What should be documented in a supportive counseling note for an adult patient with opioid use disorder, including demographics, diagnosis severity, past medical history, substance use pattern, current medications, treatment goals, readiness to change, barriers, counseling content, referrals, patient response, and follow‑up plan?

Supportive Counseling Documentation for Opioid Use Disorder

Your counseling note must document the immediate offer of medication-assisted treatment (buprenorphine or methadone combined with behavioral therapy), as this is the evidence-based standard of care that reduces mortality and overdose risk. 1, 2

Essential Documentation Components

Patient Demographics and Clinical Assessment

• Age and developmental stage: Document if patient is adolescent (≥16 years qualifies for buprenorphine), pregnant (requires buprenorphine monotherapy without naloxone), or has other age-specific considerations 3, 4
• DSM-5 diagnostic criteria met: Specify which criteria from DSM-5 the patient fulfills for opioid use disorder, including craving intensity, inability to control use, and functional impairment 1, 2
• Risk factors present: Document history of overdose, concurrent benzodiazepine use, mental health comorbidities (anxiety, depression), substance use history, hepatitis C status, and current daily opioid dose if applicable 1
• PDMP review findings: Record controlled substance prescription history, dangerous combinations identified, and high-risk dosing patterns 1

Substance Use Pattern Specifics

• Current opioid type and frequency: Document specific opioids used (heroin, fentanyl, prescription opioids), route of administration, daily quantity, and duration of use 1
• Last use timing: Critical for naltrexone consideration, which requires 7-10 days of complete abstinence before initiation 3, 4
• Withdrawal symptoms present: Document tremor, diaphoresis, agitation, insomnia, diffuse pain, cramping, anxiety, dysphoria, or anhedonia 1
• Overdose history: Number of prior overdoses, naloxone administration history, and circumstances 1

Treatment Discussion and Medication Offer

Document the specific medication-assisted treatment options discussed:

• Buprenorphine/naloxone (first-line): Partial agonist that reduces cravings and withdrawal, can be prescribed in office-based settings with DEA X-waiver, therapeutic dose 8-16 mg daily, FDA-approved for patients ≥16 years 3, 5
• Methadone (first-line): Full agonist with strongest evidence for reducing mortality and opioid use, requires certified Opioid Treatment Program, restricted for patients <18 years 3, 4, 6
• Naltrexone (second-line): Antagonist reserved for highly motivated patients who prefer opioid-free treatment and cannot/will not take agonist therapy, requires 7-10 days abstinence, available as monthly injection or daily oral 3, 4

Critical documentation point: Record that you explained medication alone is insufficient and must be combined with evidence-based behavioral therapy (cognitive-behavioral therapy, contingency management, or motivational enhancement therapy) 3, 7

Patient Response and Treatment Readiness

• Motivation level: Document specific readiness score or qualitative assessment—patients presenting for overdose typically show lower treatment readiness (mean 3.5/10) compared to those presenting for other opioid-related issues (4.2/10) 8
• Barriers identified: Document insurance status, transportation limitations, childcare needs, housing instability, employment concerns, stigma concerns, or fear of withdrawal 3
• Patient preference stated: Record which medication option the patient prefers and why, as patient choice affects adherence 5, 6
• Acceptance or refusal: If patient accepts, document plan for same-day or next-day initiation; if patient refuses, document harm reduction counseling provided and plan for re-engagement 2

Harm Reduction and Safety Planning

• Naloxone provision: Document that you provided or prescribed naloxone for overdose reversal, educated patient and family on administration, and emphasized keeping it accessible 1
• Overdose risk counseling: Explain that tolerance decreases rapidly during abstinence or treatment interruption, making relapse particularly dangerous 4
• Benzodiazepine co-prescription: If present, document plan to taper or discontinue benzodiazepines or reduce opioid dose, as concurrent use dramatically increases overdose risk 1

Behavioral Therapy Arrangement

Document the specific evidence-based therapy arranged:

• Cognitive-behavioral therapy: Produces effect sizes of 0.18-0.28 when combined with medication 3
• Contingency management: Equally effective alternative to CBT 3
• Motivational enhancement therapy: Another evidence-based option with comparable outcomes 3
• Referral details: Name of therapist/program, appointment date/time, and patient's stated commitment to attend 3

Follow-Up Plan Specifics

• Medication initiation timeline: Document when buprenorphine induction will occur (same-day, next-day, or scheduled date), or when methadone program intake is scheduled 2, 5
• Monitoring schedule: Plan for urine drug testing frequency (at minimum annually, but typically more frequent initially), PDMP review intervals (every prescription to every 3 months), and clinical reassessment timing 1
• Next appointment: Specific date within 1 week for medication follow-up and dose adjustment 5
• Crisis contact information: 24-hour crisis line, emergency department instructions, and when to use naloxone 2

Common Documentation Pitfalls to Avoid

Never document that you are "discontinuing care" or "discharging the patient" due to opioid use disorder—this constitutes patient abandonment and violates the standard of care 1, 2

Do not document offering "counseling" without specifying the evidence-based modality (CBT, contingency management, or motivational enhancement therapy), as generic counseling is insufficient 3

Avoid documenting that you will "monitor" without medication-assisted treatment—watchful waiting is not evidence-based and increases mortality risk 1, 2, 6

Never confuse buprenorphine for pain management with buprenorphine for OUD treatment—document clearly that you are treating OUD with maintenance therapy, which should never be tapered in an attempt to comply with pain guidelines 1

If you cannot provide buprenorphine yourself, document the specific referral made to a substance use disorder specialist or SAMHSA-certified program, with appointment details and patient agreement to attend 1, 2