Appendices
Appendix A: Quick-Reference Substance Assessment Checklist
Use this checklist to ensure comprehensive coverage across all ten substance categories:
□ Universal Questions (for each substance)
- First use and life context
- Current frequency and pattern
- Amount and route of administration
- Solo vs. social use
- Co-use with other substances
- Last use date
- Quit attempts and methods
- Duration of abstinence periods
- Relapse triggers
- Function/role of substance
- Consequences experienced
□ Caffeine
- Daily consumption amount
- Forms used
- Withdrawal symptoms
□ Tobacco/Nicotine
- All product types
- Time to first use after waking
- Quit attempts
□ Cannabis
- Method of use (smoked, vaped, edibles, concentrates)
- THC/CBD content awareness
- Source of product
- Medical vs. recreational use
- Withdrawal symptoms
□ Sedatives/Hypnotics/Anxiolytics
- Specific medications
- Prescription vs. diverted
- Route of administration
- Altered formulations (crushing, etc.)
- Polysubstance interactions
- Withdrawal history
□ Hallucinogens
- Specific substances used
- Bad trips or persistent effects
- Lasting changes in thinking/perception
□ Inhalants
- Type (volatile solvents, nitrous oxide, alkyl nitrites)
- Method of use
- Loss of consciousness or cardiac symptoms
- Cognitive changes
- Organ damage
□ Prescription/OTC Misuse
- Controlled substances
- Non-controlled prescriptions
- OTC products (DXM, diphenhydramine, etc.)
- Supplements and performance enhancers
- Source and pattern of misuse
□ Designer Drugs
- Synthetic cannabinoids
- Synthetic cathinones
- Ethnobotanicals
- Severe adverse effects
□ Alcohol
- Preferred beverages
- Container sizes
- Medical complications
- Blackouts
- Legal/functional consequences
- Withdrawal history and severity
- Lab markers (LFTs, CBC)
□ Opioids
- Specific opioids used
- Route of administration
- Infectious disease testing
- Overdose history
- Harm reduction practices
- Naloxone access
- MAT history
□ Stimulants
- Type (cocaine, methamphetamine, prescription)
- Route of administration
- Cardiovascular symptoms
- Psychiatric symptoms
- Polysubstance use on comedown
- Overdose history
□ Prior Treatment History
- Detoxification programs
- Inpatient/residential treatment
- Outpatient programs
- Medication-assisted treatment
- Mutual support groups
- Treatment outcomes
- Barriers to engagement
- Follow-up and relapse prevention
Appendix B: Documentation Templates
Template 1: Comprehensive Substance Use History Note
SUBSTANCE USE HISTORY:
Universal Screening: Completed systematic assessment across all 10 substance categories.
Positive Findings:
[Substance 1]:
- First use: [age/year], context: [circumstances]
- Current pattern: [frequency, amount, route]
- Last use: [date/timeframe]
- Function: [what it does for the patient]
- Consequences: [medical, legal, social, occupational]
- Quit attempts: [number, methods, longest period of abstinence]
- Withdrawal: [yes/no, symptoms, severity]
[Substance 2]: [Same format]
Polysubstance Use: [Describe patterns of co-use]
Prior Treatment:
- Detox: [dates, location, outcome]
- Inpatient/Residential: [dates, duration, program type, outcome]
- Outpatient: [dates, modality, outcome]
- MAT: [medications tried, duration, response]
- Support groups: [type, frequency, sponsorship]
Current Risk Assessment:
- Withdrawal risk: [low/moderate/high, specific concerns]
- Overdose risk: [factors present]
- Medical complications: [identified issues]
- Safety: [infectious disease risk, harm reduction needs]
Clinical Formulation:
Patient demonstrates [severity level] substance use involving [substances]. Pattern suggests [pain model formulation]. Highest immediate risks include [specific risks]. Treatment recommendations: [specific interventions].
Template 2: Brief Substance Use Documentation
Substance Use: Current [substance] use disorder, [severity]. Using [amount] [route] [frequency]. First used age [X] in context of [trigger]. Last use [date]. [#] prior quit attempts. [Withdrawal/MAT/Treatment history if relevant]. Highest risks: [withdrawal/overdose/medical complications]. Plan: [interventions].
Template 3: Negative Screening Documentation
Substance Use History: Comprehensive assessment completed across all 10 substance categories. Patient denies current or past problematic use of tobacco, alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives/hypnotics, stimulants, or other substances. No history of substance use treatment. Social alcohol use reported as [describe if applicable]. [Tobacco use: describe if applicable].
Template 4: Quick Reference Table Format
| Category | Current Use | Pattern | Risks | Interventions Needed |
| Alcohol | Yes – vodka 750ml daily | 10 years, escalating | Severe withdrawal risk, hepatic dysfunction | Medically supervised detox, thiamine, LFTs |
| Benzodiazepines | Yes – alprazolam 4mg daily | 3 years, prescribed then diverted | Severe withdrawal risk, polysubstance | Taper protocol, addiction medicine consult |
| Cannabis | Yes – daily dabs | 5 years, high-potency THC | Psychiatric symptom exacerbation | Psychoeducation, psychiatric monitoring |
| Stimulants | No | N/A | None | N/A |
Template 5: Resident vs. Attending Documentation Comparison
Resident-Level Documentation (Insufficient):
Substance Use: Patient drinks alcohol and uses marijuana. Has tried
to quit before but started again. Denies withdrawal.
Attending-Level Documentation (Comprehensive):
Substance Use History: Systematic assessment completed across all 10
substance categories revealed:
ALCOHOL: First use age 16 in context of family stress. Current use:
750ml vodka daily for past 2 years, escalated from weekend use.
Drinks alone at night for anxiety relief and sleep. 6 prior quit
attempts (longest 4 months in 2021), all relapsed after interpersonal
stressors. History of 3 prior alcohol detoxifications (most recent
2023, required benzodiazepines for tremor and tachycardia). Positive
for blackouts, morning shakes that resolve with alcohol, elevated
AST/ALT (pending results). Medical complications include
hypertension. DUI 2022. HIGH WITHDRAWAL RISK given daily heavy use
and prior complicated withdrawal.
CANNABIS: Daily high-potency dabs × 3 years for anxiety and sleep.
Reports increased paranoia and decreased motivation since starting
concentrates. Denies withdrawal symptoms with brief abstinence.
BENZODIAZEPINES: Reports obtaining alprazolam from friend’s
prescription, using 2-4mg on days unable to access alcohol. CONCERN
for cross-tolerance and combined CNS depression.
OTHER CATEGORIES: Denies tobacco, caffeine dependence, opioids,
stimulants, hallucinogens, inhalants, or other substances.
PRIOR TREATMENT: 3 inpatient detoxifications as noted. One 28-day
residential program 2021 (completed, sober 4 months post-discharge).
Attended AA sporadically, never had sponsor. Declined MAT in past.
FORMULATION: Patient’s substance use began in adolescence as coping
mechanism for family stress and untreated anxiety. Progression to
daily heavy alcohol use + cannabis + benzodiazepines represents
high-severity polysubstance use disorder with significant withdrawal
risk. Underlying pain appears related to chronic anxiety and
inadequate healthy coping mechanisms. Previous treatment attempts
limited by failure to address co-occurring anxiety disorder and lack
of continuing care post-discharge.
SAFETY PLAN: Medical detoxification required given withdrawal risk.
Thiamine supplementation initiated. LFTs pending. Addiction medicine
consult requested. Recommend concurrent anxiety treatment and MAT
(naltrexone) once medically stable. Structured aftercare essential
given relapse history.
Key Differences:
- Attending version specifies quantities, patterns, and timeline
- Documents function of substances (anxiety relief, sleep)
- Assesses withdrawal risk systematically
- Integrates pain model understanding
- Identifies polysubstance interactions
- Formulates based on both medical risk and psychological pain
- Creates specific, evidence-based safety plan
Appendix C: The Pain Model in Clinical Practice
Integrating Maté’s Framework into Assessment
The Core Questions for Understanding Pain:
- “What does [substance] do for you?”
- Opens exploration of function without judgment
- Patients often haven’t articulated this consciously
- “What was going on in your life when you first started using?”
- Identifies original pain/void the substance filled
- Reveals developmental context
- “When you’re sober, what feelings are hardest to manage?”
- Names the pain directly
- Guides treatment toward addressing root causes
- “What would you need in order to not need [substance]?”
- Explores alternative sources of relief
- Reveals insight and readiness for change
Translating Pain Understanding into Treatment
| Pain Model Finding | Treatment Implication |
| Using to escape childhood trauma | Trauma-focused therapy (EMDR, PE, CPT) + addiction treatment |
| Using to manage social anxiety | CBT for social anxiety + gradual exposure + addiction treatment |
| Using to fill sense of emptiness/unworthiness | Psychodynamic therapy, DBT skills + addiction treatment |
| Using to cope with chronic physical pain | Pain management consultation + MAT + non-pharmacologic pain interventions |
| Using to manage mood symptoms | Psychiatric treatment optimization + addiction treatment |
| Using to enhance performance/belonging | Address environmental stressors + build healthy social connections |
Documentation Language That Honors Pain Model
Instead of: “Patient made poor choices leading to addiction.”
Write: “Patient’s substance use began as adaptive response to [specific pain/trauma/need] and progressed to dependence.”
Instead of: “Patient lacks motivation to quit.”
Write: “Patient reports ambivalence about changing substance use, which currently serves essential function of [anxiety management/pain relief/emotional regulation]. Treatment must address both substance use and underlying [pain/need].”
Instead of: “Patient relapsed due to lack of willpower.”
Write: “Patient returned to use following [trigger] which activated underlying [pain/stress/trauma]. Relapse suggests need for enhanced coping strategies and trauma-focused treatment.”
Appendix D: Harm Reduction Resources and Referrals
Essential Harm Reduction Practices to Discuss
For Injection Drug Use:
- Syringe exchange programs
- Never sharing needles, cookers, or cotton
- Cleaning injection sites
- Rotating injection sites
- Testing for HIV, Hepatitis B, Hepatitis C, Tuberculosis
For Opioid Use:
- Naloxone (Narcan) prescription and training
- Fentanyl test strips
- Never using alone
- Starting with small amounts after tolerance break
- Avoiding polysubstance use (especially with benzodiazepines, alcohol)
For Stimulant Use:
- Staying hydrated
- Avoiding mixing stimulants
- Taking breaks during binges
- Cardiovascular monitoring
- Using with others present
For All Substances:
- Knowing what you’re taking
- Testing substances when possible
- Having a trusted person who knows where you are
- Keeping naloxone accessible
- Having emergency contact information
Key Referral Resources
National:
- SAMHSA National Helpline: 1-800-662-4357 (free, confidential, 24/7)
- SAMHSA Treatment Locator: findtreatment.gov
- Harm Reduction Coalition: harmreduction.org
- National Harm Reduction Coalition’s hotline for syringe exchange locator
Naloxone Access:
- NextDistro: nextdistro.org (free naloxone by mail)
- NEXT Harm Reduction: naloxoneforall.org
- Local pharmacies (many states allow pharmacist prescribing)
MAT Resources:
- Buprenorphine provider locator: samhsa.gov/medication-assisted-treatment/practitioner-program-data/treatment-practitioner-locator
- Methadone clinic locator: samhsa.gov/medication-assisted-treatment/opioid-treatment-programs
Mutual Support:
- AA: aa.org
- NA: na.org
- SMART Recovery: smartrecovery.org
- Refuge Recovery: refugerecovery.org
References
Agerwala, S. M., & McCance-Katz, E. F. (2012). Integrating screening, brief intervention, and referral to treatment (SBIRT) into clinical practice settings: A brief review. Journal of Psychoactive Drugs, 44(4), 307-317.
American Psychiatric Association. (2018). Practice guideline for the treatment of patients with substance use disorders (3rd ed.). American Psychiatric Publishing.
Dutra, L., Stathopoulou, G., Basden, S. L., Leyro, T. M., Powers, M. B., & Otto, M. W. (2008). A meta-analytic review of psychosocial interventions for substance use disorders. American Journal of Psychiatry, 165(2), 179-187.
Grant, B. F., Saha, T. D., Ruan, W. J., Goldstein, R. B., Chou, S. P., Jung, J., … & Hasin, D. S. (2016). Epidemiology of DSM-5 drug use disorder: Results from the National Epidemiologic Survey on Alcohol and Related Conditions–III. JAMA Psychiatry, 73(1), 39-47.
Maté, G. (2010). In the realm of hungry ghosts: Close encounters with addiction. North Atlantic Books.
Rowe, C., Vittinghoff, E., Santos, G. M., Behar, E., Turner, C., & Coffin, P. O. (2016). Performance measures of diagnostic codes for detecting opioid overdose in the emergency department. Academic Emergency Medicine, 23(7), 817-826.
Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Center for Behavioral Health Statistics and Quality, SAMHSA.
U.S. Preventive Services Task Force. (2020). Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: US Preventive Services Task Force Recommendation Statement. JAMA, 320(18), 1899-1909.
Further Reading
Primary Recommendations
Maté, G. (2010). In the realm of hungry ghosts: Close encounters with addiction. North Atlantic Books.
This is essential reading for any clinician working with substance use disorders. Maté’s integration of neuroscience, developmental psychology, and compassionate clinical observation provides the foundation for truly understanding addiction as a response to pain rather than a moral failing. The book transforms how you see patients and fundamentally improves the therapeutic alliance.
Sheff, D. (2013). Clean: Overcoming addiction and ending America’s greatest tragedy. Eamon Dolan/Houghton Mifflin Harcourt.
A comprehensive, accessible overview of addiction treatment that integrates research evidence with personal narratives. Particularly valuable for understanding what works in treatment and why.
Additional Valuable Resources
Lewis, M. (2015). The biology of desire: Why addiction is not a disease. PublicAffairs.
A neuroscientist’s argument for understanding addiction as learned behavior rather than disease, offering a complementary perspective to the pain model.
Hart, C. (2021). Drug use for grown-ups: Chasing liberty in the land of fear. Penguin Press.
Challenges conventional thinking about drug use and offers important perspectives on harm reduction, personal liberty, and the failures of drug policy.
American Psychiatric Association. (2018). Practice guideline for the treatment of patients with substance use disorders (3rd ed.). American Psychiatric Publishing.
Essential clinical reference for evidence-based assessment and treatment approaches.
