-free days
7. Thiamine before or with glucose
8. Naloxone wears off before fentanyl
9. Sedative withdrawal can be fatal
10. Contingency management for stimulant disorder
11. Retention on MOUD is the outcome
12. Pregnancy: continue methadone or buprenorphine
13. Pick the least intensive safe level
14. Part 2 shields SUD treatment records
15. Person-first language on every item

CARN Certified Addictions Registered Nurse

Practice Questions 115 questions Study Guide 30 topics Cheat Sheet 140 facts Flashcards 50 cards Blogs 1 blog Free CE Podcast