SOAP Notes for Substance Use Disorder: Example and Template
Overview
This guide is part of our complete SOAP notes hub — format structure, a full clinical example, and all 72 diagnosis-specific templates.
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Short answer: a substance use disorder (SUD) SOAP note records the client’s report of use since the last session (substance, days, amount, route), cravings, triggers and recovery supports in Subjective; your observations, any results shared by a prescriber or lab with the client’s consent, and the intervention you used in Objective; your clinical judgment about progress, overdose and withdrawal risk, and suicide risk in Assessment; and next steps, coordination and the next session in Plan.
Many clients with opioid use disorder (OUD) receive medication for opioid use disorder (MOUD), such as buprenorphine, methadone or extended-release naltrexone, from a separate prescriber or opioid treatment program. A counselor’s note records what the client reports about their medication, any information shared with written consent, and coordination with the prescriber, not dosing or medication decisions. Record the diagnosis with its DSM-5-TR severity (2–3 of the 11 criteria is mild, 4–5 moderate, 6 or more severe), and, if your program is covered by the federal 42 CFR Part 2 rules, follow them for consent and disclosure.
What to document in a substance use disorder SOAP note
| Section | What to document | Example wording |
|---|---|---|
| Subjective | Use since the last session: substance, days, amount, route | “No non-prescribed opioid use in the past 3 weeks by client report; one use of non-prescribed pills 3 weeks ago.” |
| Subjective | Medication as the client reports it, cravings and supports | “Taking buprenorphine-naloxone as prescribed by the clinic; cravings 4/10 at most; attended 2 peer-support meetings.” |
| Objective | Observations and results shared with consent | “Alert, speech clear, pupils not constricted. Prescriber’s note (shared with written consent): last urine drug test consistent with prescribed buprenorphine.” |
| Objective | The intervention used | “Motivational interviewing; reviewed and updated the relapse prevention and overdose response plan.” |
| Assessment | Progress and diagnosis with severity | “Opioid use disorder, severe (F11.20); 3 weeks without non-prescribed opioid use, engaged in MOUD and counseling.” |
| Assessment | Overdose and suicide risk | “Overdose risk persists if non-prescribed use resumes, particularly with an unpredictable drug supply or interrupted MOUD; naloxone at home. Denied suicidal thoughts.” |
| Plan | Client tasks, coordination with consent, next session | “Keep naloxone with them; 2 meetings; with written consent, update the prescriber on attendance. Next session in 1 week.” |
After a period of not using opioids, tolerance falls, so a return to use carries a high risk of overdose, and the illicit drug supply may contain fentanyl. Combining opioids with alcohol, benzodiazepines or other sedatives raises the risk further. Record whether the client has naloxone and knows how to use it, and whether people around them do; naloxone nasal spray is sold without a prescription in the US. If a client reports withdrawal symptoms or plans to stop a medication, refer them to their prescriber rather than advising on it. If a client reports suicidal thoughts, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means, protective factors, your risk formulation and the safety plan. The 988 Suicide & Crisis Lifeline takes calls and texts at 988; for imminent danger, call 911 or go to the nearest emergency department.
How to Document SOAP Notes for Substance Use Disorder
Subjective
Record the client's reported symptoms, concerns, mood, and perspective in their own words
When documenting the Subjective section for substance use disorder, record the client’s self-reported experiences, including their current symptoms, emotional state, triggers for use, and any concerns or cravings they describe.
- Client’s description of cravings and urges related to substance use
- Reported triggers or high-risk situations that increase likelihood of use
- Mood and affect as described by the client during the session
- Client’s perception of control over substance use or relapse risk
- Any expressed concerns about physical or psychological effects of substance use
Objective
Document clinical observations, affect, behavior, appearance, and measurable data
In the Objective section for substance use disorder, document observable clinical signs, behavioral observations, and any interventions or assessment tools employed during the session.
- Appearance and hygiene indicative of substance use or withdrawal
- Behavioral signs such as agitation, tremors, or psychomotor retardation
- Use of standardized screening tools (e.g., AUDIT, CAGE) administered during session
- Application of therapeutic techniques such as motivational interviewing or cognitive-behavioral strategies
- Client’s engagement level and responsiveness throughout the session
Assessment
Provide clinical interpretation, diagnostic impressions, and progress evaluation
The Assessment section should summarize clinical impressions, progress toward treatment goals, diagnostic considerations, and the client’s response to interventions specific to substance use disorder.
- Clinical impressions regarding severity and pattern of substance use
- Evaluation of client’s motivation and readiness for change
- Progress toward abstinence or harm reduction goals since last session
- Identification of co-occurring mental health symptoms impacting substance use
- Client’s response and insight gained from therapeutic interventions
Plan
Outline treatment strategy, interventions, homework, and follow-up schedule
Document in the Plan section the next steps for treatment, including recommended interventions, referrals, homework assignments, and scheduling specific to managing substance use disorder.
- Referral to specialized addiction treatment programs or support groups
- Assignment of coping skills or relapse prevention homework
- Modification of treatment goals based on current progress and challenges
- Scheduling frequency and type of follow-up sessions
- Coordination with other healthcare providers for integrated care
DAP Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
BIRP Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
Progress Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
SIRP Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
GIRP Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
PIE Notes for Substance Use Disorder
Alternative format for documenting substance use disorder
Example SOAP Note for Substance Use Disorder
Fictional documentation example, not treatment guidance. Every detail is invented. Adapt it to the session you actually provided and your organization’s requirements.
Subjective: Fictional adult client, session 7 of outpatient counseling for opioid use disorder, severe (F11.20; 7 of 11 DSM-5-TR criteria at intake), 50 minutes in person. Client receives buprenorphine-naloxone from the clinic’s prescriber, started 6 weeks ago. Treatment-plan goals: (1) no non-prescribed opioid use; (2) use a coping step when cravings reach 5/10 or more; (3) attend 2 peer-support meetings a week; (4) return to part-time work. Client reported no non-prescribed opioid use in the past 3 weeks; 3 weeks ago they used non-prescribed pills once after an argument with their brother. Said they are taking the medication as prescribed and that cravings have peaked at 4/10, mostly on paydays. Attended 2 peer-support meetings this week. Denied alcohol, benzodiazepine and other drug use. Said, “I want to be someone my kids can count on again.”
Objective: On time, alert, speech clear and coherent, pupils not constricted, no signs of intoxication or withdrawal observed. Affect euthymic, brighter when talking about their children. The prescriber’s most recent note, shared with the client’s written consent, reports a urine drug test consistent with prescribed buprenorphine. Used motivational interviewing to strengthen the client’s reasons for staying in treatment, reviewed the payday trigger and built a plan (direct deposit to a joint account with their partner, a call to their sponsor on payday evenings). Reviewed the overdose response plan: the client keeps naloxone at home and their partner has been shown how to use it.
Assessment: Progress toward goal 1 (3 weeks without non-prescribed opioid use) and goal 3 (2 of 2 meetings this week), with good engagement in MOUD and counseling. Paydays and family conflict are the main triggers. Goal 2 is partly met (no cravings at 5/10 or more this week to test it), and goal 4 has not yet started. Return to non-prescribed opioid use would carry overdose risk because pill contents and potency are unpredictable. Ongoing buprenorphine treatment is protective; the reported interval without non-prescribed use does not establish loss of opioid tolerance. Interrupting MOUD and returning to use would increase concern. Protective factors include engagement in MOUD, naloxone in the home and family support; medication questions remain with the prescriber. Asked directly: denied suicidal thoughts, plan or intent, now and since the last session; no past attempts reported.
Plan: Continue weekly individual sessions. Client: payday plan as agreed, 2 peer-support meetings next week, carry naloxone when out. With the client’s written consent, send the prescriber a brief update on attendance and the payday plan. Begin goal 4 next session (contact with the vocational counselor). Client knows to call or text 988, or call 911 in an emergency, and to call 911 and use naloxone if anyone shows signs of overdose. Next session in 1 week.
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Tips for SOAP Notes for Substance Use Disorder
1. Quantify use
Record the substance, number of days, amount and route since the last session, compared with the week before or intake.
2. Record MOUD as reported
Note the medication the client reports taking and who prescribes it. Leave dosing and medication decisions to the prescriber.
3. Keep overdose risk visible
Record lowered tolerance, mixing with sedatives, whether the client has naloxone, and who around them can use it.
4. Attribute shared results
When a prescriber or lab shares a drug test result, record the source, the date and that the client consented to the sharing.
5. Name the intervention
Write “motivational interviewing,” “relapse prevention planning” or “trigger analysis,” not just “discussed recovery.”
6. Follow consent rules for coordination
Before contacting a prescriber, family member or court, record the client’s written consent and what you shared, following 42 CFR Part 2 if your program is covered.
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Further Reading
- SAMHSA — Provides authoritative resources and guidelines on substance use disorder treatment and documentation best practices.
- DSM-5-TR — Offers standardized diagnostic criteria essential for accurate assessment and documentation of Substance Use Disorders.
- CMS Documentation Requirements — Details regulatory standards for clinical documentation, ensuring SOAP notes meet compliance for billing and treatment verification.