Write a SOAP note for a 34‑year‑old patient with opioid use disorder who is stable on buprenorphine/naloxone (Suboxone) 8 mg/2 mg daily for six months, adherent, with no cravings or withdrawal, normal vital signs and laboratory results, and attending weekly counseling.

SOAP Note for Stable Patient on Buprenorphine/Naloxone Maintenance

For a stable patient on buprenorphine/naloxone 8 mg/2 mg daily for opioid use disorder, document adherence, absence of cravings/withdrawal, normal vitals and labs, continued counseling participation, and negative urine drug screens, then continue current dose with regular monitoring. 1, 2, 3

Subjective

Chief Complaint:

• Follow-up for opioid use disorder maintenance treatment 3

History of Present Illness:

• 34-year-old patient with opioid use disorder on buprenorphine/naloxone (Suboxone) 8 mg/2 mg sublingual daily for 6 months 1
• Reports no cravings for opioids 3
• Reports no withdrawal symptoms (assess specifically for: anxiety, muscle aches, sweating, abdominal cramping, nausea, insomnia) 4
• Medication adherence: Taking medication as prescribed, holding under tongue for 5-10 minutes until dissolved 2
• No illicit opioid use since starting treatment 2, 3
• Attending weekly counseling sessions consistently 1, 2

Substance Use History:

• No use of non-prescribed opioids, heroin, or fentanyl 3
• Assess for use of alcohol, benzodiazepines, cocaine, methamphetamine, or other substances 5, 6

Psychiatric Review:

• Screen for depression, anxiety, post-traumatic stress disorder, and other mental health conditions that commonly co-occur with OUD 5
• Assess sleep quality and any insomnia 5

Social History:

• Living environment is stable and substance-free 3
• Employment/educational status 5
• Support system and family involvement 5

Objective

Vital Signs:

• Blood pressure, heart rate, respiratory rate, temperature all within normal limits 1

Physical Examination:

• General appearance: Alert, oriented, no acute distress 3
• Mental status: Appropriate affect, no signs of intoxication or withdrawal 4
• Respiratory: No respiratory depression (buprenorphine has ceiling effect for respiratory depression) 1, 3

Laboratory Results:

• Urine drug screen: Negative for non-study opioids (heroin, fentanyl, other illicit opioids) 2, 3, 6
• Positive for buprenorphine (confirms medication adherence) 3
• Hepatitis C and HIV screening completed as part of comprehensive care 1
• Liver function tests within normal limits (baseline and every 3-6 months monitoring not required for buprenorphine, unlike naltrexone) 5

Prescription Drug Monitoring Program (PDMP):

• Check state prescription database for any controlled substance prescriptions from other providers 3

Pill/Wrapper Count:

• Appropriate number remaining, consistent with prescribed dosing 3

Assessment

Primary Diagnosis:

• Opioid use disorder, in sustained remission on medication-assisted treatment with buprenorphine/naloxone 3, 7

Treatment Response:

• Excellent response to current dose of 8 mg/2 mg daily (within therapeutic range of 8-16 mg daily) 1, 2
• No evidence of relapse or sporadic opioid use 3
• Stable psychiatric comorbidities 3
• Engaged in comprehensive treatment including counseling 1, 2

Plan

Medication Management:

• Continue buprenorphine/naloxone 8 mg/2 mg sublingual daily (current dose is effective; therapeutic range is 8-16 mg daily, with 16 mg as target for most patients, but this patient is stable at 8 mg) 1, 2
• Reinforce proper administration technique: hold under tongue for 5-10 minutes until completely dissolved 2
• Provide 30-day supply with appropriate refills 3

Monitoring:

• Next follow-up visit in 4 weeks (stable patients can be seen monthly) 3
• Continue random urine drug testing at each visit to assess for illicit opioid use 1, 3
• Monitor for reemergence of cravings or withdrawal symptoms 3
• Repeat PDMP check at next visit 3

Behavioral Health:

• Continue weekly counseling sessions as part of comprehensive "whole-patient" approach 1, 2
• Address any emerging psychiatric symptoms (depression, anxiety) 5

Patient Education:

• Discussed that sporadic opioid use can occur in early treatment but patient has successfully avoided this 3
• Reviewed that longer duration of treatment is associated with better outcomes and restoration of social connections 7
• Counseled on continued HIV risk reduction 2
• Discussed that discontinuation of treatment increases risk of opioid overdose and death due to decreased tolerance 5

Special Considerations:

• If patient requires acute pain management in future: continue usual buprenorphine dose and use short-acting opioid analgesics for breakthrough pain (higher doses may be needed due to buprenorphine's high receptor affinity) 1
• If patient develops inadequate pain control or complex persistent dependence symptoms in future, current dose is appropriate (buprenorphine has been used off-label for chronic pain) 5

Common Pitfalls to Avoid:

• Do not discontinue buprenorphine abruptly due to increased overdose risk from decreased tolerance 5
• Do not co-prescribe QT-prolonging agents (contraindicated with buprenorphine) 1
• Do not interpret occasional positive urine screens in first months as treatment failure—address with increased visit frequency and more intensive behavioral therapy 3