Relapse Prevention Plan (SUD)

Date: [Date]    Effective until: [Date or triggering event for revision]

Author: [Name, credentials]    Setting/Level of Care: [outpatient / IOP / PHP / residential / inpatient / OTP / telehealth / other]

Participants: [Patient name or initials]; [Other participants with roles] (Include only those with documented consent. Note consent status and scope.)

Primary Substance(s)/Diagnosis: [SUD diagnosis with severity]; [Co-occurring conditions affecting relapse risk] (Use person-first, non-stigmatizing language.)

Terminology: "Lapse" denotes a brief or single episode of use; "return to use/relapse" denotes a sustained or problematic pattern. Recurrence is part of a chronic condition and is used for learning and plan revision, not judgment. (Adjust terms to align with patient preference.)

Recovery Goals & Context

Reason for plan now: [Rationale for creation or update] (e.g., discharge planning, aftercare initiation, post-lapse update, new trigger identified, level of care change)

Patient-stated recovery goals: [Direct quote or close paraphrase of patient's goals] (If goals not fully elicited, state that goals will be revisited on [specific date]. Do not infer goals.)

Treatment targets addressed by this plan: [Specific targets] (e.g., prevent return to [substance], reduce [pattern/frequency], maintain medication adherence)

Clinician-proposed goals: [Goal — patient endorsed / declined] (Include only if applicable.)

Warning Signs & Triggers

(Distinguish patient-identified items from clinician-suggested possibilities. Document as facts only what patient endorsed or clinician directly observed.)

Early Warning Signs

• Cognitive: [Patient-identified cognitive warning signs] (e.g., minimization, bargaining, fantasizing about use)
• Emotional: [Patient-identified emotional warning signs]
• Behavioral: [Patient-identified behavioral warning signs]
• Physiological: [Patient-identified physiological warning signs]
• Treatment adherence signals: [Indicators such as missed medications/appointments, disengaging from supports] (Note if patient-identified or observed.)
• Clinician-suggested (discussed): [Warning signs explored but not yet endorsed] (Include only if applicable.)

High-Risk Triggers

• Internal: [Patient-identified internal triggers] (e.g., specific emotions, craving patterns, stressors, pain, trauma reminders)
• External: [Patient-identified external triggers] (e.g., specific people, places, situations, paydays, unstructured time)
• Clinician-suggested (discussed): [Triggers explored — note patient agreement or disagreement] (Include only if applicable.)

(If assessment is partial, document what is known and plan to complete by [specific date].)

Coping Plan & Skills

(List 3–5 concrete, actionable strategies the patient commits to using when warning signs or triggers occur.)

• [Coping skill with specific action and time frame]
• [Coping skill with specific action and time frame]
• [Coping skill with specific action and time frame]
• [Additional coping skill] (Include only if identified.)
• [Additional coping skill] (Include only if identified.)

Environmental controls: [Agreed steps such as removing paraphernalia, blocking contacts, route changes, limiting cash access] (Include only controls patient agreed to.)

Skills coaching/practice plan: [Skills introduced or practiced today; between-visit practice plan] (Include if patient has not yet identified effective skills.)

Medication Adherence

(Include only if recovery-relevant medications are part of treatment. Omit entire subsection otherwise.)

Medications: [Medication name, dose, schedule] (MOUD, alcohol pharmacotherapy, or other recovery-relevant medications only)

How patient takes medications: [Routine and method]

Adherence supports: [Alarms, pill organizer, refill plan, supporter reminders]

If a dose is missed: [Specific instructions and who to contact]

Medication contacts: [Prescriber name, phone; after-hours instructions]

Support Contacts

(Include only contacts patient agrees to list. Note consent status for clinician outreach.)

Professional Supports

• [Name, role, phone, best time to reach, after-hours instructions, consent status]
• [Name, role, phone, best time to reach, after-hours instructions, consent status]

Peer/Community Supports

• Sponsor/peer support: [Name, phone, best time to reach] (If not yet established, note plan and target date.)
• Mutual-help meetings: [Type, location/link, days/times]
• Other community supports: [Name, contact, meeting times] (Include only if applicable.)

Weekly connection plan: [Schedule of days/times and which supports patient will engage]

If supports declined: [Document refusal, barriers explored, alternatives offered] (Include only if applicable.)

Response Plan

(Staged, time-ordered steps. Specify patient actions versus clinician actions.)

1) Early Warning Signs (pre-lapse)

1. Patient actions immediately: [Specific actions with time anchors]
2. Same-day clinical actions if needed: [How to contact clinician/clinic; urgent concern instructions]

2) Lapse (single or brief use) — First 24 hours

1. Patient safety: Stop use; move to safe environment; avoid driving
2. Contact: [Who to notify first, phone numbers]
3. Overdose precautions: Do not use alone; ensure naloxone is available at [location]; [name] is trained to administer; call 911 for [overdose signs] (Include for opioid-involved cases.)
4. Tolerance warning: Reduced tolerance after abstinence increases overdose risk (Include for opioid-involved cases.)
5. Clinician actions: [Outreach plan; appointment timing; risk assessment]

3) Stabilization — 24–72 hours after lapse

1. Patient actions: [Review triggers; increase meeting frequency; implement coping skills; engage supports]
2. Medication reassessment: [Evaluate cravings/withdrawal; coordinate with prescriber] (Include only if applicable.)
3. Clinician actions: [Follow-up scheduling; consider step-up in care; team coordination with consent]

4) Return to Problematic Pattern

1. Urgent appointment: [How to access urgent/same-day care; crisis options]
2. Higher level of care: [Options matched to patient preferences and clinical need]
3. Medical considerations: [Medically supervised withdrawal if indicated; MOUD initiation/adjustment; safety checks]
4. Clinician coordination: [Referrals; care team communication with documented consent]

(If patient declines to plan for relapse response, document declination and include at minimum: crisis line [number] and 911 for immediate danger.)

Plan Review & Agreement

• Patient understanding: [Patient verbalized understanding and can state initial actions: yes / no; details]
• Elements declined by patient: [List with brief rationale if provided] (Include only if applicable.)
• Copy provided: [printed / patient portal / secure email] on [date]
• Next scheduled review date: [Date]
• Triggers for earlier revision: [New lapse; medication change; major stressor; level of care change]
• Coordination actions completed today: [Referrals; contact with supports/team; consents updated] (Include only if applicable.)