Provide a SOAP note for a 35‑year‑old adult with opioid use disorder stable on buprenorphine/naloxone (Suboxone) who continues intranasal cocaine use several times weekly.

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SOAP Note: Opioid Use Disorder on Buprenorphine/Naloxone with Ongoing Cocaine Use

Subjective

Chief Concern:

  • 35-year-old adult with opioid use disorder (OUD) currently maintained on buprenorphine/naloxone (Suboxone) 16 mg daily, reporting continued intranasal cocaine use several times weekly. 1

Opioid Use Disorder Status:

  • Patient denies opioid cravings or withdrawal symptoms on current buprenorphine dose. 1
  • Reports no illicit opioid use since starting buprenorphine maintenance. 1
  • Adherent to daily sublingual buprenorphine/naloxone dosing regimen. 2

Cocaine Use Pattern:

  • Intranasal cocaine use 3–4 times per week. 3
  • Patient acknowledges cocaine use interferes with treatment goals but has not achieved abstinence. 3

Psychosocial Stability:

  • Stable housing situation. 2
  • Currently employed. 2
  • Supportive family relationships present. 2
  • Participating in Narcotics Anonymous meetings weekly. 2

Review of Systems:

  • Denies fever, chills, night sweats. 2
  • Denies chest pain, palpitations, or shortness of breath. 2
  • Reports occasional insomnia related to cocaine use. 2
  • Denies depression or suicidal ideation; screening for anxiety, PTSD, and mood disorders should be documented. 2

Objective

Vital Signs:

  • Blood pressure, heart rate, respiratory rate, and temperature documented and within normal limits. 2

Physical Examination:

  • General: Alert, cooperative, no acute distress. 2
  • Skin: Examine nasal mucosa for septal perforation or irritation from intranasal cocaine use; assess for track marks or injection-related findings (abscesses, cellulitis). 2
  • Cardiovascular: Regular rate and rhythm; no murmurs. 2
  • Respiratory: Clear to auscultation bilaterally. 2

Laboratory & Monitoring:

  • Urine drug screen (UDS): Positive for buprenorphine (confirms adherence); positive for cocaine metabolites (benzoylecgonine); negative for illicit opioids, amphetamines, and benzodiazepines. 2
  • Prescription Drug Monitoring Program (PDMP) check: No concerning prescriptions from other providers. 2
  • Hepatitis C and HIV screening status reviewed; if not completed, offer testing today. 1, 2

Assessment

Primary Diagnosis:

  1. Opioid use disorder, moderate-to-severe, in sustained remission on medication-assisted treatment (buprenorphine/naloxone 16 mg daily). 1, 2

    • Patient demonstrates excellent adherence to buprenorphine regimen with no illicit opioid use and absence of withdrawal or cravings. 1, 2

  2. Cocaine use disorder, moderate-to-severe, active use. 3, 4

    • Continued intranasal cocaine use 3–4 times weekly despite buprenorphine maintenance. 3
    • Cocaine use is a well-documented risk factor for non-adherence to buprenorphine treatment and predicts poorer outcomes even when controlling for opioid use. 3

Clinical Context & Evidence:

  • Buprenorphine maintenance at 16 mg daily is the evidence-based standard dose and should be continued indefinitely; discontinuation precipitates withdrawal and dramatically increases relapse risk to illicit opioids and overdose death. 1, 2
  • Cocaine use does not contraindicate buprenorphine continuation. 4 Early preclinical and clinical data suggest buprenorphine may reduce cocaine self-administration, though this effect is inconsistent and not the primary indication. 4
  • Sporadic non-opioid substance use (including cocaine) during the first months of medication-assisted treatment is common and should be addressed with increased visit frequency and more intensive behavioral therapy rather than buprenorphine discontinuation. 5

Plan

1. Continue Buprenorphine/Naloxone Maintenance

  • Maintain buprenorphine/naloxone 16 mg sublingual daily. 1, 2
  • Do not taper or discontinue buprenorphine due to cocaine use; medication-assisted treatment for OUD must remain the priority to prevent opioid relapse and overdose. 1, 6, 7
  • Prescribe 30-day supply with no refills; patient to return in 2 weeks for intensified monitoring. 6, 5

2. Intensify Behavioral and Psychosocial Interventions

  • Increase visit frequency to every 1–2 weeks (from monthly) to address ongoing cocaine use. 6, 5
  • Refer to or increase engagement in cognitive behavioral therapy (CBT); CBT attendance is significantly associated with improved adherence to buprenorphine and reduced substance use. 3
  • Encourage continued participation in Narcotics Anonymous or SMART Recovery mutual-help groups. 2
  • Consider referral to intensive outpatient program (IOP) or specialized addiction treatment if cocaine use persists despite increased support. 6

3. Monitoring & Safety

  • Random urine drug screening at every visit to monitor buprenorphine adherence and detect cocaine, illicit opioids, benzodiazepines, and amphetamines. 2, 6, 5
  • PDMP check at every visit. 2
  • Provide or renew take-home naloxone rescue kit and overdose prevention education (risk of polysubstance overdose remains elevated with cocaine use). 1, 2
  • Screen for depression, anxiety, PTSD, and sleep disturbances at next visit; treat comorbid psychiatric conditions as indicated. 2

4. Address Cocaine Use Disorder Directly

  • Counsel patient that cocaine use is associated with non-adherence to buprenorphine and poorer treatment outcomes; emphasize goal of complete abstinence from all non-prescribed substances. 3
  • No FDA-approved pharmacotherapy exists for cocaine use disorder; behavioral interventions (CBT, contingency management) are first-line. 3, 4
  • Assess for cardiovascular complications of cocaine use (chest pain, palpitations, hypertension) at each visit. 4

5. Hepatitis C & HIV Screening

  • If not completed, offer hepatitis C and HIV testing today given history of substance use. 1, 2

6. Reproductive Health Counseling

  • Offer reproductive health counseling and contraception if applicable. 1

7. Common Pitfalls to Avoid

  • Do not discontinue or taper buprenorphine in response to cocaine use; this increases risk of opioid relapse and overdose death. 1, 6, 7
  • Do not prescribe benzodiazepines concurrently with buprenorphine due to FDA black-box warning for respiratory depression and death. 1
  • Do not reduce visit frequency or monitoring intensity while cocaine use continues; non-adherence risk is elevated. 6, 5, 3

8. Follow-Up

  • Return in 2 weeks for reassessment of cocaine use, buprenorphine adherence, UDS, PDMP check, and engagement in behavioral therapy. 6, 5
  • If cocaine use persists at 2-week follow-up, consider referral to higher level of care (IOP or residential treatment). 6

References

1
Guideline

Medications for Managing Opioid Withdrawal

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

2
Guideline

Buprenorphine Therapy for Opioid Addiction

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

5
Research

Buprenorphine Therapy for Opioid Use Disorder.

American family physician, 2018

7
Research

Medication Treatment of Opioid Use Disorder.

Biological psychiatry, 2020

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