Ideal Medical Records Documentation

This guidance is adapted from NIDA’s Words Matter: Preferred language for talking about addiction.  

Terms to use, terms to avoid, and why

The chart below can help you choose words to reduce stigma and use person-first language when talking about addiction.

Talking about someone with pain

Use... Instead of... Because...
  • Person with chronic pain
  • Person with a particular chronic pain condition
  • (Chronic) Pain patient
  • Using person-first language shows that chronic pain is an illness.
  • Using these words shows that a person with a chronic pain “has” a problem/illness, rather than “is” the problem.
  • Person who is asking for opioid medications for pain
  • "Drug seeker"
  • "Addict"
  • Use medically accurate terminology the same way it would be used for other medical conditions. 
  • When a person sees multiple clinicians for their chronic pain and/or opioid prescription
  • "Doctor shopping"
  • Use medically accurate terminology the same way it would be used for other medical conditions. 

Talking about someone with a substance use disorder

Use... Instead of... Because...
  • Person with a substance use disorder
  • Person with an opioid use disorder (OUD) or person with opioid addiction
  • Addict
  • User
  • Substance or drug abuser
  • Junkie
  • Using person-first language shows that SUD is an illness.
  • Using these words shows that a person with a SUD “has” a problem/illness, rather than “is” the problem.
  • The terms avoid elicit negative associations, punitive attitudes, and individual blame. The term recovery does not reflect that substance use disorders are chronic relapsing conditions.
  • Person with alcohol use disorder
  • Person who consumes alcohol 
  • Alcoholic
  • Drunk
  • See above
  • Person with sustained abstinence/decreased use/person who previously used drugs
  • Former addict
  • Reformed addict
  • In recovery
  • See above
  • Testing positive (on a drug screen)
  • Dirty
  • Failing a drug test
  • Use medically accurate terminology the same way it would be used for other medical conditions. 
  • These terms may decrease a person’s sense of hope and self-efficacy for change. 

Talking about using substances

Use... Instead of... Because...
  • Substance use disorder
  • Drug addiction
  • Habit
  • "Habit" implies that a person is choosing to use substances or can choose to stop. This implication is inaccurate. 
  • Describing SUD as a habit makes the illness seem less serious than it is.
  • Use (for illicit drugs)
  • Misuse (for prescription medications used other than prescribed)
  • Abuse
  • The term "abuse" was found to have a high association with negative judgments and punishment. 
  • Use outside of the parameters of how medications were prescribed is misuse.

Talking about recovery and treatment

Use... Instead of... Because...
  • Medication treatment for OUD
  • Medications for OUD
  • Medications for addiction treatment
  • Opioid agonist therapy
  • Pharmacotherapy
  • Medication for a substance use disorder
  • Opioid substitution
  • Replacement therapy
  • Medication-assisted treatment (MAT)
  • It is a misconception that medications merely “substitute” one drug or “one addiction” for another.  
  • The term MAT implies that medication should have a supplemental or temporary role in treatment. Using “MOUD” aligns with the way other psychiatric medications are understood (e.g., antidepressants, antipsychotics), as critical tools that are central to a patient’s treatment plan.
  • Abstinent from drugs
  • Person with sustained abstinence/decreased use/person who previously used drugs 
  • Not consuming alcohol or taking drugs
  • Testing negative (on a drug screen)
  • Clean
  • In recovery
  • Use of medical terminology (the same way you would for other illnesses) can help reduce stigma. 
  • The term recovery does not reflect that substance use disorders are chronic relapsing conditions.
  • Buprenorphine initiation
  • Low dose buprenorphine
  • Buprenorphine induction
  • "Microdosing" buprenorphine
  • Using the term "initiation" as one would for any medication demystifies starting buprenorphine. 
  • "Microdosing" is a term associated with psychedelics, and is inappropriate in this context. Describing what is being done, which is using a low dose of buprenorphine, is preferred.

Additional tips for documentation to reduce bias

Clinicians should be aware of how they use ICD10 codes. Black patients are less likely to have pain documented on problem list, are more frequently drug tested, and receive fewer referrals to pain management.