Write a SOAP note for a 35‑year‑old male with opioid use disorder who is stable on buprenorphine/naloxone (Suboxone) 8 mg/2 mg daily for eight months, has mild anxiety, no other substance use, a supportive partner, stable housing and employment, occasional transportation difficulty, and wishes to continue medication‑assisted treatment with future taper planning.

SOAP Note for Stable Patient on Buprenorphine/Naloxone Maintenance

Subjective

Chief Concern: Follow-up for opioid use disorder (OUD) maintenance treatment

History of Present Illness:

• 35-year-old male with OUD, stable on buprenorphine/naloxone 8 mg/2 mg daily for 8 months 1
• Reports no cravings for opioids, no withdrawal symptoms 1
• Denies illicit opioid use since treatment initiation 1
• Reports mild anxiety symptoms (assess severity, frequency, triggers, impact on daily function) 1
• No concurrent alcohol, benzodiazepine, cocaine, or methamphetamine use 1
• Medication adherence: taking as prescribed, no missed doses 2
• Supportive partner involved in recovery 1
• Stable housing and employment 1
• Occasional transportation difficulty to appointments 1
• Expresses desire to continue medication-assisted treatment with future taper planning 1

Review of Systems:

• Sleep: assess quality and presence of insomnia 1
• Mood: screen for depression symptoms 1
• Pain: assess for any chronic pain complaints 1
• Constitutional: denies fever, chills, night sweats
• Gastrointestinal: assess for constipation (common buprenorphine side effect) 2

Objective

Vital Signs:

• Blood pressure: [document] 1
• Heart rate: [document] 1
• Respiratory rate: [document] 1
• Temperature: [document] 1

Physical Examination:

• General: alert, cooperative, no acute distress
• Skin: examine for track marks, abscesses, or other signs of injection drug use 1
• Neurological: assess for sedation, pupil size 1
• Mental status: mood, affect, thought process 1

Laboratory/Monitoring:

• Urine drug screen: [document results—should show buprenorphine/norbuprenorphine present, no illicit opioids] 2
• State prescription drug monitoring program check: [document—should show no other controlled substances] 2
• Hepatitis C and HIV status: [document if previously screened, or offer screening if not done] 1
• Note: Routine liver function testing every 3–6 months is NOT required for buprenorphine/naloxone maintenance (unlike naltrexone) 1

Assessment

1. Opioid use disorder, in sustained remission on medication-assisted treatment 1, 2

   • Stable on buprenorphine/naloxone 8 mg/2 mg daily for 8 months
   • No evidence of relapse or diversion
   • Therapeutic dose range is 8–16 mg daily; patient is at lower end of range 1

2. Mild anxiety disorder 1

   • Requires systematic screening to differentiate generalized anxiety disorder, post-traumatic stress disorder, or other anxiety spectrum disorders 1
   • Buprenorphine may provide some anxiolytic benefit 3
   • Consider non-benzodiazepine anxiolytics (SSRIs, SNRIs, buspirone, gabapentin) given FDA black-box warning against combining benzodiazepines with buprenorphine 1

3. Stable psychosocial situation 1

   • Supportive partner, stable housing, employment maintained

Plan

Medication Management

Continue buprenorphine/naloxone 8 mg/2 mg sublingual daily 1, 2

• Current dose is effective for maintaining abstinence 2
• Standard maintenance range is 8–16 mg daily; patient may benefit from dose optimization to 16 mg if any breakthrough cravings emerge 1
• Do not discontinue or taper at this time: Abrupt discontinuation markedly increases risk of opioid overdose and death due to reduced tolerance 1
• Treatment should be combined with counseling and behavioral therapies for optimal outcomes 1

Anxiety Management

Address mild anxiety without benzodiazepines 1

• Avoid benzodiazepines: FDA black-box warning for respiratory depression and death when combined with buprenorphine 1
• Consider non-benzodiazepine options:
  • SSRIs (e.g., sertraline, escitalopram) for generalized anxiety 1
  • SNRIs (e.g., venlafaxine, duloxetine) 1
  • Buspirone 15–30 mg daily divided 1
  • Gabapentin 300–600 mg three times daily 1
• Refer to behavioral therapy/counseling for anxiety management 1

Monitoring and Follow-up

Schedule follow-up visit in [specify interval, typically monthly for stable patients] 2

• Continue random urine drug testing to assess for illicit substance use 1, 2
• Perform pill/wrapper counts to assess adherence 2
• Check state prescription drug monitoring program at each visit 2
• Monitor for reemergence of cravings or withdrawal symptoms 2
• Reassess anxiety symptoms and response to any initiated treatment 1

Safety and Harm Reduction

Provide naloxone rescue kit 1, 4

• Educate patient and partner on overdose recognition and naloxone administration 1
• Naloxone 4 mg intranasal or 0.4 mg intramuscular for overdose reversal 4

Acute pain management planning 1

• If acute pain arises, continue usual buprenorphine 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

Future Taper Planning

Defer taper discussion until patient demonstrates prolonged stability (minimum 12–24 months) 1

• Maintenance therapy is superior to tapering: Buprenorphine maintenance significantly reduces relapse and mortality compared to discontinuation 1, 4, 5
• There is no maximum recommended duration of treatment; patients may require indefinite maintenance 1
• If taper is pursued in the future, use a slow schedule (~10% dose reduction per month over 10 months) to minimize withdrawal symptoms 1
• Taper may be paused, restarted, or slowed at any point based on patient tolerance 1

Psychosocial Support

Continue engagement with supportive partner and stable environment 1

• Encourage continued participation in mutual help meetings (Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery) 6
• Address transportation barriers: explore telehealth options for some visits, community transportation resources, or partner assistance 1

Common Pitfalls to Avoid

• Do not taper buprenorphine to comply with opioid dose guidelines: Buprenorphine for OUD has a ceiling effect on respiratory depression and should not be reduced 1
• Do not prescribe benzodiazepines for anxiety: Combination dramatically increases respiratory depression risk 1
• Do not discontinue buprenorphine prematurely: Discontinuation precipitates withdrawal and increases relapse to more dangerous opioids 1, 4

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Provider Signature: _______________
Date: _______________