Can you write a SOAP note for a middle‑aged adult with opioid use disorder stable on buprenorphine/naloxone (16 mg/4 mg daily) who has hazardous alcohol use (2–3 drinks daily with weekend binge episodes), mild transaminitis, normotension, normal heart rate, normal respiratory rate, afebrile, normal CBC, AUDIT‑C score of 6, no opioid withdrawal on COWS, and no suicidal ideation, focusing on integrated management?

SOAP Note for Patient with OUD on Buprenorphine/Naloxone and Hazardous Alcohol Use

Subjective

Chief Concern:

• Patient reports stable on buprenorphine/naloxone 16 mg/4 mg daily for opioid use disorder but struggling with alcohol consumption 1, 2
• Drinking pattern: 2–3 drinks daily with weekend binge episodes 3, 4
• AUDIT-C score of 6 indicates hazardous alcohol use requiring intervention 3

Substance Use History:

• No opioid cravings or withdrawal symptoms on current buprenorphine dose 1, 2
• COWS score of 0 confirms absence of opioid withdrawal 1, 2
• Denies use of illicit opioids, benzodiazepines, cocaine, or methamphetamine 1
• No suicidal ideation or self-harm thoughts 1

Psychosocial Factors:

• Employment and housing status should be documented 1
• Support system and family involvement assessment needed 1
• Participation in mutual-help groups (NA, AA, SMART Recovery) should be verified 1

Objective

Vital Signs:

• Blood pressure: normotensive 1
• Heart rate: normal 1
• Respiratory rate: normal 1
• Temperature: afebrile 1

Physical Examination:

• Examine for signs of injection drug use (track marks, skin abscesses) 1
• No fever, chills, or night sweats reported 1

Laboratory Results:

• CBC: normal 1
• Liver function tests: mild transaminitis (likely alcohol-related given drinking pattern) 3, 4
• Critical consideration: Approximately one-third of patients in opioid maintenance therapy show increased alcohol consumption and alcohol use disorders 3

Monitoring:

• Urine drug screen should show presence of buprenorphine and absence of illicit opioids 1
• PDMP check should reveal no concerning prescriptions from other providers 1

Assessment

Primary Diagnoses:

1. Opioid Use Disorder, in sustained remission on medication-assisted treatment 1, 2

   • Stable on buprenorphine/naloxone 16 mg/4 mg daily (optimal therapeutic dose) 1, 2
   • No withdrawal symptoms (COWS = 0) 1, 2
   • Buprenorphine maintenance is as effective as methadone for treatment retention and reducing illicit opioid use 2, 5

2. Alcohol Use Disorder, moderate severity (AUDIT-C = 6) 3, 4

   • Hazardous drinking pattern with daily use plus weekend binges 3, 4
   • Mild transaminitis consistent with alcohol-related liver injury 3, 4
   • Comorbid alcohol use disorder is a significant risk factor for poor clinical outcomes, including liver disorders, noncompliance, social deterioration, and increased mortality 3

Key Clinical Considerations:

• Buprenorphine and methadone carry little risk of liver toxicity, but alcohol use in this context requires careful monitoring 3
• Most studies show no change in alcohol use after initiation of opioid maintenance therapy, meaning the buprenorphine is not causing the alcohol problem but also not preventing it 3
• The combination of alcohol use disorder with opioid maintenance therapy increases risk of overdose if patient relapses to opioids 1, 5

Plan

1. Continue Buprenorphine/Naloxone Maintenance

Medication Management:

• Continue buprenorphine/naloxone 16 mg/4 mg daily sublingually 1, 2
• This dose is optimal for most patients and should not be adjusted based on alcohol use alone 1, 2
• Buprenorphine maintenance must be combined with counseling and behavioral therapies for comprehensive "whole-patient" approach 1, 2

Monitoring:

• Random urine drug testing at every follow-up visit to confirm adherence and detect diversion 1
• PDMP checks at every visit 1
• No routine liver function testing required specifically for buprenorphine (unlike naltrexone), but continue monitoring given alcohol use 1

2. Address Alcohol Use Disorder with FDA-Approved Pharmacotherapy

Medication Recommendation:

Prescribe naltrexone 50 mg orally daily OR extended-release naltrexone (Vivitrol) 380 mg IM monthly for alcohol use disorder 6, 7

Rationale:

• Naltrexone is FDA-approved for alcohol use disorder and reduces relapse rates by approximately 50% when combined with behavioral therapy 6
• Naltrexone blocks opioid receptors, dampening activation of the reward pathway by alcohol, thereby decreasing excessive drinking and increasing abstinence duration 6
• Critical safety point: Patient must remain completely opioid-free while on naltrexone, as it will block the therapeutic effects of buprenorphine 6
• Therefore, naltrexone CANNOT be used concurrently with buprenorphine maintenance 6, 7

Alternative Pharmacotherapy Options (since naltrexone is contraindicated):

The four FDA-approved medications for alcohol use disorder are: disulfiram, oral naltrexone, extended-release injectable naltrexone, and acamprosate—none of which include buprenorphine 7

Given the patient is on buprenorphine, the appropriate choices are:

1. Acamprosate 666 mg (two 333-mg tablets) three times daily 7

   • No interaction with buprenorphine 7
   • Increases abstinence rates 7
   • Safe in patients on opioid maintenance therapy 7

2. Disulfiram 250 mg daily 7

   • No interaction with buprenorphine 7
   • Increases abstinence by creating aversive reaction to alcohol 7
   • Requires high patient motivation and commitment 7

Preferred Recommendation: Start acamprosate 666 mg (two 333-mg tablets) orally three times daily 7

• This is the safest option for patients on buprenorphine maintenance 7
• No drug-drug interactions with buprenorphine 7
• Proven efficacy in increasing abstinence from alcohol 7

3. Liver Function Monitoring

Laboratory Surveillance:

• Repeat liver function tests in 3 months to assess for progression of alcohol-related liver injury 3, 4
• If transaminitis worsens, consider hepatology referral 3
• Buprenorphine itself carries little risk of hepatotoxicity, so elevated LFTs are attributable to alcohol use 3

4. Intensify Psychosocial Interventions

Behavioral Therapy:

• Brief intervention strategies have shown promise in reducing alcohol intake in patients on opioid maintenance therapy 3
• Increase frequency of individual counseling sessions to weekly (from current schedule) 1, 2
• Refer to specialized alcohol use disorder counseling or dual-diagnosis program 1, 3

Mutual-Help Groups:

• Strongly encourage daily attendance at AA meetings, with focus on dual-recovery groups that address both opioid and alcohol use disorders 1
• Consider SMART Recovery as alternative if patient prefers non-12-step approach 1

Contingency Management:

• Implement alcohol biomarker monitoring (e.g., ethyl glucuronide, phosphatidylethanol) at each visit 3
• Provide positive reinforcement for negative alcohol screens 3

5. Overdose Prevention

Naloxone Distribution:

• Provide or renew naloxone rescue kit at this visit 1
• Educate patient that if they discontinue buprenorphine, they will have decreased opioid tolerance and markedly increased risk of overdose and death if they return to opioid use 1
• Counsel that alcohol use increases risk of respiratory depression if patient relapses to opioids 8, 5

6. Follow-Up Schedule

Visit Frequency:

• Increase to weekly visits for first month given hazardous alcohol use 2, 3
• At each visit: document relapses, reemergence of cravings or withdrawal, perform random urine drug testing, conduct pill/wrapper counts, and check PDMP 2
• After stabilization on acamprosate and reduction in alcohol use, may space to every 2 weeks, then monthly 2

7. Screening for Psychiatric Comorbidities

Mental Health Assessment:

• Screen for depression, anxiety, PTSD, and other psychiatric comorbidities at next visit using validated tools 1
• Assess sleep quality and identify insomnia 1
• These conditions are common in patients with dual substance use disorders and require treatment 1

8. Common Pitfalls to Avoid

Critical Safety Considerations:

• Never prescribe naltrexone to a patient currently on buprenorphine maintenance, as it will precipitate withdrawal and block therapeutic effects 6, 7
• Do not abruptly discontinue buprenorphine due to alcohol use, as this markedly increases risk of opioid relapse and overdose death 1, 5
• Avoid "cold referrals" to addiction specialists; ensure warm handoff with confirmed appointment 1
• Do not delay addressing alcohol use disorder; approximately one-third of patients in opioid maintenance therapy have problematic alcohol use, and it is associated with increased mortality 3, 4

9. Patient Education

Key Counseling Points:

• Explain that alcohol use disorder is a separate condition requiring its own treatment 3, 4
• Emphasize that acamprosate works best when combined with complete abstinence from alcohol 7
• Discuss increased risk of liver disease with continued alcohol use 3, 4
• Reinforce that buprenorphine maintenance should continue regardless of alcohol use status 3, 4
• Warn about dangers of combining alcohol with any sedating medications 8, 5

Disposition:

• Return to clinic in 1 week for reassessment of alcohol use and acamprosate tolerability 3
• Emergency contact information provided for crisis situations 1
• Referral to intensive outpatient program for dual diagnosis if alcohol use does not improve within 4 weeks 3, 4