Prior Treatment History: Assessing What’s Been Tried and Why It Matters
This is Part 4 in our series on Substance Use History.
Read Part 3: Identifying Substances, Quantities, and Routes for the previous component.
Understanding what treatments a patient has already tried provides crucial information about their engagement, what’s worked, what hasn’t, and appropriate next steps in care. Prior treatment history reveals patterns of relapse, treatment response, barriers to engagement, and readiness for change.
Learning Objectives
- Identify key categories of prior treatment relevant to substance use disorders
- Gather structured details about previous programs and medication-assisted treatments
- Evaluate treatment effectiveness, barriers to engagement, and follow-up participation
- Incorporate prior treatment data into diagnostic formulation and treatment planning
- Document treatment history at appropriate levels of detail for clinical decision-making
Start With Chart Review
Before interviewing the patient, review available documentation:
- Discharge summaries: Confirm detox completion, withdrawal medications used, and level of care recommendations
- Prescription history: Cross-check methadone, buprenorphine, naltrexone, acamprosate, or disulfiram fills
- Prior treatment notes: Extract reasons for non-completion, therapeutic interventions used, and treatment response
- Emergency department records: Identify overdoses, withdrawal presentations, or substance-related medical complications
💡 Clinical Pearl: Reviewing pharmacy fills can reveal silent relapses or discontinuation patterns that patients may not spontaneously disclose.
Interview the Patient
Detoxification Programs
- “Have you ever been through medical detox?”
- “Was it inpatient or outpatient?”
- “Did they use medications to help with withdrawal?”
💡 Clinical Pearl: Clarify whether withdrawal management included benzodiazepines, clonidine, alpha-2 agonists, or supportive care only. This reveals severity of prior withdrawal and treatment intensity.
Why this matters: History of medically managed detox suggests physiologic dependence and withdrawal risk. Patients who required inpatient detox have higher relapse risk and may benefit from residential rather than outpatient follow-up.
Inpatient/Residential Programs
- “Have you been to inpatient rehab or residential treatment?”
- “How long was the program?”
- “What was the treatment approach: 12-step, therapeutic community, other?”
Why this matters: Duration of residential treatment predicts likelihood of sustained abstinence. Programs shorter than 90 days have higher relapse rates. Treatment philosophy affects patient buy-in and satisfaction.
Outpatient Programs
- “Have you participated in outpatient treatment?”
- “What did that involve: individual therapy, group therapy, medication management?”
- “How often did you attend?”
Why this matters: Outpatient treatment history reveals whether less intensive interventions have been tried. Repeated outpatient failures suggest need for higher level of care.
Medication-Assisted Treatment
- “Have you used medications for substance use disorder, like methadone, buprenorphine (Suboxone), naltrexone (Vivitrol), acamprosate, or disulfiram?”
- “How long were you on the medication?”
- “Did it help?”
- “Why did you stop?”
💡 Clinical Pearl: Medication-assisted treatment significantly improves outcomes for opioid and alcohol use disorders. Prior successful response increases likelihood of future benefit. Clarify whether discontinuation was due to side effects, stigma, access barriers, or relapse.
Why this matters: MAT history identifies evidence-based interventions that worked previously and should be reintroduced. Barriers to continuation inform treatment planning and support needs.
Mutual Support Groups
- “Have you attended AA, NA, SMART Recovery, or other support groups?”
- “How regularly did you attend?”
- “Did you have a sponsor?”
Why this matters: Structured aftercare and peer support reduce relapse rates. Understanding prior engagement helps assess readiness for 12-step or alternative recovery frameworks.
Evaluating Treatment Effectiveness
Treatment Response
- “Did the treatment help you achieve abstinence or reduce your use?”
- “Were there improvements in other areas: relationships, work, legal issues, physical health?”
- “How long did the benefits last after you completed the program?”
Why this matters: Treatment response history distinguishes between effective interventions that were discontinued prematurely and interventions that failed despite adequate engagement.
Barriers and Facilitators
- “What challenges did you face: transportation, cost, childcare, work schedules, stigma?”
- “Were there issues with the program itself that made it harder to engage?”
- “Did co-occurring mental health conditions affect your ability to participate?”
- “What helped you stay engaged and get the most out of treatment?”
🚩 Red Flag: Patient attributes failure solely to external factors without acknowledging personal contribution—may signal limited insight or external locus of control. Address gently through motivational interviewing techniques.
Why this matters: Identifying modifiable barriers allows treatment planning that addresses real-world obstacles. Recognizing facilitators guides selection of programs with similar supportive elements.
Follow-Up and Relapse Prevention
- “Did the program include ongoing support after completion: alumni groups, step-down care, continuing therapy?”
- “Are you currently involved in any continuing care or recovery support services?”
- “Did you have a relapse prevention plan? Do you still use it?”
💡 Clinical Pearl: Structured aftercare participation strongly predicts reduced relapse rates. Absence of continuing care is a significant relapse risk factor.
Why this matters: Continuity of care is essential for sustained recovery. Gaps in aftercare explain relapse patterns and guide recommendations for more comprehensive discharge planning.
Patient Goals and Satisfaction
- “What were your goals for that treatment, and were they met?”
- “How satisfied were you with the program overall?”
- “Would you consider returning to that program or trying something similar?”
- “If you could change anything about your treatment experience, what would it be?”
Why this matters: Patient-centered goal alignment improves engagement and outcomes. Understanding dissatisfaction prevents referral to similar programs that may fail for predictable reasons.
Documentation
| Documentation Level | What to Include | Example | When to Use This Level |
|---|---|---|---|
| Minimal | Types of programs attended, approximate dates, reason ended | “Completed 7-day detox in 2022, outpatient program in 2023, ended due to work schedule.” | Quick assessments or initial intake with limited time |
| Standard | Minimal + duration, response, and barriers | “Two prior programs: 7-day detox (benzodiazepine taper, successful), 10-week outpatient CBT (partial adherence due to transportation).” | Routine evaluations requiring baseline formulation |
| Detailed | Standard + insight, patterns, readiness for change, recommendations | “Multiple inpatient stays, pattern of relapse within 3 months. Reports benefit from MAT (buprenorphine) but stopped when sponsor discouraged it. Shows awareness of triggers, open to longer residential treatment with MAT integration.” | Complex relapse patterns, treatment-resistant cases, or pre-rehab assessments |
Why This Information Matters
Prior treatment history is essential for three core clinical functions:
Diagnostic clarity: Repeated treatment failures may reflect misdiagnosis rather than treatment resistance. For example, persistent relapse despite multiple interventions may indicate undiagnosed trauma, untreated co-occurring psychiatric disorder, or inadequate medication-assisted treatment.
Prognosis and readiness for change: Treatment history reveals the patient’s trajectory through stages of change. Multiple treatment episodes demonstrate persistence and resilience, even when outcomes have been unsuccessful. This information guides realistic goal-setting and therapeutic alliance.
Treatment planning: Understanding what has and hasn’t worked allows clinicians to recommend appropriate level of care, avoid repeating ineffective interventions, and match patients with evidence-based treatments they haven’t yet tried. For instance, a patient with multiple outpatient failures may need residential care, while someone who responded well to buprenorphine but discontinued due to stigma may benefit from education and re-initiation with enhanced support.
Prior treatment assessment is not about documenting failure—it’s about understanding the path taken so far and identifying the most promising next step forward.
Next in this series: Part 5 – Assessing Patterns of Use and Functional Impact
Previous post: Part 3 – Identifying Substances, Quantities, and Routes
