Substance Abuse SOAP Note Example: Complete Documentation Guide for Addiction Medicine

Documentation in addiction medicine carries weight that goes far beyond typical medical notes.

Your words become part of legal proceedings, insurance determinations, custody battles, employment decisions, and treatment access.

I've worked with addiction medicine specialists, psychiatrists, and primary care providers who've seen their documentation used in ways they never intended—sometimes helping patients access life-saving treatment, other times becoming barriers to housing, employment, or family reunification.

The challenge is that substance use disorder documentation must simultaneously serve multiple masters: regulatory compliance for controlled substance prescribing, insurance authorization for treatment programs, legal protection for both you and your patient, and most importantly, actually supporting recovery.

Getting this balance right isn't intuitive, and the stakes for getting it wrong are enormous.

That's why I built SOAP Notes Doctor with specific features for addiction medicine documentation—helping you write notes that meet every regulatory requirement while treating patients with the dignity they deserve.

Let me show you how to document substance use disorders effectively.

Why Substance Abuse Documentation Is Uniquely Challenging

Substance use disorder documentation operates under constraints that don't exist in other medical specialties.

DEA scrutiny: If you prescribe buprenorphine or other controlled substances for addiction treatment, your documentation will be reviewed for diversion risk and prescribing appropriateness.

Insurance prior authorizations: Treatment programs, long-term residential care, and MAT medications often require extensive documentation proving medical necessity and showing that lower levels of care have failed.

Legal implications: Your notes may be subpoenaed for criminal cases, child custody proceedings, disability claims, or employment disputes—often without your knowledge or consent.

Stigma and discrimination: Language in your notes can follow patients for years, affecting their access to pain management, surgical care, housing, and employment.

Confidentiality regulations: 42 CFR Part 2 creates additional privacy protections for substance use disorder records that go beyond regular HIPAA requirements.

Recovery sensitivity: Your documentation needs to support hope and recovery rather than labeling patients in ways that become self-fulfilling prophecies.

This creates a documentation paradox: you need comprehensive notes for regulatory and insurance purposes, but you also need to protect patients from the discriminatory consequences of having a documented substance use disorder.

Person-First Language and Recovery-Oriented Documentation

Before we get into SOAP note structure, let's address language.

The words you choose in substance use disorder documentation have profound implications.

Instead of: "Addict," "alcoholic," "substance abuser," "clean," "dirty"

Use: "Person with opioid use disorder," "person in recovery," "patient," "negative urine screen," "positive for [substance]"

Instead of: "Denies drug use" (implies disbelief)

Use: "Reports abstinence from [substance]" or "States no recent use"

Instead of: "Non-compliant" or "failed treatment"

Use: "Did not complete program" or "treatment episode ended before completion"

This isn't just political correctness. Language shapes how other providers treat your patients, how insurance companies view treatment requests, and how patients see themselves.

Recovery-oriented documentation acknowledges that substance use disorders are chronic medical conditions with the possibility of remission, not moral failures requiring punishment.

Understanding Required Documentation Elements

Substance use disorder SOAP notes need specific elements that other medical notes don't require:

For MAT Prescribing (Buprenorphine/Naltrexone)

• Documentation of opioid use disorder diagnosis using DSM-5 criteria
• Assessment of withdrawal symptoms if applicable
• Urine drug screen results with interpretation
• Diversion risk assessment
• Psychosocial stability and support system
• Concurrent psychiatric conditions
• Treatment history including previous MAT attempts

For Insurance Authorization

• ASAM criteria level of care determination
• Specific functional impairments caused by substance use
• Previous treatment episodes and outcomes
• Current risk factors (overdose risk, injection use, polysubstance use)
• Barriers to recovery and how proposed treatment addresses them
• Family/social support availability

For Regulatory Compliance

• Informed consent documentation for MAT
• Controlled substance agreement for Schedule II-IV prescriptions
• Pill counts or medication monitoring when indicated
• Documentation of naloxone prescription and education
• Coordination with behavioral health services

Let's look at how this translates into actual SOAP notes.

Example 1: Initial MAT Evaluation for Opioid Use Disorder

Patient: 34-year-old male
Chief Complaint: Seeking medication assistance for opioid dependence
Visit: Initial buprenorphine evaluation

S – Subjective:

Patient self-presents requesting medication-assisted treatment for opioid use disorder. Reports 8-year history of opioid use beginning with prescription hydrocodone after back injury, progressing to heroin over past 3 years. Current use: smoking approximately 1 gram heroin daily, last use yesterday evening. Multiple previous attempts to quit including outpatient counseling (2022, attended 4 sessions before stopping) and one medical detox (2023, relapsed within 1 week). Motivated for treatment now due to financial strain, relationship stress with partner who is in recovery, and fear of overdose after friend died from fentanyl-laced heroin last month. Reports mild withdrawal symptoms this morning: muscle aches, rhinorrhea, anxiety, craving. Denies current suicidal ideation. Living situation stable, rents apartment with employed partner. Works part-time in construction when able. Has insurance through partner's employer. Expresses understanding that medication is part of comprehensive treatment requiring counseling.

O – Objective:

Vital Signs: BP 142/88, HR 92, Temp 98.8°F, pupils 4mm and reactive
General: Appears mildly anxious, cooperative, no acute distress
COWS Score: 11 (moderate withdrawal) - yawning, rhinorrhea, piloerection, restlessness, dilated pupils, mild tachycardia
Mental Status: Alert and oriented x4, mood anxious, affect congruent, thought process organized, denies SI/HI, judgment fair, insight developing
Track marks: Healed scars bilateral antecubital fossae, no acute injection sites
Urine Drug Screen: Positive for opiates and THC, negative for fentanyl, cocaine, amphetamines, benzodiazepines
Recent Labs: HIV negative, Hep C positive (aware of diagnosis, not yet treated), LFTs mildly elevated (AST 68, ALT 72)

A – Assessment:

Opioid use disorder, severe (meets 8 of 11 DSM-5 criteria: tolerance, withdrawal, larger amounts/longer than intended, persistent desire to cut down, significant time obtaining/using/recovering, continued use despite social/interpersonal problems, giving up activities, use in hazardous situations). Currently experiencing moderate opioid withdrawal. Patient demonstrates motivation for treatment and realistic understanding of recovery process. Risk factors include: 8-year duration of use, history of relapse after detox, exposure to fentanyl-contaminated supply, injection drug use history (though not current), chronic HCV infection. Protective factors include: stable housing, employed partner supportive of recovery, recent overdose death of friend providing motivation, insurance coverage for treatment, no active suicidal ideation, voluntary treatment seeking. Appropriate candidate for office-based buprenorphine treatment per SAMHSA guidelines.

P – Plan:

Medication-Assisted Treatment: Initiated buprenorphine/naloxone 8mg/2mg sublingual. Provided dosing instructions for home induction: take first dose when experiencing moderate withdrawal (12-24 hours after last opioid use), may repeat 4mg after 2 hours if needed, maximum 16mg first day. Patient demonstrated understanding of induction process and risks of precipitated withdrawal. Prescribed buprenorphine/naloxone 8mg/2mg sublingual film, #28, dose 8-16mg daily, dispensed as daily dosing (not split), 2 refills (will transition to monthly after stabilization).

Harm Reduction: Prescribed naloxone 4mg nasal spray x2, educated on overdose recognition and administration. Discussed fentanyl testing strips and safer use practices if any return to use occurs.

Counseling Requirement: Referred to outpatient substance use counseling, provided list of three local providers accepting his insurance. Explained that buprenorphone is FDA-approved and counseling, while strongly recommended, is not required to receive medication per current guidelines. However, combined treatment offers best outcomes.

Treatment Agreement: Reviewed and signed controlled substance treatment agreement including expectations for: keeping scheduled appointments, not obtaining opioids from other sources, random urine drug screens, secure medication storage, single prescriber/pharmacy.

Medical Management: Discussed HCV treatment once stabilized on MAT. Will coordinate with infectious disease or hepatology. Referred to primary care for general health maintenance if doesn't have established PCP.

Follow-up: Return in 3 days for induction check and dose adjustment. Then weekly visits x 4 weeks until stable, followed by every-other-week visits x 2 months, then monthly if doing well. Patient provided crisis numbers for after-hours support. Discussed signs requiring immediate medical attention: severe sedation, difficulty breathing, confusion. Patient verbalized understanding of treatment plan and recovery is a process requiring time and support.

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Example 2: Established MAT Patient, Stable in Recovery

Patient: 41-year-old female
Chief Complaint: Routine follow-up, buprenorphine refill
Visit: Established patient, monthly MAT visit

S – Subjective:

Patient presents for routine buprenorphine follow-up. Reports doing well, feeling stable on current dose of buprenorphine/naloxone 16mg daily. No cravings, no withdrawal symptoms, sleeping well. Continues abstinence from all non-prescribed substances for 7 months now. Attending weekly outpatient counseling with good engagement, finds group therapy particularly helpful. Working full-time as medical assistant, recently received positive performance review. Relationship with teenage daughter improving, recently allowed unsupervised visits. Maintaining active recovery support through weekly NA meetings. Reports significant improvement in depression since starting sertraline 3 months ago. Denies any medication side effects. No medication diversion concerns, keeps medication in locked safe.

O – Objective:

Vital Signs: BP 118/76, HR 72
General: Well-groomed, appropriate dress, engaged and conversational
Mental Status: Euthymic mood, full affect, coherent thought process, denies SI/HI
Pill Count: 30 pills expected, 30 pills present (100% compliance)
Urine Drug Screen: Positive for buprenorphine, negative for all other substances including opiates, cocaine, amphetamines, benzodiazepines, THC
PDMP Review: No controlled substances from other prescribers, all buprenorphine fills consistent with prescribed amounts from this office only

A – Assessment:

Opioid use disorder, in sustained remission on medication-assisted treatment. Patient demonstrates excellent treatment adherence, engagement with psychosocial support, and functional recovery. No evidence of diversion, concurrent substance use, or treatment complications. Current dose appropriate and well-tolerated. Depression stable on SSRI therapy. Patient meeting all treatment goals and making substantial progress in family, occupational, and social functioning.

P – Plan:

Medications: Continue buprenorphine/naloxone 16mg daily, #30, 1 refill. Continue sertraline 100mg daily for depression management. Naloxone prescription reviewed, patient has unexpired naloxone at home.

Counseling: Continue weekly outpatient therapy and NA attendance. Patient finds current level of support helpful and appropriate.

Monitoring: Return in 4 weeks for routine follow-up and refill. Will continue monthly urine drug screens and PDMP checks per protocol. No changes to monitoring frequency needed given stable course.

Taper Discussion: Briefly discussed long-term treatment planning. Patient expresses comfort remaining on current dose and does not feel ready to consider taper. Educated that buprenorphine is safe for long-term maintenance, many patients benefit from years of treatment, and tapering is an option when patient feels ready and has strong recovery foundation. No pressure to taper.

Patient continues making excellent progress in recovery. Encouraged to maintain current treatment engagement.

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Example 3: Acute Relapse Episode During MAT Treatment

Patient: 28-year-old male
Chief Complaint: Used cocaine over the weekend, concerned about treatment
Visit: Unscheduled walk-in appointment

S – Subjective:

Patient presents for unscheduled visit, appears distressed. Reports using cocaine on Saturday night at a party, first use of any substance since starting buprenorphine treatment 4 months ago. States he went to a friend's birthday party, felt confident in recovery, but several people were using and he "made a bad decision in the moment." Used approximately $40 worth of cocaine, did not use any opioids. Feels guilty and ashamed, worried about being discharged from treatment. Continues taking buprenorphine as prescribed, no missed doses. Denies ongoing cravings for cocaine or opioids. Recognized he should have left the party when drug use began, plans to avoid similar situations. Has not contacted counselor yet but plans to discuss in session tomorrow. No suicidal ideation but describes feeling "disappointed in myself." Did not use any injection drugs.

O – Objective:

Vital Signs: BP 128/82, HR 78
General: Tearful at times, visibly distressed, makes good eye contact
Mental Status: Alert and oriented, mood depressed/anxious, affect congruent, thought process intact, no SI/HI, insight good - recognizes relapse triggers and need for behavior change
Urine Drug Screen: Positive for buprenorphine and cocaine metabolite, negative for opiates, fentanyl, amphetamines, benzodiazepines
Pill Count: 120 pills expected (from monthly supply), 123 present (appropriate - patient takes 4 per day)

A – Assessment:

Opioid use disorder, early remission with recent cocaine use. Patient experiencing isolated relapse episode with cocaine while maintaining adherence to buprenorphine and abstinence from opioids. Demonstrates good insight into trigger situation (party environment with active drug use), appropriate emotional response, and immediate help-seeking behavior. This represents a lapse rather than full relapse to opioid use. Cocaine use concerning but patient not meeting criteria for stimulant use disorder currently. Patient maintaining protective factors: medication adherence, employment, housing, supportive relationships, engagement with treatment. Appears genuinely motivated to return to full abstinence.

P – Plan:

Continued MAT: Continuing buprenorphine treatment unchanged. Reinforced that seeking help after using is exactly the right response, not a reason for discharge from treatment. Recovery is not always linear, lapses happen, and the important thing is returning to recovery-focused behaviors quickly.

Enhanced Support: Patient to contact counselor today to schedule additional session this week. Discussed increasing counseling frequency temporarily from weekly to twice weekly for next month. Encouraged increased NA meeting attendance, particularly meetings focused on preventing relapse.

Trigger Management: Reviewed high-risk situations and relapse prevention strategies. Discussed importance of having exit plan when attending social events, bringing supportive friend, limiting time in triggering environments. Talked about "playing the tape forward" - thinking through consequences before using.

Monitoring: Return in 1 week for follow-up rather than waiting until scheduled monthly visit. Will reassess at that time whether additional interventions needed. Random urine screens may be increased temporarily based on next week's assessment.

No Punitive Measures: Explicitly stated that this cocaine use does not result in treatment termination, reduction in take-home doses, or other consequences beyond increased monitoring for patient safety. The goal is supporting return to recovery, not punishment.

Patient expressed relief about continued treatment and commitment to working on recovery skills. Encouraged to reach out immediately if experiences strong cravings or feels at risk for further use.

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Critical Documentation Mistakes to Avoid

Based on years of reviewing substance use disorder notes and seeing how they're used (and misused), here are the most damaging documentation errors:

Using Stigmatizing Language

Writing "drug-seeking behavior" when you mean "requesting pain medication" can follow patients for years and prevent them from receiving appropriate pain management even for legitimate conditions like cancer or post-surgical pain.

Over-documenting Legal History

Include only what's clinically relevant. "Patient has 3 prior arrests for possession" isn't necessary unless it directly impacts current clinical decision-making. This information can be used against patients in custody battles, housing applications, or employment.

Labeling Patients as "Manipulative"

This subjective judgment tells future providers to distrust the patient. If you're concerned about deception, document specific behaviors: "Patient's report of running out of medication early is inconsistent with pill count showing medication remaining."

Not Documenting Improvement

Notes often document every relapse but fail to document periods of stability, employment success, family reunification, or other recovery milestones. Balance is important for showing that treatment is working and should continue.

Violating 42 CFR Part 2

Substance use disorder treatment records require specific consent for disclosure that's separate from regular HIPAA authorization. Sending records without proper consent violates federal law.

Missing Positive UDS Interpretation

Don't just document "positive cocaine." Explain the clinical significance: "Urine positive for cocaine metabolite, which patient disclosed using 2 days ago. Patient remains engaged in treatment, no evidence of return to opioid use, counseling session scheduled to address relapse prevention."

Documentation Requirements for Different Treatment Settings

The level of detail required varies by setting:

Office-Based MAT

Focus on: medication monitoring, diversion risk assessment, UDS results, counseling engagement, functional recovery metrics. Monthly notes can be relatively brief for stable patients.

Intensive Outpatient Programs (IOP)

Require: daily attendance documentation, group therapy participation notes, individual counseling sessions, random UDS results, progress toward treatment plan goals measured weekly.

Residential Treatment

Most comprehensive documentation: daily nursing notes, weekly physician evaluations, group therapy process notes, individual counseling sessions, family therapy when applicable, discharge planning starting day one.

Hospital Consultation for Substance Use

Different focus: medical stability, withdrawal management, motivation for treatment, safe discharge planning, referral to outpatient treatment, naloxone prescription.

How SOAP Notes Doctor Handles Addiction Medicine Documentation

When you use SOAP Notes Doctor for substance use disorder visits, the system:

• Automatically uses person-first, recovery-oriented language
• Includes required elements for MAT prescribing and regulatory compliance
• Documents ASAM criteria and medical necessity appropriately for insurance
• Balances comprehensive documentation with privacy protection
• Structures notes to support treatment continuation rather than discharge
• Includes harm reduction principles in treatment planning
• Maintains appropriate professional tone while showing patient respect

You provide the clinical observations and decisions—SOAP Notes Doctor formats everything to meet regulatory requirements while protecting patient dignity.

Visit soapnotes.doctor to see how it transforms addiction medicine documentation.

Final Thoughts on Substance Use Disorder Documentation

Documentation in addiction medicine carries unique weight and responsibility.

Your notes can open doors to life-saving treatment or create barriers that last for years.

The key is documenting comprehensively enough to satisfy regulatory and insurance requirements while protecting patients from the stigma and discrimination that too often follow substance use disorder diagnoses.

Use person-first language, focus on recovery rather than pathology, document both challenges and successes, and remember that your words may be read in contexts you never intended.

Good documentation supports recovery, justifies continued treatment, and helps patients access the care they need while protecting their dignity.

That's what addiction medicine documentation should be.

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Ready to improve your substance use disorder documentation?
Visit soapnotes.doctor and create recovery-oriented notes that meet all regulatory requirements.