Substance Use Board Prep for Family Medicine

Five-minute daily sessions on alcohol, opioids, tobacco, and the addiction medicine that family physicians now own.

Substance use has moved from the margins of family medicine training to its center, and the ABFM has followed. Family physicians now prescribe buprenorphine without a waiver, manage alcohol use disorder with medications that most patients are never offered, and deliver the tobacco cessation counseling that remains the single highest-value intervention in primary care. The exam tests all of it — screening, brief intervention, pharmacotherapy, and withdrawal management — through the kind of outpatient vignettes you see in a real clinic week.

The regulatory landscape matters and is tested. The federal X-waiver requirement for buprenorphine was eliminated in 2023, meaning any prescriber with a standard DEA registration can treat opioid use disorder in the office. Exam questions increasingly frame buprenorphine as routine primary care rather than specialty referral material. Similarly, naloxone co-prescribing for patients at overdose risk is standard practice, and questions reward offering it without hesitation.

Screening questions anchor on USPSTF recommendations: screen all adults for unhealthy alcohol use with a validated tool like AUDIT-C or the single-question screen, screen adults for unhealthy drug use when services are available, and ask every patient about tobacco. Brief intervention follows the SBIRT model. The exam favors nonjudgmental, motivational-interviewing-flavored responses over confrontation — if an answer choice lectures or threatens discharge from the practice, it is nearly always wrong.

Treatment knowledge is where points are won and lost. Naltrexone and acamprosate for alcohol use disorder, buprenorphine and methadone for opioid use disorder, varenicline and combination nicotine replacement for tobacco — each has initiation rules, contraindications, and patient-selection details the exam tests directly. Withdrawal management (CIWA-guided benzodiazepines for alcohol, COWS-guided buprenorphine induction for opioids) rounds out the core.

High-yield substance use topics

• Alcohol use disorder pharmacotherapy. Naltrexone (oral daily or monthly injectable) is first-line — it reduces heavy drinking days and does not require abstinence to start; avoid in patients on opioids or with acute hepatitis or liver failure. Acamprosate suits patients with liver disease but requires renal dose adjustment. Disulfiram is rarely tested as a right answer and requires a motivated, abstinent patient.
• Alcohol withdrawal recognition and management. Symptom-triggered benzodiazepines guided by a CIWA score are the standard. Know the timeline: tremor and anxiety at 6 to 12 hours, alcoholic hallucinosis at 12 to 24, withdrawal seizures at 24 to 48, delirium tremens at 48 to 96 hours. Give thiamine before glucose. Outpatient management is reasonable for mild withdrawal without prior seizures or DTs.
• Buprenorphine for opioid use disorder. Partial mu agonist with a ceiling on respiratory depression. No waiver is required since 2023. Start when the patient is in mild-to-moderate withdrawal (COWS-guided) to avoid precipitated withdrawal; home induction is acceptable. Continue indefinitely — medication treatment cuts overdose mortality roughly in half, and tapering off is associated with relapse and overdose.
• Methadone and naltrexone for OUD. Methadone requires a federally certified opioid treatment program for addiction treatment — it cannot be prescribed from a routine office for OUD. Extended-release naltrexone requires 7 to 10 days of opioid abstinence before the first dose, which limits its practicality. Buprenorphine is the exam's usual best answer for office-based treatment.
• Tobacco cessation: varenicline, NRT, and bupropion. Varenicline is the most effective single agent, and its neuropsychiatric boxed warning was removed after the EAGLES trial — it is safe in stable psychiatric illness. Combination NRT (patch plus short-acting gum or lozenge) rivals varenicline. Bupropion helps and suits patients with comorbid depression; avoid with seizure history. Counseling plus medication beats either alone.
• Screening and brief intervention (SBIRT). USPSTF grade B: screen adults for unhealthy alcohol use (AUDIT-C or single-question screen: "How many times in the past year have you had 5 or more drinks in a day?" — 4 for women) and provide brief behavioral counseling. Screen adults for drug use when treatment can be offered. Risky drinking thresholds: more than 14 drinks weekly or more than 4 per occasion for men; more than 7 weekly or more than 3 per occasion for women.
• Opioid prescribing safety and naloxone. Check the PDMP, avoid concurrent benzodiazepines, and co-prescribe naloxone for patients on higher opioid doses (50 morphine milligram equivalents or more), on concurrent sedatives, or with any history of overdose or substance use disorder. The CDC 2022 guideline dropped rigid dose ceilings in favor of individualized risk-benefit decisions — abrupt tapering is discouraged and tested as a wrong answer.
• Substance use in pregnancy. Buprenorphine (or methadone) is the standard of care for opioid use disorder in pregnancy — medically supervised withdrawal is not recommended. Screen all pregnant patients for alcohol and substance use. Neonatal opioid withdrawal is treatable and expected; it is not a reason to withhold maternal treatment. Punitive framings are always the wrong answer.

ABFM exam tips

Buprenorphine is the default right answer for opioid use disorder. Office-based, no waiver needed, mortality benefit, safe ceiling effect. If the vignette shows a patient with OUD asking for help in a family medicine clinic, starting buprenorphine beats referral-only answers, detox-only answers, and naltrexone in almost every stem.

Wait for withdrawal before the first buprenorphine dose. Starting too early precipitates withdrawal by displacing full agonists from the receptor. The stem will give you a COWS score or describe objective withdrawal signs — that is your green light.

Know the alcohol withdrawal clock. Seizures at 24 to 48 hours, DTs at 48 to 96. A patient two days after their last drink with fever, tachycardia, hypertension, and confusion has delirium tremens and needs inpatient benzodiazepines — this timeline question recurs constantly.

Varenicline no longer carries the neuropsychiatric boxed warning. The EAGLES trial led FDA to remove it in 2016. A question offering "avoid varenicline because of depression history" as an answer is testing whether your knowledge is current — stable psychiatric illness is not a contraindication.

Naltrexone and opioids do not mix. Naltrexone blocks mu receptors: it precipitates withdrawal in opioid-dependent patients and blunts opioid analgesia. Before starting it for alcohol use disorder, confirm the patient is not using opioids. This interaction is a favorite distractor.

Motivational interviewing beats confrontation in every counseling stem. Ask permission, reflect ambivalence, support autonomy. Answer choices that lecture, scare, or set ultimatums are wrong. The exam also rewards harm-reduction framing: naloxone kits, syringe services, and continued engagement even during active use.

Common pitfalls

Do not taper or discontinue buprenorphine just because a patient is stable. Stability on medication is the goal, not a stopping point. Discontinuation is associated with relapse and overdose death. Questions suggesting a time-limited course of buprenorphine are testing whether you treat OUD as the chronic disease it is.

Do not use metronidazole-style caution as a reason to skip naltrexone — but do check the liver and the opioid history. The real contraindications are current opioid use, anticipated opioid need, and acute hepatitis or liver failure. Mild transaminase elevation from alcohol itself is not a contraindication.

Do not manage alcohol withdrawal with fixed-schedule benzodiazepines in every patient. Symptom-triggered dosing by CIWA reduces total benzodiazepine exposure and shortens treatment. Fixed dosing is reserved for patients who cannot be reliably scored or have a history of severe withdrawal.

Do not forget thiamine before glucose in heavy drinkers. Glucose loading in a thiamine-deficient patient can precipitate Wernicke encephalopathy — confusion, ataxia, ophthalmoplegia. Give thiamine first; this ordering detail is tested.

Methadone for addiction cannot come from your office. For OUD, methadone is dispensed only through certified opioid treatment programs. (Prescribing methadone for pain from an office is legal but is a different scenario.) Conflating the two is a classic exam trap.

Do not treat neonatal opioid withdrawal risk as a reason to stop maternal buprenorphine. Continuing medication in pregnancy improves outcomes for both patient and infant. Recommending withdrawal or dose reduction in pregnancy is the wrong answer.

Cannabis and stimulant use disorders have no FDA-approved medication. The evidence-based answer is psychosocial: contingency management for stimulant use disorder is the best-supported option. A stem offering a medication for stimulant use disorder is usually testing that no approved one exists.

Frequently asked questions

What substance use topics are most tested on the ABFM?

Alcohol screening and pharmacotherapy (naltrexone, acamprosate), alcohol withdrawal timelines and CIWA-guided treatment, buprenorphine initiation and maintenance for opioid use disorder, tobacco cessation pharmacotherapy (varenicline, combination NRT, bupropion), naloxone co-prescribing, and SBIRT-style screening and brief intervention. Substance use in pregnancy appears regularly.

Do family physicians still need a waiver to prescribe buprenorphine?

No. The X-waiver was eliminated by federal law in early 2023. Any clinician with a standard DEA registration can prescribe buprenorphine for opioid use disorder, and recent exams treat office-based buprenorphine as core family medicine. Older question banks written in the waiver era can be misleading on this point.

Which alcohol use disorder medication should I pick on the exam?

Naltrexone first, unless the stem gives you a reason not to: current opioid use or anticipated opioid need, or acute hepatitis or liver failure. With significant liver disease, choose acamprosate (adjust for renal function). Disulfiram is almost never the best answer — it requires supervised abstinence and motivation, and the evidence is weaker.

How is alcohol withdrawal severity tested?

Through timeline recognition and disposition decisions. Know that tremor starts at 6 to 12 hours, seizures cluster at 24 to 48 hours, and delirium tremens at 48 to 96 hours. Mild withdrawal without prior complications can be managed outpatient; prior withdrawal seizures, DTs, comorbidity, or an unreliable environment push toward inpatient symptom-triggered benzodiazepines.

What is the most effective tobacco cessation approach?

Varenicline or combination nicotine replacement (patch plus short-acting form), each paired with behavioral counseling — the combination of medication and counseling outperforms either alone. Varenicline is safe in stable psychiatric illness since the boxed warning was removed. E-cigarettes are not a first-line recommendation on the boards.

When should naloxone be co-prescribed?

For patients on 50 morphine milligram equivalents per day or more, anyone on concurrent benzodiazepines or other sedatives, patients with a history of overdose or substance use disorder, and household exposure risks. On the exam, offering naloxone is essentially never wrong, and withholding it to "avoid enabling" is always wrong.

How should I study substance use in five-minute daily sessions?

Drill the decision rules: which alcohol medication for which patient, the withdrawal timeline, buprenorphine induction timing, and tobacco pharmacotherapy selection. These are discrete, repeatable facts that spaced repetition locks in quickly. Then practice counseling-style vignettes, where recognizing the motivational-interviewing answer is the skill being tested.