Write a SOAP note for a stable 35‑year‑old male with opioid use disorder on buprenorphine/naloxone (Suboxone) 8 mg/2 mg daily, no cravings, attending weekly counseling, and taking sertraline 50 mg daily for depression.

SOAP Note for Stable Patient on Buprenorphine/Naloxone Maintenance

For a stable patient with opioid use disorder on buprenorphine/naloxone 8 mg/2 mg daily, document continued medication adherence, absence of cravings and withdrawal symptoms, negative urine drug screens, engagement in counseling, and assessment of psychiatric comorbidities including depression treatment response. 1

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Subjective

Opioid Use Disorder Status

• Document absence of opioid cravings and withdrawal symptoms since last visit 1, 2
• Ask specifically about any illicit opioid use, as each additional day of buprenorphine adherence is associated with 8% higher rate of negative urine drug tests 3
• Inquire about missed doses over the past 7 days, as non-adherence (even sporadic) increases risk of relapse 3

Concurrent Substance Use Screening

• Routinely screen for alcohol, benzodiazepines, cocaine, methamphetamine, and other non-prescribed substances 1
• Document any polysubstance use patterns

Mental Health Assessment

• Systematically screen for depression, anxiety, PTSD, and other psychiatric comorbidities 1
• For this patient on sertraline 50 mg daily: assess current depressive symptoms, as buprenorphine itself may have antidepressant effects 4, 5
• Evaluate sleep quality and identify insomnia 1
• Document suicidal ideation, as buprenorphine has demonstrated rapid antisuicidal effects 4

Social and Functional Status

• Document employment and educational status 1
• Assess support system and family involvement 1
• Inquire about legal, interpersonal, and employment problems, as these are commonly associated with opioid use disorder 6

Counseling Engagement

• Confirm weekly counseling attendance, as treatment should combine medication with behavioral therapies for a "whole-patient" approach 1, 2

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Objective

Vital Signs

• Document blood pressure, heart rate, respiratory rate, temperature

Physical Examination

• General appearance and affect
• Pupil size (should be normal on stable buprenorphine maintenance)
• Signs of injection drug use (track marks, abscesses)

Laboratory Testing

• Urine drug screen: Document results for opioids (should show buprenorphine/norbuprenorphine), illicit opioids (should be negative), and other substances 1, 2
• Liver function tests: Unlike naltrexone, routine monitoring every 3–6 months is not required for buprenorphine/naloxone 1
• Consider hepatitis C and HIV screening as part of comprehensive care 1

Medication Verification

• Pill or wrapper counts to assess adherence 2
• Check state prescription drug monitoring program for controlled substance prescriptions 2

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Assessment

Primary Diagnosis

• Opioid Use Disorder, in sustained remission on medication-assisted treatment (use DSM-5 criteria) 1
• Document stability: no cravings, no withdrawal, negative urine drug screens, engaged in counseling

Secondary Diagnoses

• Major Depressive Disorder, stable on sertraline 50 mg daily
• Note that buprenorphine may contribute to mood stabilization 4, 5

Current Medication Regimen

• Buprenorphine/naloxone 8 mg/2 mg daily (within therapeutic range of 8-16 mg, though 16 mg is target for most patients) 1, 2
• Sertraline 50 mg daily

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Plan

Medication Management

• Continue buprenorphine/naloxone 8 mg/2 mg daily 1
• Consider dose optimization to 16 mg daily if any breakthrough cravings emerge, as this is the target dose for most patients 1, 2
• Continue sertraline 50 mg daily for depression management
• Emphasize that abrupt discontinuation of buprenorphine markedly increases risk of opioid overdose and death due to reduced opioid tolerance 1

Monitoring and Follow-Up

• Schedule next visit in 2-4 weeks (frequency can be extended as stability continues)
• Random urine drug testing at each visit to assess for illicit opioid use 1
• Reinforce importance of daily adherence, as missed doses significantly increase risk of illicit opioid use 3

Behavioral Health

• Continue weekly counseling sessions as part of comprehensive treatment 1, 2
• Longer duration of treatment allows restoration of social connections and is associated with better outcomes 6

Patient Education

• Acute pain management: If acute pain arises, continue usual buprenorphine dose and use short-acting opioid analgesics for breakthrough pain; higher opioid doses may be necessary due to buprenorphine's high receptor affinity 7, 1
• Provide take-home naloxone for overdose reversal in case of relapse 6
• Counsel on avoiding concomitant use with QT-prolonging agents due to cardiac complications risk 1

Safety Considerations

• Never initiate buprenorphine while under influence of full opioid agonists to avoid precipitated withdrawal 1
• If patient requires surgery: decision to continue or hold buprenorphine should be individualized based on daily dose, risk of relapse, and expected post-surgical pain 1

Addressing Non-Adherence

• If sporadic opioid use emerges (not uncommon in first months), increase visit frequency and intensify behavioral therapy engagement 2
• Each missed day of buprenorphine increases risk of positive urine drug test by approximately 8% 3