Substance Use in Primary Care: Screening Tools, Alcohol Withdrawal Risk, Buprenorphine and When to Refer

Substance use care in primary care runs from screening to risk stratification to treatment the provider can start in the office. The USPSTF recommends screening all adults for unhealthy alcohol use (2018, grade B) and for unhealthy drug use (2020, grade B). For alcohol withdrawal, the ASAM 2020 guideline uses withdrawal severity and the risk of complicated withdrawal to decide between home and hospital, and for opioid use disorder, buprenorphine can now be prescribed by any provider with a Schedule III DEA registration, started at 2 to 4 mg once objective withdrawal is present.

Screening

Who to screen

The tools and their cut-offs

The key exam distinction: AUDIT-C and the single question find risky drinking early, when brief counseling works; CAGE finds dependence, often too late for prevention, and asks about lifetime rather than current use.

After a positive screen

1. Assess quantity, pattern, consequences and DSM-5 criteria for a substance use disorder.
2. Give brief counseling for risky use: feedback on the result, advice to cut down, a goal the patient sets and a follow-up plan.
3. For a use disorder, offer medication and referral to treatment.
4. Screen for coexisting depression, anxiety and suicide risk; give the 988 Suicide and Crisis Lifeline number (call or text 988) to any patient with suicidal thoughts, since substance use raises suicide risk.

DSM-5 substance use disorder

Eleven criteria within 12 months, grouped as impaired control, social impairment, risky use and pharmacologic criteria (tolerance, withdrawal). Two to three criteria are mild, four to five moderate, and six or more severe. Tolerance and withdrawal do not count when the drug is taken as prescribed, such as a patient on long-term opioid therapy for pain.

Alcohol withdrawal

Time course

Withdrawal begins within hours of the last drink. Withdrawal seizures generally occur within the first 48 hours, with peak risk around 24 hours. Alcoholic hallucinosis appears within 12 to 24 hours and usually resolves within 24 to 48 hours. Alcohol withdrawal delirium (formerly delirium tremens) appears between 72 and 96 hours after the last drink and usually lasts 2 to 3 days.

Severity and the CIWA-Ar

The CIWA-Ar scores ten items (nausea and vomiting, tremor, sweating, anxiety, agitation, tactile, auditory and visual disturbances, headache, orientation) for a maximum of 67. ASAM 2020 uses it to grade severity and guide treatment, while noting that clinicians may choose other ranges for their population.

ASAM also treats a CIWA-Ar of 10 or more at presentation as one marker of risk for severe or complicated withdrawal. The CIWA-Ar is a severity and monitoring scale, not a diagnostic test; the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) is one of the tools ASAM lists to predict risk of severe withdrawal.

Who can stay home

ASAM 2020 states that alcohol withdrawal can typically be managed safely in an ambulatory setting for patients with limited or mitigated risk factors. Risk rises with a history of severe or complicated withdrawal (the strongest predictor is prior withdrawal seizures or delirium), an acute medical, psychiatric or surgical illness, severe coronary artery disease, and signs of withdrawal while the blood alcohol is still positive. Patients with active suicide risk need a setting able to manage it, often inpatient psychiatry with withdrawal services. Low support at home or an unsafe environment favors a more intensive level of care.

Ambulatory management under ASAM 2020

• Daily check-in with a qualified health provider for up to 5 days after stopping or reducing alcohol; alternating in-person and phone or video visits is acceptable.
• At each check-in: vital signs, hydration, orientation, sleep, mood including suicidal thoughts, alcohol use (breathalyzer if available) and a validated severity score.
• Benzodiazepines, when used, should be longer-acting agents; in significant liver disease or while awaiting liver tests, choose one with less hepatic metabolism. Prescribe the minimum amount needed and stop the benzodiazepine when withdrawal treatment ends.
• Offer oral thiamine, typically 100 mg daily for 3 to 5 days, plus non-caffeinated fluids and a daily multivitamin.
• Transfer to a higher level of care for persistent agitation or tremor despite repeated doses, persistent vomiting, hallucinations, confusion, seizure, over-sedation, return to drinking, syncope or unstable vital signs, or worsening of an existing condition.
• Start alcohol use disorder treatment during withdrawal management when cognition allows.

Medications for alcohol use disorder

The APA 2018 guideline recommends naltrexone or acamprosate for patients with moderate to severe alcohol use disorder who want to reduce or stop drinking, prefer medication or have not responded to non-drug treatment, and have no contraindications. Disulfiram is for patients who aim for abstinence, understand the risks and choose it. Topiramate or gabapentin are options when naltrexone and acamprosate are not tolerated or not preferred.

• Naltrexone (50 mg orally daily is the usual labeled dose): avoid in patients taking or needing opioids and in acute hepatitis or liver failure.
• Acamprosate (666 mg three times daily is the usual labeled dose): renally cleared; adjust the dose in renal impairment and avoid in severe renal impairment. Safe in liver disease.

Opioid use disorder

What changed after the X-waiver

Section 1262 of the Consolidated Appropriations Act, 2023 eliminated the federal DATA 2000 waiver. Any practitioner with a current DEA registration that includes Schedule III authority may now prescribe buprenorphine for opioid use disorder where state law allows, with no federal patient limit. Under the MATE Act, since June 27, 2023, new and renewing DEA registrants attest to at least 8 hours of training on opioid or other substance use disorders, or to qualifying board certification or recent graduation from a program that included that content. State rules may still differ, so check the state's requirements. Methadone for opioid use disorder can still be dispensed only through a certified opioid treatment program.

Choosing the medication

ASAM 2020 asks the provider to weigh patient preference, past treatment, current illness and treatment setting when choosing among the three, and sets no time limit on treatment with buprenorphine or methadone.

Starting buprenorphine

1. Confirm the diagnosis and review the PDMP; check for benzodiazepine and alcohol use, pregnancy and liver disease.
2. Wait for objective signs of withdrawal before the first dose, to avoid precipitated withdrawal. Withdrawal is commonly documented with the Clinical Opiate Withdrawal Scale (COWS).
3. Give 2 to 4 mg, then titrate in further doses until withdrawal is controlled and the patient is comfortable.
4. Office-based and home-based initiation are both considered safe and effective.
5. With fentanyl and other high-potency synthetic opioids, precipitated withdrawal is more frequent and alternative initiation strategies (low-dose or high-dose approaches) are evolving; confirm the current guidance before choosing one.

Rules that matter on the exam

• Psychosocial treatment should be offered, but a patient's refusal or lack of access should not preclude or delay medication.
• Naloxone kits and training for every patient with opioid use disorder, everyone at risk of relapse, and family members or other potential bystanders.
• Pregnancy: buprenorphine or methadone; buprenorphine is a recommended alternative to methadone. Do not push a pregnant patient toward withdrawal management instead of medication.
• Surgery: discontinuation of methadone or buprenorphine before surgery is not required.
• Tapering buprenorphine, if the patient chooses it, is generally accomplished over several months.
• Telehealth: the DEA and HHS telemedicine flexibilities for controlled substances run through December 31, 2026; confirm the current rule before starting buprenorphine without an in-person visit.

Referral and admission triggers

• Severe or complicated alcohol withdrawal, a history of withdrawal seizures or delirium, or withdrawal with serious medical or psychiatric illness: inpatient.
• Active suicide risk: a setting equipped to manage it, and the 988 Lifeline in the plan.
• Patients who need methadone: refer to an opioid treatment program.
• Concurrent benzodiazepine or sedative dependence, or polysubstance use that complicates withdrawal.
• Pregnancy with a substance use disorder: co-management with obstetrics and addiction specialists.
• Failure of ambulatory treatment, unsafe home environment or no support person.

Patient and family education

• Unhealthy alcohol use is a spectrum; cutting down lowers risk even before abstinence.
• Do not stop heavy daily drinking abruptly without a plan; withdrawal can cause seizures.
• On buprenorphine: no alcohol or sedatives, store securely away from children, and keep naloxone where family can find it.
• Family members should learn the signs of overdose and how to give naloxone, then call 911.
• Medication for opioid use disorder is treatment, not substituting one addiction for another, and it lowers overdose death risk.
• Relapse is part of a chronic condition; return to care rather than stopping treatment.

How the exam tests this

• CAGE as the screening tool. It identifies dependence, not risky drinking; AUDIT-C is the better screen.
• Adolescent screening. USPSTF gives an I statement for alcohol and drug screening in adolescents, unlike depression and anxiety.
• Waiver distractors. "Refer because the NP lacks an X-waiver" is outdated; the waiver no longer exists.
• Dosing too early. Buprenorphine before objective withdrawal causes precipitated withdrawal.
• Counseling as a precondition. Wrong under ASAM 2020.
• Naltrexone in a patient on opioids. Precipitates withdrawal; requires an opioid-free interval.
• Acamprosate in renal failure or naltrexone in liver failure. Classic contraindication swaps.
• Withdrawal with a positive blood alcohol, or a past withdrawal seizure. Higher risk; not a candidate for simple home management.
• Short-acting benzodiazepines at home. ASAM prefers longer-acting agents, except when liver disease calls for less hepatic metabolism.

Practice question

A 29-year-old man with opioid use disorder asks to start treatment today. He uses immediate-release oxycodone tablets bought on the street, confirmed on urine testing, and last used 4 hours ago. He is alert with normal pupils, no yawning, sweating, rhinorrhea or piloerection. He declines counseling but accepts medication. His state allows NPs to prescribe Schedule III drugs, and the NP has a current DEA registration with Schedule III authority. Which of the following is the most appropriate plan?

• A. Give buprenorphine-naloxone 8 mg now in the office.
• B. Wait until objective withdrawal signs appear, then give 2 to 4 mg of buprenorphine and titrate, with a naloxone kit and an offer of counseling.
• C. Postpone medication until he enrolls in counseling.
• D. Refer him to a physician because buprenorphine requires an X-waiver.

Answer: B. ASAM 2020 recommends waiting for objective signs of opioid withdrawal before the first buprenorphine dose, starting with 2 to 4 mg and titrating, and providing naloxone to every patient with opioid use disorder. Option A gives buprenorphine while full agonist opioid is still active, which risks precipitated withdrawal. Option C conflicts with ASAM's statement that declining psychosocial treatment should not preclude or delay medication. Option D is outdated, because the Consolidated Appropriations Act, 2023 eliminated the X-waiver and any practitioner with Schedule III DEA authority can prescribe buprenorphine for opioid use disorder where state law permits.

Key points

Related NPPace guides

• ADHD in Primary Care: Assessment Across Ages, Stimulant Choice, Monitoring and Controlled-Substance Rules
• Anxiety Disorders for the NP Exam: GAD-7, Panic, First-Line Drugs and When Benzodiazepines Are Wrong
• Depression in Primary Care: PHQ-9 Screening, Starting an SSRI and the Follow-Up Schedule
• How to Read a Primary-Care Vignette Like a Provider: The 5-Step Method
• AANP vs ANCC: Which NP Certification Exam Should You Take?