CCFP priority topic 95 of 105
Substance use and addiction on the CCFP exam
11 key features, the mistakes that cost marks, and a practice question.
Checked by a Canadian family physician, MD, CCFP. Updated October 20, 2026.
What the exam tests
Key features
The CFPC’s 11 key features for Substance use and addiction. Each one below has how the exam asks it, the common mistakes and the approach.
Practice question
Try one before you read
A real case from the bank, in the new short-menu format. Answer it first. Then read the key features.
Key feature 1 of 11
Ask everyone
Ask every patient about smoking, drinking and drug use, most of all those with mental illness.
CFPC skill Patient-centred approach, selectivityPhase History, hypothesis generationSources CRISM / BCCSU 2023
On the exam
A visit for something else, in a patient with depression. Expect a short menu (pick several from a list).
Pick the questions to ask today.
Common mistakes
Asking about substances only because the complaint points there, or skipping it because depression explains the patient's mood. Use is easy to miss when mental illness is present.
Approach
- Ask about tobacco, alcohol, cannabis and other drugs at routine visits, not only when the complaint points there.
- Screen every adult and youth for drinking above low risk. The Canadian alcohol guideline makes this a strong recommendation.
- A positive screen gets brief advice, then a diagnostic interview using the standard criteria (DSM-5).
- Use Canada's Guidance on Alcohol and Health to open the talk about drinking.
- Ask with extra care when mental illness or a disability is present. Use is easy to miss there.
- Ask plainly and without judgement.
Key feature 2 of 11
Harms and safer use
Talk with anyone who uses, even now and then, about harm to others and how to lower risk.
CFPC skill Patient-centred approach, professionalism, clinical reasoningPhase TreatmentSources CRISM / CMAJ 2024, CRISM / BCCSU 2023
On the exam
A man on buprenorphine–naloxone who snorts opioids, here with his partner. Expect a short menu (pick several from a list).
Pick the steps that lower his risk.
Common mistakes
Needle exchange for a man who snorts, or teaching only him to use naloxone. He cannot give his own dose; his partner must know how.
Approach
- Give a take-home naloxone kit and overdose teaching to anyone who uses opioids, even when stable on treatment.
- Teach the people at home to use the kit. A person who is overdosing cannot give their own dose.
- Match supplies to the route. Sterile injecting gear helps only someone who injects.
- Ask about children in the home, driving, and sex while high or drunk.
- Advise no driving for at least 6 hours after cannabis. Never drive after cannabis and alcohol together.
- Offer harm reduction as part of care, not as a reward for stopping.
Key feature 3 of 11
Confusion and decline
In new confusion or a slide in function, look for substance use or withdrawal, even if another cause seems obvious.
CFPC skill Clinical reasoningPhase Hypothesis generation, diagnosisSources Choosing Wisely Canada, CRISM / BCCSU 2023
On the exam
A man in his seventies with two months of forgetfulness and a fall, on an opioid and a sleeping pill. Expect a short menu (pick several from a list).
Pick the findings that point to the cause.
Common mistakes
A dementia work-up because his mother had Alzheimer disease. Drowsiness and small pupils point first to his medicines.
Approach
- List every sedating drug: opioids, benzodiazepines, zopiclone, alcohol and cannabis. Ask about recent stopping too.
- Drowsiness with small pupils suggests opioid effect. Look for it before you order tests.
- In older adults, benzodiazepines and other sleeping pills can more than double the risk of falls, hip fracture and car crashes.
- Don't use a benzodiazepine or other sleeping pill as the first choice for delirium in an older adult.
- Alcohol withdrawal can cause seizures and delirium tremens (severe withdrawal with confusion). Past seizures or delirium tremens raise the risk.
- Review and reduce sedating drugs before you label the change dementia.
| Risk of severe withdrawal | Medicine | Where |
|---|---|---|
| Low: Prediction of Alcohol Withdrawal Severity Scale (PAWSS) under 4 | Gabapentin, carbamazepine or clonidine | Outpatient, such as the office or virtual care |
| High: PAWSS 4 or more | A short benzodiazepine course | Ideally inpatient. Outpatient only with close monitoring. |
| After withdrawal | Offer ongoing treatment for the disorder | Every patient |
Key feature 4 of 11
Teens
When a teen's grades or conduct slip, ask about substance use with the teen and the family.
CFPC skill Clinical reasoning, patient-centred approachPhase Hypothesis generation, treatmentSources CRISM / BCCSU 2023, Choosing Wisely Canada
On the exam
A 16-year-old boy using cannabis daily, failing classes, with a worried mother. Expect a short menu (pick several from a list).
Pick what to do, and what to avoid.
Common mistakes
A urine drug test, or telling his mother against his wishes. He already told you, and a capable teen's health information is confidential.
Approach
- See the teen alone for part of the visit. Explain what stays private and when it would not.
- Encourage the teen to bring a parent into the plan. Don't simply accept, or force, leaving them out.
- Advise delay. Cannabis started before 16 is tied to more harm to health and life later.
- Daily or near-daily use carries the most harm. If not stopping, aim for occasional use at most.
- Ask about pills and synthetic cannabinoids. Edibles act slowly, which leads to taking too much.
- Order a urine drug screen only with a clear clinical reason.
Key feature 5 of 11
Not getting better
When a problem fails to respond to sound treatment, look for substance use behind it.
CFPC skill Clinical reasoning, patient-centred approachPhase Hypothesis generation, treatmentSources CRISM / BCCSU 2023
On the exam
A woman whose asthma stays poorly controlled on a sound inhaler plan smokes cannabis daily. Expect one best answer.
Pick the next step.
Common mistakes
Raising her inhaler dose or adding a drug before asking what she smokes. Smoked cannabis harms the airways, so ask first.
Approach
- Ask about substances when a treatable problem stays uncontrolled despite a sound plan.
- High triglycerides that will not come down: ask about alcohol.
- Asthma that stays poorly controlled: ask about smoking cannabis, tobacco or other inhaled drugs. Smoked cannabis harms the airways.
- Ask before you add another drug or another test.
Key feature 6 of 11
Long-term controlled drugs
For anyone on long-term opioids or sedatives, recheck the need, plan tapering and teach safe storage.
CFPC skill Clinical reasoning, selectivity, patient-centred approachPhase History, follow-up, treatmentSources Choosing Wisely Canada
On the exam
An older man, drowsy and falling, on an opioid and zopiclone for four years. Expect one best answer.
Pick the plan for his medicines.
Common mistakes
Stopping both drugs at once, or keeping both because he has been stable. Sudden stopping risks withdrawal and seizures; staying on keeps the falls.
Approach
- At each review, judge benefit by function, not by a pain score.
- Opioids with a benzodiazepine raise the risk of breathing that slows or stops.
- Zopiclone is a sleeping pill too. In older adults, avoid it and benzodiazepines as the first choice for sleep.
- Plan a slow taper the patient agrees to, rather than stopping suddenly.
- Teach safe storage, away from children, and how to return unused doses.
Key feature 7 of 11
A new prescription
Before starting an opioid, stimulant or sedative, ask about substance use and weigh the risk of misuse.
CFPC skill Clinical reasoning, professionalismPhase History, hypothesis generation, treatmentSources Choosing Wisely Canada, CRISM / CMAJ 2024
On the exam
A man just out of custody with back pain asks for the oxycodone he took before. Expect a short menu (pick several from a list).
Pick what to find out before prescribing.
Common mistakes
Restarting his old dose, or spending the visit on the disc bulge. Tolerance fades in custody, and the scan says nothing about misuse risk.
Approach
- Ask about alcohol, drug use and any past substance use disorder before a new opioid, stimulant or sedative.
- Ask about past overdose, mental illness and who else lives in the home.
- After custody or a break in use, tolerance may be gone. An old dose is no guide.
- Don't start opioids long-term for chronic pain. Physical activity is the base of care for chronic low back pain.
- For acute pain, give the lowest dose and fewest doses. That is usually 3 days or less, rarely more than 7.
- If he has opioid use disorder, treat it with buprenorphine or methadone, not oxycodone for pain.
- Explain the benefits and risks, and agree on what you will watch, before the first prescription.
Key feature 8 of 11
Readiness to change
Check, visit after visit, how ready the patient is to change their use.
CFPC skill Clinical reasoning, patient-centred approachPhase Diagnosis, follow-upSources CRISM / BCCSU 2023
On the exam
A man who drinks heavily says he is not ready to cut down. Expect one best answer.
Pick the best response today.
Common mistakes
Pushing a treatment plan he has turned down, or dropping the subject for good. Readiness shifts, so ask again next time.
Approach
- Ask how important change is to the patient, and how confident they feel about it.
- Not ready: give brief advice, link use to their own concerns, and keep the door open.
- Unsure: explore the good and bad of their use, in their words.
- Ready: agree on a goal. Cutting down is a valid goal, not only stopping.
- Ask again at each visit, and after a crisis or a setback.
- A return to use means adjusting the plan, not ending care.
Key feature 9 of 11
The treatment plan
Build a plan with the patient for withdrawal and ongoing care, using medicine, community help and your follow-up.
CFPC skill Patient-centred approach, clinical reasoningPhase TreatmentSources CRISM / CMAJ 2024, CRISM / BCCSU 2023, Choosing Wisely Canada
On the exam
A man using street opioids daily, who did well on buprenorphine–naloxone before, wants to stop. Expect one best answer.
Pick the best treatment for him.
Common mistakes
A short withdrawal course alone, or switching him to methadone without asking what he wants. Withdrawal alone raises overdose risk; his good past response and his wishes come first.
Approach
- Offer buprenorphine or methadone. Both are first-line. Choose with the patient: past response, preference, safety and access.
- Don't offer withdrawal management alone: relapse, illness and death rise. Pair it with long-term treatment.
- Slow-release oral morphine is second-line, for those who did not do well on first-line options. Only an experienced prescriber starts it, or one guided by an expert.
- Alcohol: offer naltrexone or acamprosate for moderate to severe disorder. Topiramate or gabapentin come next.
- No benzodiazepine as ongoing alcohol treatment, and none for opioid withdrawal.
- Offer counselling and peer support as add-ons. Never make counselling a condition of opioid agonist therapy (treatment with buprenorphine or methadone).
- See the patient often in the first weeks, and keep a naloxone kit in the home.
| Medicine | Place | Know this |
|---|---|---|
| Buprenorphine–naloxone | First-line, opioid use disorder | More dropout after the first month. If it happens, offer methadone or another option. |
| Methadone | First-line, opioid use disorder | Higher risk of death in the first month. Watch for overdose. |
| Slow-release oral morphine | Second-line, opioid use disorder | When first-line options have not worked. Only an experienced prescriber, or one guided by an expert. |
| Naltrexone | First-line, alcohol use disorder | Goal of stopping or cutting down. Without suspected liver disease, don't wait for liver tests. |
| Acamprosate | First-line, alcohol use disorder | Goal of stopping. |
Key feature 10 of 11
Linked illness and hardship
Use visits with a patient who has an addiction to look for linked illness, hardship and late harms.
CFPC skill Clinical reasoning, patient-centred approachPhase History, physicalSources Choosing Wisely Canada
On the exam
A man stable on opioid agonist therapy for a month. Expect a short menu (pick several from a list).
Pick the screening to offer now.
Common mistakes
A visit spent only on his dose and urine tests. His infections, mood, housing and liver go unchecked.
Approach
- Ask about injecting, shared supplies and sex, and offer the infection testing the risk calls for.
- Ask about mood, anxiety, thoughts of suicide and psychosis.
- Ask about housing, income, food, legal trouble and violence.
- Look for late harms of use, such as liver disease from alcohol or hepatitis C.
- Order urine drug tests only for a clear reason, such as confirming use at the start.
Key feature 11 of 11
Support the family
Offer help to relatives hurt by someone's addiction, even when the person who uses sees another doctor.
CFPC skill Patient-centred approachPhase Treatment
On the exam
A mother asks for help with her adult son's drinking; he sees another doctor. Expect a short menu (pick several from a list).
Pick the support to offer her.
Common mistakes
Turning her away because her son is someone else's patient, or discussing his care without his consent. She is your patient, and her needs count.
Approach
- Ask how it affects her: mood, sleep, money and safety at home.
- Ask about violence in the home and whether children are safe.
- Point her to family peer groups and local addiction services.
- If opioids are involved, tell her where to get a naloxone kit and training.
- Share nothing about him without his consent. Listening to her breaks no rule.
Flashcards
Answer it first, then check.
KF 1Who should be screened for drinking above low risk?
Every adult and youth, routinely. A positive screen gets brief advice and a diagnostic interview. Source: CRISM / BCCSU 2023
KF 3Low risk of severe alcohol withdrawal. What can manage it outside hospital?
A non-benzodiazepine: gabapentin, carbamazepine or clonidine. High risk needs a short benzodiazepine course, ideally inpatient. Source: CRISM / BCCSU 2023
KF 4A 15-year-old uses cannabis daily. Which two facts raise the risk?
Starting before 16, and using daily or nearly daily. Both are tied to more harm later. Source: CRISM / BCCSU 2023
KF 6He takes an opioid and a benzodiazepine every night. What is the main danger?
Breathing that slows or stops. Recheck whether each drug is still needed. Source: Choosing Wisely Canada
KF 7An opioid for acute pain after an injury. How long should the course last?
Usually 3 days or less, rarely more than 7, at the lowest dose that works. Source: Choosing Wisely Canada
KF 9Opioid use disorder: buprenorphine or methadone first?
Either. Both are first-line. Choose with the patient by past response, preference, safety and access. Source: CRISM / CMAJ 2024
KF 9Why not offer opioid withdrawal management on its own?
It raises rates of relapse, illness and death. Pair it with long-term addiction treatment. Source: CRISM / CMAJ 2024
KF 9Alcohol use disorder, and her goal is to cut down. Which medicine?
Naltrexone. Acamprosate suits a goal of stopping completely. Source: CRISM / BCCSU 2023
FAQ
Is buprenorphine still preferred over methadone?
Not since the 2024 Canadian update. Both are first-line. Choose using the patient's preference, past response, safety and access. Slow-release oral morphine is second-line.
Should I order a urine drug screen for every patient who uses drugs?
No. Choosing Wisely Canada advises against urine drug screens without a clear clinical reason. Confirming use at the start of treatment is one. A point-of-care test is usually enough.
Can a teen's substance use be kept from the parents?
Usually, yes, if the teen is capable of making the decision. Breaking confidence needs a serious risk of harm. Encourage, rather than force, bringing a parent into the plan.
Do I need a special exemption to prescribe methadone?
Not a federal one: that exemption ended in 2018. Your province or college may still set its own training rules, so check them before you start prescribing.
Sources
Written from the CFPC Assessment Objectives and Canadian guidelines first. Checked by a Canadian family physician, MD, CCFP.
Last reviewed October 20, 2026For exam study. Not advice for a patient in front of you.
- Assessment Objectives for Certification in Family Medicine, 2nd editionCollege of Family Physicians of Canada · 2020
- CRISM national clinical resourcesCRISM / BCCSU · 2023
- Management of opioid use disorder: 2024 national guideline updateCRISM / CMAJ · 2024
- Choosing Wisely recommendationsChoosing Wisely Canada