Presenting Problems

Substance Use Patterns & Loss of Control

• Difficulty reducing, controlling, or stopping substance use
• Repeated unsuccessful attempts to change or reduce substance use
• Increasing time, attention, or resources devoted to substance use
• Difficulty maintaining intended limits around substance use

Consequences & Functional Impairment

• Substance use interfering with relationships, family functioning, work, school, parenting, finances, or daily responsibilities
• Continued substance use despite awareness of negative consequences
• Engagement in risky behaviors or situations related to substance use
• Decline in functioning associated with ongoing substance use

Cravings, Triggers & Emotional Coping

• Recurrent cravings or strong urges to use
• Difficulty identifying or managing substance use triggers
• Reliance on substances to manage uncomfortable emotions or psychological distress
• Increased vulnerability to substance use during periods of stress or emotional dysregulation

Motivation, Ambivalence & Readiness

• Uncertainty or ambivalence regarding changing substance use
• Difficulty identifying meaningful reasons for change
• Desire for change accompanied by perceived barriers to reducing or stopping use
• Limited readiness or confidence in ability to change substance use behaviors

Recovery & Relapse Vulnerability

• Difficulty maintaining abstinence or reduced substance use over time
• Recurrence of substance use following periods of progress or recovery
• Difficulty recognizing or responding to early warning signs of recurrence
• Increased vulnerability to substance use during stress, conflict, environmental exposure, or reduced support

Co-Occurring Symptoms & Safety

• Mental health symptoms occurring alongside substance use
• Substance use contributing to or exacerbating emotional or behavioral symptoms
• Concerns related to withdrawal, intoxication, overdose, or other substance related safety risks
• Need for coordination with medical, psychiatric, behavioral health, or substance use services

Example Documentation Language

• Client presents with substance use concerns characterized by difficulty reducing or controlling use, increased cravings, and continued use despite negative consequences.
• Patient reports substance use patterns that interfere with daily functioning, relationships, responsibilities, emotional regulation, or overall wellbeing.
• Client presents with increased vulnerability to substance use during periods of stress, conflict, emotional distress, or exposure to identified triggers.
• Patient reports ambivalence about changing substance use patterns and may benefit from support with motivation, coping skills, relapse prevention, and harm reduction planning.
• Client demonstrates functional impairment related to substance use, including difficulty maintaining routines, managing responsibilities, and engaging consistently in recovery supportive behaviors.