Substance Use Disorders: PMHNP Board Review

Substance use disorders (SUDs) are diagnosed using a single DSM-5-TR list of 11 criteria, with severity graded by how many are met. The highest-yield board point: alcohol and benzodiazepine withdrawal can be life-threatening (seizures, delirium tremens), whereas opioid withdrawal is intensely uncomfortable but rarely fatal. Knowing which withdrawal syndromes can kill — and how to manage them — is the backbone of SUD questions.

This review covers the diagnostic framework, intoxication and withdrawal by substance, CIWA, medication-assisted treatment, and screening.

Diagnostic criteria (DSM-5-TR)

A single set of 11 criteria applies across substances, clustered into four groups:

• Impaired control: Using more/longer than intended; unsuccessful efforts to cut down; time spent obtaining/using/recovering; craving.

• Social impairment: Failure to fulfill obligations; continued use despite social problems; giving up activities.

• Risky use: Use in hazardous situations; continued use despite physical/psychological harm.

• Pharmacologic criteria: Tolerance and withdrawal. (Tolerance/withdrawal occurring under appropriate medical supervision do not count toward the diagnosis.)

Severity:

• Mild: 2–3 criteria.

• Moderate: 4–5 criteria.

• Severe: 6 or more criteria.

DSM-5-TR uses "substance use disorder" rather than the older abuse/dependence split — a tested update. Note also that craving was added as a criterion in the DSM-5 revision, while the legal-problems criterion from prior editions was removed.

Keep two definitions straight, because the exam contrasts them:

• Tolerance: Needing markedly more of a substance to achieve the same effect, or a diminished effect with the same amount.

• Withdrawal: A substance-specific syndrome that develops on cessation or reduction in a person who used heavily and persistently, often relieved by taking the substance again.

A related concept frequently tested is the distinction between physical dependence (a normal physiologic adaptation, which can occur with appropriately prescribed opioids or benzodiazepines) and addiction (the behavioral disorder of compulsive use despite harm). Physical dependence alone is not a substance use disorder, which is why supervised tolerance and withdrawal do not count toward the diagnosis.

Intoxication and withdrawal syndromes

Alcohol

• Intoxication: Slurred speech, ataxia, disinhibition, sedation; respiratory depression at high levels.

• Withdrawal timeline: Tremor/anxiety/autonomic hyperactivity at 6–24 hours; withdrawal seizures at 12–48 hours; alcoholic hallucinosis at 12–24 hours; delirium tremens (DTs) at 48–96 hours.

• DTs = confusion, autonomic instability, hallucinations; mortality if untreated. A medical emergency.

• Treatment: benzodiazepines (e.g., lorazepam, chlordiazepoxide, diazepam) are first-line. Give thiamine before glucose to prevent Wernicke encephalopathy.

Benzodiazepines / sedative-hypnotics

• Withdrawal mirrors alcohol — can cause seizures and delirium and is potentially fatal. Manage with a slow taper rather than abrupt discontinuation.

Opioids

• Intoxication: Miosis (pinpoint pupils), respiratory depression, sedation, decreased bowel sounds. Naloxone reverses overdose.

• Withdrawal: Dysphoria, myalgias, nausea/vomiting/diarrhea, lacrimation, rhinorrhea, yawning, piloerection, mydriasis. Uncomfortable but not life-threatening in healthy adults — a key board contrast with alcohol/benzo withdrawal.

• Symptomatic relief: clonidine, loperamide, NSAIDs; or transition to MAT.

Stimulants (cocaine, amphetamines)

• Intoxication: Euphoria, agitation, mydriasis, tachycardia, hypertension, hyperthermia; risk of seizures, MI, stroke, and psychosis.

• Cocaine-associated chest pain: Avoid beta-blockers (unopposed alpha concern); use benzodiazepines first.

• Withdrawal ("crash"): Dysphoria, fatigue, hypersomnia, increased appetite, vivid dreams. Psychologically severe but not physiologically dangerous.

For stimulant pharmacology overlap, see our ADHD medications review.

Other substances worth knowing

• Cannabis: Withdrawal (irritability, sleep disturbance, decreased appetite, restlessness) has been a recognized diagnosis since DSM-5 (2013); intoxication causes conjunctival injection, increased appetite, and tachycardia.

• Hallucinogens (LSD, psilocybin): Perceptual changes with intact orientation; managed supportively ("talk down," benzodiazepines for severe agitation). Persisting perception disorder ("flashbacks") is a tested complication.

• PCP: Violent agitation, nystagmus (vertical, horizontal, or rotatory), and analgesia; benzodiazepines and a low-stimulation environment are preferred.

• Inhalants: Common in adolescents; risk of sudden sniffing death from arrhythmia.

• Nicotine: Often overlooked; withdrawal causes irritability and craving, and varenicline plus behavioral support is first-line for cessation.

CIWA — alcohol withdrawal scoring

The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores symptom severity (tremor, sweats, anxiety, agitation, hallucinations, orientation, etc.) to guide symptom-triggered benzodiazepine dosing.

• Higher scores → more benzodiazepine.

• Symptom-triggered dosing generally uses less total medication than fixed schedules.

• Recognizing that CIWA guides benzo dosing in alcohol withdrawal is a frequent exam item.

Medication-assisted treatment (MAT)

Opioid use disorder

• Methadone: Full mu-opioid agonist; dispensed through licensed opioid treatment programs.

• Buprenorphine: Partial agonist (often with naloxone as Suboxone); precipitates withdrawal if started too early — wait for moderate withdrawal (e.g., COWS-guided) before induction.

• Naltrexone: Opioid antagonist; patient must be fully detoxed (7–10 days opioid-free) before starting or it precipitates withdrawal.

Alcohol use disorder

• Naltrexone: Reduces craving and heavy drinking (first-line for many patients).

• Acamprosate: Supports abstinence; renally cleared, good in liver disease.

• Disulfiram: Aversive (flushing, nausea with alcohol); requires high motivation and intact liver.

See our dedicated MAT and substance use guide for deeper coverage.

Screening

• CAGE: Brief 4-item alcohol screen.

• AUDIT: More detailed alcohol screen.

• CRAFFT: Adolescent substance-use screen.

• SBIRT (Screening, Brief Intervention, Referral to Treatment) is the recommended primary-care framework.

• Laboratory markers can support a history of heavy alcohol use: elevated GGT, AST:ALT ratio greater than 2:1, elevated MCV, and carbohydrate-deficient transferrin.

Psychiatric and behavioral management

Medication is only part of treatment. The board expects familiarity with the broader recovery framework:

• Motivational interviewing is a core, evidence-based, patient-centered approach that resolves ambivalence and is favored over confrontation.

• The stages of change (precontemplation, contemplation, preparation, action, maintenance) guide how you tailor interventions; matching the intervention to the stage is a frequently tested concept.

• Mutual-help groups (Alcoholics Anonymous, Narcotics Anonymous) and contingency management, CBT, and relapse-prevention strategies improve outcomes.

• Harm reduction — naloxone distribution, syringe services, and treating substance use without requiring immediate abstinence — is increasingly emphasized and is the compassionate, evidence-aligned answer in many scenarios.

Co-occurring psychiatric disorders are common, and integrated treatment of both the substance use disorder and the mental illness produces better outcomes than treating either alone.

Special populations and overdose response

A few additional points round out the topic. In pregnancy, opioid use disorder is managed with methadone or buprenorphine rather than forced withdrawal, because abrupt detoxification risks fetal distress and relapse; neonatal opioid withdrawal syndrome is then managed after birth. Naloxone kits and education should be offered to anyone at overdose risk and their families, and repeat dosing may be needed because naloxone's duration is shorter than that of many opioids. In stimulant or opioid intoxication with agitation or psychosis, ensure safety, use benzodiazepines for agitation, and provide supportive medical care. Finally, remember that relapse is common and is a feature of a chronic, relapsing disease — the board-appropriate response is re-engagement and treatment intensification, not punishment or discharge from care.

High-yield board pearls

• Alcohol and benzo withdrawal can kill (seizures, DTs); opioid and stimulant withdrawal are miserable but rarely fatal.

• Benzodiazepines treat alcohol withdrawal; CIWA guides dosing.

• Thiamine before glucose to prevent Wernicke encephalopathy.

• Naloxone for opioid overdose; opioid intoxication = pinpoint pupils + respiratory depression.

• Buprenorphine precipitates withdrawal if started too soon; naltrexone requires full detox first.

• Avoid beta-blockers in acute cocaine intoxication.

• DSM-5-TR uses a unified "use disorder" with severity by criteria count.

Common exam traps

• Treating alcohol withdrawal with an antipsychotic instead of a benzodiazepine.

• Giving glucose before thiamine in a malnourished alcohol-dependent patient.

• Starting buprenorphine while the patient is comfortable (not yet in withdrawal) — precipitates withdrawal.

• Starting naltrexone in an actively using opioid patient.

• Using a beta-blocker for cocaine chest pain.

• Assuming opioid withdrawal is dangerous enough to require inpatient benzodiazepine management — it usually isn't life-threatening.

All detoxification and MAT decisions must follow current guidelines, controlled-substance regulations, and individualized assessment; this review summarizes board concepts, not prescribing direction.

Keep building your board readiness

SUD questions hinge on three contrasts: which withdrawals are deadly, which medications match which substance, and which screening tool fits which population. Master them with focused practice. Explore the full PMHNP question bank and study tools, find your gaps with a quick diagnostic assessment, or review the related perinatal mood disorders board review. Ready to drill? Create a free account.