Addiction Medicine Specialist - Follow-Up Review Note

Follow-Up Review Note Review Date: 1 November 2024, routine clinic review Substance Use Since Last Visit: Patient reports occasional alcohol use (2-3 units per week) since last visit, primarily on weekends. Denies use of cannabis, nyaope, methamphetamine, or codeine. Urine drug screen performed today was negative for illicit substances. Medication Adherence: Reports good adherence to prescribed buprenorphine/naloxone, taking 8mg daily as directed. Denies any significant side effects. Continues on fluoxetine 20mg daily for depression with good adherence. No missed doses reported for either medication. Withdrawal or Craving Symptoms: Reports mild, intermittent cravings for alcohol, especially in social settings. Intensity rated as 2/10. Denies any withdrawal symptoms. Patient is utilising coping strategies discussed previously, including calling his sponsor and attending AA meetings. Also reports using deep breathing exercises when cravings arise. Mental and Physical Health Status: Mental state: Mood is stable, sleep has improved, reports 7-8 hours per night. Concentration is good. Denies any suicidal ideation. Physical complaints: Reports occasional mild headaches, which are managed with over-the-counter paracetamol. No new physical comorbidities reported. HIV status remains undetectable, TB treatment completed last year. Social Functioning: Currently employed part-time at a local supermarket, working 20 hours per week. Income is stable. Has a strong social support network, including family and friends. Living in formal housing with his partner. No current legal issues. Receiving SASSA disability grant for his depression. Actively engaged with his support group and family. Plan: - Continue buprenorphine/naloxone 8mg daily. - Continue fluoxetine 20mg daily. - Encourage continued engagement with AA and use of coping strategies for cravings. - Referral to a vocational counsellor to explore full-time employment opportunities. - Next review scheduled for 1 February 2025.