Substance Use History
Comprehensive assessment documenting a patient's past and current substance use patterns, including substances used, frequency, duration, and previous treatment attempts.
Full Definition
A detailed clinical documentation of a patient's relationship with substances across their lifetime, including age of first use, patterns of escalation, substances of choice, routes of administration, and treatment history. This assessment forms the foundation for diagnosis, treatment planning, and risk stratification in addiction medicine. The history includes both licit and illicit substances, over-the-counter medications, and prescription drug misuse. It also documents functional impairment, legal consequences, and social impacts of substance use.
Usage
Usage note: Preferred over 'substance abuse history' which carries stigmatizing connotations in modern addiction medicine practice.
In Context
- "The intake coordinator completed a thorough substance use history during the patient's first appointment." — Treatment center documentation
- "Previous substance use history indicated multiple failed attempts at self-detoxification." — Clinical assessment report