Please provide a SOAP note for a 35-year-old male with opioid use disorder on buprenorphine/naloxone (BUP/NLX) 8 mg/2 mg daily and major depressive disorder stable on sertraline 50 mg daily, who reports no cravings, no withdrawal, adherent to weekly counseling, with normal blood pressure (BP), normal heart rate (HR), normal respiratory rate (RR), and normal temperature (Temp), and a negative urine drug screen.

SOAP Note for 35-Year-Old Male with Opioid Use Disorder on Buprenorphine/Naloxone Maintenance

Subjective

• Chief Concern: Follow-up visit for opioid use disorder (OUD) and major depressive disorder (MDD)
• Opioid Use Disorder Status:
  • Currently maintained on buprenorphine/naloxone 8 mg/2 mg daily 1
  • Reports zero cravings for opioids 1
  • Denies any withdrawal symptoms 1
  • Reports 100% medication adherence 1
  • Attending weekly counseling sessions as prescribed 1
  • Denies any illicit opioid use since last visit 1
• Mental Health:
  • Major depressive disorder stable on sertraline 50 mg daily 2
  • Mood described as "good" with no current depressive symptoms 2
  • Denies suicidal ideation, homicidal ideation, or self-harm thoughts 3
  • Sleep quality adequate, no insomnia 1
• Psychosocial Functioning:
  • Employment status: [document current status] 1
  • Support system: [document family/social support] 1
  • No legal issues reported 4

Objective

• Vital Signs:
  • Blood pressure: [normal range] 1
  • Heart rate: [normal range] 1
  • Respiratory rate: [normal range] 1
  • Temperature: [normal range] 1
• Physical Examination:
  • General appearance: Well-appearing, no acute distress 1
  • Skin: No track marks, abscesses, or signs of injection drug use 1
  • Cardiovascular: Regular rate and rhythm 5
  • Respiratory: Clear to auscultation bilaterally 1
  • Psychiatric: Alert and oriented x3, appropriate affect, no psychomotor agitation or retardation 2
• Laboratory Results:
  • Urine drug screen: Negative for illicit substances (positive for buprenorphine as expected) 1
  • Note: Routine liver function testing is not required for patients on buprenorphine/naloxone maintenance 1

Assessment

1. Opioid Use Disorder (F11.20) - In sustained remission

   • Patient meets criteria for sustained remission with no cravings, no withdrawal, negative urine drug screen, and excellent treatment adherence 1, 4
   • Current buprenorphine/naloxone dose of 8 mg/2 mg is within therapeutic range (target 8-16 mg daily for most patients) 1
   • Buprenorphine/naloxone is the preferred formulation for most patients with OUD due to safety features that prevent misuse 1
   • Patient demonstrates excellent response to medication-assisted treatment combined with weekly counseling, consistent with evidence-based "whole-patient" approach 1

2. Major Depressive Disorder (F32.9) - Stable, in remission

   • Depression well-controlled on sertraline 50 mg daily 2
   • Both buprenorphine and sertraline likely contributing to mood stabilization, as buprenorphine has demonstrated rapid antidepressant effects through κ-opioid receptor antagonism 3, 6
   • Studies show buprenorphine/naloxone significantly reduces depressive symptoms in patients with OUD, with effects partially independent of opioid use reduction 2

Plan

Medication Management

• Continue buprenorphine/naloxone 8 mg/2 mg daily 1
  • Current dose is effective for maintaining remission with no cravings or withdrawal 1
  • No dose adjustment needed at this time 1
  • Reinforce importance of daily adherence 1
• Continue sertraline 50 mg daily 2
  • Effective for mood stabilization 2
  • No drug interactions between buprenorphine/naloxone and sertraline 1

Monitoring and Follow-up

• Schedule next follow-up visit in 4 weeks 1
• Continue urine drug screening at each visit to monitor for illicit substance use 1
• Assess vital signs (BP, HR, RR, temperature) at each visit 1
• Screen for injection drug use signs during physical examination 1
• Monitor for co-occurring substance use including alcohol, benzodiazepines, cocaine, and methamphetamine 1

Psychosocial Interventions

• Continue weekly counseling sessions 1
  • Medication-assisted treatment must be combined with behavioral therapies for optimal outcomes 1, 4
  • Counseling addresses coping strategies, relapse prevention, and psychosocial stressors 5
• Assess employment and educational status at next visit 1
• Evaluate support system and family involvement 1

Patient Education and Safety

• Educate about overdose risk if treatment discontinued 1
  • Abrupt discontinuation of buprenorphine/naloxone markedly increases risk of opioid overdose and death due to reduced opioid tolerance 1
  • Never stop medication abruptly without medical supervision 1
• Acute pain management counseling 1
  • If acute pain occurs, continue usual buprenorphine/naloxone dose and use short-acting opioid analgesics for breakthrough pain 1
  • Higher opioid doses may be necessary due to buprenorphine's high receptor affinity 1
• Provide naloxone prescription for overdose reversal in case of relapse 5

Screening and Preventive Care

• Screen for hepatitis C and HIV if not done recently 1
• Continue monitoring for psychiatric comorbidities including anxiety, PTSD, and sleep disturbances 1

Common Pitfalls to Avoid

• Never initiate buprenorphine while patient is under influence of full opioid agonists to avoid precipitated withdrawal 1
• Do not discontinue buprenorphine/naloxone prematurely even when patient appears stable, as longer treatment duration is associated with better outcomes 4
• Avoid concomitant use with QT-prolonging agents due to cardiac risk 1

Treatment Duration

• Plan for long-term maintenance therapy 4
  • Longer duration of treatment allows restoration of social connections and is associated with better outcomes 4
  • No predetermined endpoint for discontinuation; continue as long as patient benefits 4

5, 1, 3, 4, 2