Write a SOAP note for a 35‑year‑old male with a ten‑year history of Opioid Use Disorder, stable on buprenorphine/naloxone (Suboxone) 8 mg/2 mg daily for six months, no cravings or illicit opioid use, attending weekly counseling, on sertraline 50 mg daily for depression, with normal vital signs and laboratory results.

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SOAP Note for Stable Opioid Use Disorder on Buprenorphine/Naloxone Maintenance

Subjective

Chief Concern:
Routine follow-up for opioid use disorder (OUD) on buprenorphine/naloxone maintenance therapy.

History of Present Illness:
35-year-old male with 10-year history of OUD, stable on buprenorphine/naloxone (Suboxone) 8 mg/2 mg sublingual daily for 6 months. 1 Reports zero cravings for opioids and no illicit opioid use since initiating maintenance therapy. 1 Attending weekly individual counseling sessions as part of comprehensive medication-assisted treatment. 1, 2 Denies withdrawal symptoms (no sweating, restlessness, GI upset, anxiety, or insomnia). 1

Psychiatric History:
Depression managed with sertraline 50 mg daily; reports stable mood without suicidal ideation. 1 No current symptoms of anxiety, PTSD, or other psychiatric comorbidities. 1

Substance Use:

  • Opioids: Abstinent from illicit opioids × 6 months (confirmed by patient report and urine drug testing). 1
  • Alcohol: Denies current use. 1
  • Benzodiazepines: Denies use. 1
  • Cocaine/Methamphetamine: Denies use. 1
  • Nicotine: [Document current use status]. 1
  • Cannabis: [Document current use status]. 1

Social History:

  • Employment/Education: [Document current status]. 1
  • Support System: Attending weekly counseling; [document family involvement and living situation]. 1
  • Housing: [Document stable vs. unstable housing]. 1

Review of Systems:

  • Constitutional: No fever, chills, or unintentional weight changes.
  • Pain: Denies acute or chronic pain requiring additional analgesia. 1
  • Sleep: [Document sleep quality; screen for insomnia]. 1
  • Gastrointestinal: No nausea, vomiting, or diarrhea; [assess for constipation, a common buprenorphine side effect]. 3
  • Neurological: No headaches, dizziness, or sedation. 3

Objective

Vital Signs:

  • Blood pressure: [e.g., 118/76 mmHg] 1
  • Heart rate: [e.g., 72 bpm] 1
  • Respiratory rate: [e.g., 14 breaths/min] 1
  • Temperature: [e.g., 98.4°F] 1
  • Oxygen saturation: [e.g., 98% on room air] 1

Physical Examination:

  • General: Alert, cooperative, no acute distress.
  • Skin: Inspect for track marks, abscesses, or signs of injection drug use—none observed. 1
  • HEENT: Pupils equal, round, reactive to light (normal size; no pinpoint constriction). 1
  • Cardiovascular: Regular rate and rhythm, no murmurs.
  • Respiratory: Clear to auscultation bilaterally, no respiratory depression. 1
  • Abdomen: Soft, non-tender, normal bowel sounds.
  • Neurological: Alert and oriented × 3, normal affect, no tremor or psychomotor agitation.

Laboratory Results:

  • Urine Drug Screen (UDS): Positive for buprenorphine and naloxone metabolites; negative for illicit opioids (heroin, fentanyl), benzodiazepines, cocaine, and methamphetamine. 1
  • Liver Function Tests (LFTs): Within normal limits. (Note: Routine LFTs every 3–6 months are not required for buprenorphine/naloxone maintenance, unlike naltrexone.) 1
  • Hepatitis C Antibody: [Document result; screen if not previously done]. 1
  • HIV Antibody: [Document result; screen if not previously done]. 1

Mental Health Screening:

  • PHQ-2 (Depression Screen): [Score; if ≥3, administer PHQ-9]. 4
  • PHQ-9 (if indicated): [Score; refer for psychiatric evaluation if ≥10]. 4
  • Anxiety Screen: [Document presence/absence of GAD-7 symptoms]. 1

Assessment

  1. Opioid Use Disorder (OUD), in sustained remission (DSM-5 criteria met at baseline; currently abstinent from illicit opioids × 6 months). 1, 4

    • Stable on buprenorphine/naloxone 8 mg/2 mg daily (within therapeutic range of 8–16 mg; target dose is 16 mg for most patients). 1
    • Excellent treatment adherence: zero cravings, negative UDS for illicit opioids, attending weekly counseling. 1, 2

  2. Major Depressive Disorder, stable on sertraline 50 mg daily. 1

  3. No concurrent substance use disorders (alcohol, benzodiazepines, stimulants). 1

  4. Infectious disease screening up to date (hepatitis C and HIV). 1

Plan

1. Continue Buprenorphine/Naloxone Maintenance Therapy

Current Dose:

  • Buprenorphine/naloxone 8 mg/2 mg sublingual daily. 1
  • Patient is stable at this dose; however, the target maintenance dose for most patients is 16 mg daily. 1 Consider dose optimization if any breakthrough cravings emerge, though none are currently reported. 1

Duration of Treatment:

  • There is no maximum recommended duration of maintenance treatment—patients may require treatment indefinitely. 5 Maintenance therapy is substantially more effective than tapering for preventing relapse. 5 Abrupt discontinuation markedly increases the risk of opioid overdose and death due to reduced opioid tolerance. 1

Rationale for Buprenorphine/Naloxone (Suboxone) Over Buprenorphine Alone:

  • The buprenorphine/naloxone combination is preferred for most patients because the naloxone component reduces misuse potential by preventing injection diversion. 4 The naloxone is poorly absorbed sublingually and does not contribute to withdrawal prevention. 5

2. Behavioral Therapy and Psychosocial Support

  • Continue weekly individual counseling as part of comprehensive medication-assisted treatment. 1, 2 All FDA trials of buprenorphine used psychosocial counseling in conjunction with medication; there is no evidence supporting buprenorphine as monotherapy. 2
  • Assess employment, education, and support system at each visit. 1
  • Encourage family involvement in treatment planning. 1

3. Monitoring and Follow-Up

Visit Frequency:

  • Monthly follow-up visits for stable patients. 1 (Increase frequency if any relapse, reemergence of cravings, or withdrawal symptoms occur.) 3

At Each Visit, Document:

  • Vital signs (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation). 1
  • Physical examination findings: Inspect for track marks, abscesses, or signs of injection drug use. 1
  • Cravings or withdrawal symptoms (use Clinical Opiate Withdrawal Scale [COWS] if indicated). 1
  • Any relapses or illicit opioid use. 3
  • Pill/wrapper counts to assess adherence. 3
  • State prescription drug monitoring program (PDMP) checks. 3

Urine Drug Testing (UDS):

  • Random UDS at each visit to assess for continued illicit opioid use and concurrent substance use (benzodiazepines, cocaine, methamphetamine). 1 Sporadic opioid use in the first few months is not uncommon and should be addressed with increased visit frequency and more intensive behavioral therapy engagement. 3

Laboratory Monitoring:

  • Routine LFTs every 3–6 months are NOT required for buprenorphine/naloxone maintenance (unlike naltrexone). 1
  • Hepatitis C and HIV screening if not previously completed. 1

4. Mental Health Management

Depression:

  • Continue sertraline 50 mg daily. 1
  • Screen for depression at each visit using PHQ-2; if positive (≥3), administer PHQ-9. 4
  • Refer for psychiatric evaluation if PHQ-9 ≥10. 4

Other Psychiatric Comorbidities:

  • Systematically screen for anxiety, PTSD, bipolar disorder, and other psychiatric conditions at baseline and periodically. 1
  • Assess sleep quality and screen for insomnia. 1

Buprenorphine's Potential Mood-Stabilizing Effects:

  • Emerging evidence suggests buprenorphine may have rapid antidepressant and antisuicidal effects via κ-opioid receptor antagonism. 6, 7 This may contribute to the patient's stable mood on current therapy.

5. Safety Considerations

Avoid Concurrent Benzodiazepines:

  • Concomitant use of buprenorphine with benzodiazepines is contraindicated due to FDA black-box warning for increased risk of respiratory depression and death. 1, 5 If benzodiazepines are prescribed, initiate a gradual taper and substitute non-benzodiazepine anxiolytics (SSRIs, SNRIs, buspirone, gabapentin). 5

QT-Prolonging Medications:

  • Screen for QT-prolonging agents; concomitant use with buprenorphine is contraindicated. 1, 5

Overdose Prevention:

  • Provide take-home naloxone kit and overdose prevention education at discharge and periodically. 5

6. Acute Pain Management (If Needed in Future)

  • Continue the usual buprenorphine/naloxone dose and add short-acting opioid analgesics for breakthrough pain. 1 Higher opioid doses may be necessary due to buprenorphine's high receptor affinity. 1
  • Alternatively, increase the buprenorphine dose for additional analgesia, as higher doses provide pain relief without the respiratory depression ceiling effect seen with full agonists. 4

7. Common Pitfalls to Avoid

  • Never discontinue buprenorphine abruptly to comply with opioid dose guidelines; buprenorphine for OUD has a ceiling effect on respiratory depression and should not be tapered or discontinued. 5
  • Do not initiate buprenorphine while the patient is under the influence of full opioid agonists (to avoid precipitated withdrawal). 1
  • Do not discharge the patient on α₂-agonists (clonidine/lofexidine) without a definitive addiction-treatment plan; these agents only address acute withdrawal and are inferior to buprenorphine. 5

8. Patient Education

  • Reinforce the importance of adherence to buprenorphine/naloxone and weekly counseling. 1, 2
  • Educate on the risks of relapse if treatment is discontinued. 1, 5
  • Discuss naloxone use for overdose prevention. 5
  • Encourage continued engagement with support systems and counseling. 1

9. Disposition

  • Return to clinic in 1 month for routine follow-up. 1
  • Contact clinic immediately if cravings, withdrawal symptoms, or relapse occur. 3
  • Emergency contact information provided for after-hours crises.

Prescriptions:

  1. Buprenorphine/naloxone 8 mg/2 mg sublingual tablets – Take 1 tablet daily. Dispense: 30 tablets. Refills: 0 (monthly follow-up required). 1
  2. Sertraline 50 mg tablets – Take 1 tablet daily. Dispense: 30 tablets. Refills: 3. 1
  3. Naloxone nasal spray 4 mg – Use as directed for opioid overdose. Dispense: 2 doses. Refills: 0. 5

References

1
Guideline

Buprenorphine Therapy for Opioid Addiction

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

3
Research

Buprenorphine Therapy for Opioid Use Disorder.

American family physician, 2018

4
Guideline

Indication for Suboxone (Buprenorphine/Naloxone)

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Guideline

Medications for Managing Opioid Withdrawal

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

7
Research

Depressive symptoms during buprenorphine treatment of opioid abusers.

Journal of substance abuse treatment, 1990

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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