The intertwined public health issues of chronic pain management and the risks of opioid use and misuse continue to receive national attention. Family physicians find themselves at the crux of the issue, balancing the care of patients who have chronic pain with the challenges of managing opioid misuse and opioid use disorders. Pain is one of the oldest challenges for medicine. Despite advances in evidence and understanding of its pathophysiology, chronic pain continues to burden patients in a medical system not designed to care for them effectively. Opioids have been used in the treatment of pain for centuries, despite limited evidence and knowledge about their long-term benefits, but there is a growing body of evidence regarding their risks. As a result of limited science, external pressures, physician behavior and pharmacologic development, we have seen the significant consequences of opioid overprescribing, misuse, diversion and dependence.
In the face of this crisis, family physicians have a breadth of knowledge and skills that allow them to be part of the solution. Pain management and dependence therapy require patient-centered, compassionate care as the foundation of treatment, attributes family physicians readily bring to their relationships with patients. With a paucity of physicians trained in addiction management and limited resources for patients with substance use disorders/OUDs to receive needed treatment, family physicians have a unique opportunity to champion this treatment and fill this public health need.1
While our currently fragmented health care system is not well-prepared to address chronic pain or often interrelated OUDs, the specialty of family medicine is well suited for this task. The American Academy of Family Physicians is actively engaged in the national discussion on pain management and opioid misuse. Committed to ensuring that our specialty remains part of the solution to these public health crises, the AAFP challenges itself and its members at the physician, practice, community, education and advocacy levels to address the needs of a population struggling with chronic pain and/or OUDs.
Call to Action
The AAFP is committed to addressing the dual public health crises of undertreated pain and opioid misuse/abuse at both the national and grassroots levels. To this end, the AAFP has formed a cross-commission advisory committee to address the multiple issues involved. Through its efforts with other physician and medical organizations, as well as governmental entities, the AAFP is committed to being a leader in promoting the advancement of safe pain management and opioid prescribing and addressing the growing burden of OUDs. Therefore, the AAFP challenges itself and its members to take action at the following levels:
Physician Level
Practice Level
Community Level
Education Level
Advocacy Level
Chronic pain and opioid misuse are significant and interrelated health care issues that are important to our patients, the medical community and society as a whole. A core tenet of medicine is to relieve suffering, with undertreating pain deemed a public health crisis by the National Academies of Sciences, Engineering, and Medicine.11 Uncertainties exist in the medical community when managing a patient’s chronic pain in the face of an epidemic of opioid misuse, as well as the morbidity and mortality associated with overdose. Drug overdose is the leading cause of unintentional death in the United States,12 and opioid addiction is driving this epidemic, such that the national opioid crisis was declared a public health emergency in 2017 and renewed as such a declaration in 2024.13 A family physician is uniquely positioned to help support patients in both their chronic pain management needs and their substance use and misuse health challenges and requires the training, support and resources to do so.
The U.S. health care system is poorly equipped to address the needs of a patient who has chronic pain and/or an OUD. Patients can feel abandoned in their care, marked with the stigma of addiction and labeled as “drug seekers” by their communities. Additionally, health care providers can be fired from medical practices for opioid misuse. Chronic pain should be managed with compassionate, multidisciplinary care, yet family physicians often do not have the resources, training or personnel to provide such care. They must work within a fragmented health care system where patients can obtain prescriptions from multiple sources and physicians. Since family physicians treat the whole patient and not just a subset of diseases, they face the challenge of treating patients with multiple comorbidities, which complicates managing chronic pain and balancing competing priorities during the office visit. Furthermore, the payment structure for the system at large (and for medications in particular) often rewards a fast-track approach instead of the comprehensive and time-consuming processes required to deliver the most appropriate care to patients struggling with chronic pain and/or opioid dependence and an OUD.
Despite these challenges, family physicians must understand the history of managing chronic pain and OUDs, the public health crisis of SUD and the current evidence-based science to treat them. They must also be prepared to be a key part of the solution. This position paper provides family physicians with critical information and calls on them to help address chronic pain and OUDs.
Pain and Opioids: How Did We Get Here?
Pain is one of the oldest medical problems and has a long history in medicine, religion and social science. It is also a nuanced problem. Chronic pain is common, with approximately 11% of the U.S. population reporting daily pain.14 In addition, pain is often more severe and more frequently undertreated in vulnerable populations, including the elderly, racial/ethnic minorities, women and socioeconomically challenged groups.11 Efforts to address the significant morbidity of chronic pain led to an increased emphasis on the recognition and treatment of chronic pain. These efforts — highlighted by actions of the U.S. Congress, National Academy of Medicine and multiple professional organizations — focused on improving care, increasing research into pain and its management and improving the training of physicians who manage pain.11,15,16
Opioid use for pain dates back to the 1800s. The use of opioids increased due to the need to treat devastating injuries sustained in warfare. Opioid use was also affected by advancements in pain physiology, the discovery of endogenous endorphins and opioid receptors and the development of synthetic opioids.17-19 In her founding of the modern-day hospice movement, Cicely Saunders coined the concept of total pain, which sought to encompass all of the emotional, spiritual, physical and social facets of pain a person feels.20 Beyond this, the category of physical pain alone can be divided into the categories of neuropathic, nociceptive and nociplastic, each of which can be further characterized based on the specific tissue affected.21 The complexity of pain makes it challenging to standardize its treatment to fit in the bounds of a 15-minute patient visit that is burdened with the demands of other quality measures that must be met.22
Misled by the push in 1999 from the U.S. Department of Veterans Affairs to recognize pain as a “fifth vital sign” and the once-held and now debunked view that “concern about the problems of addiction…[are] greater than the actual risk [of addiction],”23 the Joint Commission on Accreditation of Healthcare Organizations announced in 2000 that “excuses for inadequate pain control appear to have run their course and will no longer be accepted because poor pain control is unethical, clinically unsound and economically wasteful.”24 Turning to this guidance and receiving a sense of reassurance from the widely circulated 1980 article in the New England Journal of Medicine entitled “Addiction rare in patients treated with narcotics,”25 physicians and other clinicians, practices and health systems turned to prescribing opioids as a way to efficiently respond to their patients’ pain in the often pressed-for-time primary care setting.
While opioid pain relievers can effectively reduce pain,26 studies have shown that pain relief lasts less than 16 weeks, and there has been scarce data suggesting the longer-term effectiveness of opioids for chronic pain.27 But based on this limited data, the U.S. Food and Drug Administration still approved many of the current extended-release opioids.28 This resulted in a false sense of security in the physician community about the efficacy and safety of these medications to address the growing issue of chronic pain. While the CDC has since updated its clinical practice guidelines with more robust data to recommend that opioids not be used as a first line for chronic pain management,26 the impacts of increased prescribing remain, including opioid misuse and addiction.
Current Issues with Opioid Misuse and Abuse
Regular opioid use, including the use in an appropriate therapeutic context, is associated with both tolerance and dependence. Tolerance occurs when an individual needs more of a substance to achieve the same desired therapeutic effect, while dependence is characterized by specific signs or symptoms when a drug is stopped. Tolerance or dependence does not necessarily mean an individual has an OUD. Still, it can be a cause for concern when medication use is not monitored by a physician. It can potentially lead to opioid misuse, which broadly refers to any situation in which opioid use is outside of prescribed parameters. This can range from a simple misunderstanding of instructions to self-medication for other symptoms or, more dangerously, a compulsive use driven by an OUD.29 Abuse is also a broad term that refers to the use of a drug without a prescription for a reason other than that prescribed use or to elicit certain sensory responses.
While cause and effect are unclear, the fact that rates of opioid use increased following a period in which physicians were being criticized for their undertreatment of pain is probably not a coincidence. As noted, efforts to improve pain control led to pain being referred to as the “fifth vital sign,” and physicians were encouraged to address pain aggressively. So much so that in 2012, the number of opioid prescriptions written (259 million) equaled the adult population of the United States.29
Not surprisingly, the prescribing practices of physicians have come under scrutiny during the past decade. A 2016-17 study showed family physicians were the highest prescribing specialty group (20.5% of dispensed opioid prescriptions during the study period), followed by internists, dentists, nurse practitioners and physician assistants.30
Rates of prescribing opioids remained high throughout the 2000s, peaking in 2012 when opioid prescriptions totaled 81 prescriptions for every 100 people.31 Since then, we have witnessed a dramatic decrease (52%) of opioids being prescribed from all health care providers from 2012 to 2023.32 However, this reduction in the number of prescriptions has not led to significant reductions in overdose deaths. In fact, the opposite has occurred with the most recent data showing more than 107,000 overdose deaths in 2023 alone.
The reality is this trend is partially related to the misuse of prescription medications. In 2021, almost 2.5 million Americans 18 or older had an OUD,33 and in 2023, approximately 8.9 million people 12 years or older (3.1%) misused opioids, with 8.6 million of that population having misused prescription pain relievers.34
Opioids and the Management of Pain
There are key differences between acute and chronic pain. Acute pain is a warning symptom that functions as a bodily defense in the immune system and resolves with tissue recovery.35 It is mediated by intact neural pathways, and when needed, the pain can be controlled with opioids. Chronic pain arises from a complex web of heterogeneous illnesses and injuries and affects a patient physically, psychologically and emotionally. Frequently, it is associated with undue social and functional consequences, leading to lost productivity, reduced quality of life and social stigma. Not surprisingly, addressing chronic pain requires a comprehensive approach, with an emphasis on safe and compassionate patient-centered care. Chronic pain usually cannot be managed by prescription therapy alone.36 It must also be recognized that there are significant barriers to non-pharmacologic treatment for patients and physicians.
Recognizing this complexity, family physicians need guidance on how to best provide patient-centered, compassionate care to patients experiencing chronic pain. While guidelines and policy statements provide some assistance, the evidence available to support such recommendations and guidance is minimal. Previous guidelines have encouraged physicians to access and use specific resources, such as opioid risk assessment screeners, urine drug screening, standardized pain scales and prescription drug monitoring databases.37-39 Incorporating these resources into everyday practice adds time to already busy patient visits, so it is not surprising that many are not routinely used by physicians prescribing opioids for chronic pain.40 Additionally, an Agency for Healthcare Research and Quality study found “insufficient evidence to demonstrate long-term benefits of prescription opioid treatment for chronic pain, and long-term prescription opioid use was associated with increased risk for overdose and opioid misuse, among other risks,”26 which further complicates treatment decisions.
The FSMB has continued to update policies to help state medical boards ensure the practice of both appropriate pain management and safe, appropriate opioid prescribing. These policies address key areas for medical boards, physicians and patients concerning the following41:
The CDC Clinical Practice Guideline for Prescribing Opioids for Pain addressed many concerns with its 2016 policy, especially those surrounding inappropriate implementation of recommendations and highlighted the importance of individualized care.26 However, concerns remained about the quality of evidence and inconsistencies in the inclusion and exclusion criteria within the document, so the AAFP did not endorse the guideline but reaffirmed the guideline’s overall value to family physicians. Deficiencies in the 2016 CDC document led the VA/U.S. Department of Defense to issue a clinical guideline for managing chronic pain and the U.S. Department of Health and Human Services to release a best practices report.
While guidelines and policies such as these are readily available to physicians, there remains a substantial deficit in the peer-reviewed research necessary to form a reliable evidence base of best practices. Specific areas for further study include comparing the effectiveness of different analgesic agents and tapering and risk mitigation strategies to manage patients receiving long-term opioid therapy. To fill this gap, it is imperative that family physicians actively advocate for, and engage in, research opportunities on appropriate pain management strategies.
Role of Family Medicine in Care of Patients with Opioid Use Disorders
Screening for Opioid Abuse and Misuse
Most guidelines recommend screening patients to determine the risks of drug misuse and abuse and to mitigate those risks as much as possible. In 2021, the U.S. Preventive Services Task Force changed their screening recommendation for adults 18 years and older from an I statement (insufficient evidence) to a B statement (net benefit in favor) based on new evidence that identified a moderate net benefit if patients were screened for unhealthy drug use when services and treatment could be offered.42,43
Screening is typically based on risk factors identified with a thorough patient history and/or validated self- or clinician-administered assessment tool. Caution must be taken when obtaining a history, as cited risk factors, such as sociodemographic factors, psychological comorbidity, family history, and alcohol use disorders and SUDs, may lead to discriminatory practices that affect care for vulnerable populations.44 Still, validated screening tools may be useful, particularly when integrated into electronic health records and/or clinic processes. In its meta-analysis for the USPSTF updated recommendations, the AHRQ assessed existing screening tools and found several to be highly sensitive and specific for identifying drug use and misuse.45 Possible tools for general screening of drug use and misuse include the four-item National Institute on Drug Abuse Quick Screen, the eight-item Alcohol, Smoking and Substance Involvement Screening Tests, and the Tobacco, Alcohol, Prescription Medication, and Other Substance Use.
For specific populations, the Prenatal Risk Overview screens for drug dependence in women who are pregnant. For patients being assessed for prescription treatment with opioids, the Opioid Risk Tool may be used as a way to identify those at higher risk for an OUD.
Prescription Drug Monitoring Program
PDMPs are electronic databases that track the prescribing and dispensing of controlled prescription drugs, detect suspected abuse or diversion and identify patients at risk so they can benefit from early intervention.46 They are most useful if health care providers can access the system before prescribing a medication. Several states have enacted policies requiring clinicians to check the PDMP before prescribing controlled substances. Advocating for easy access to the PDMP database through integration within EHR systems is one way family physicians can increase participation using this valuable public health tool to change prescribing habits and reduce prescription medication misuse and abuse.
Naloxone
Family physicians should be aware of the lifesaving medication naloxone in combating opioid overdoses. In many states, the use of naloxone as a reversal agent for opioid overdose is standard practice for law enforcement and emergency medical service personnel (i.e., first responders and emergency department clinicians).47 Over the past two decades, naloxone has been increasingly provided to laypeople for use in an opioid overdose. In 2023, the FDA approved the first over-the-counter naloxone nasal spray to help reduce drug overdose by increasing access to this lifesaving medication in the community.48
One study from 2020 to 2022 found that while the rate of EMS-administered naloxone decreased by 6%, the rate of layperson-administered naloxone increased by nearly 44%.49 The trend of layperson use of naloxone is only likely to increase with the FDA approval of the OTC nasal spray. All states provide for increased layperson access to naloxone, and most states provide legal immunity to individuals who administer naloxone for opioid reversal. The vast majority of states also have added Good Samaritan provisions for prescribers and laypeople.
These opioid reversals are often part of an overdose education and naloxone distribution program. The SAMSHA and the AMA Substance Use and Pain Care Task Force encourage physicians to identify patients at higher risk of overdose and to prescribe them naloxone.32,50 The U.S. Department of Health and Human Services identified several indicators of patients with a higher risk of opioid overdose, with the recommendation that clinicians should strongly consider prescribing or co-prescribing naloxone. The indicators include patients51:
Medication-Assisted Treatment
The use of MAT for opioid and heroin dependence has existed for more than five decades and involves some form of opioid substitution treatment.52 Initially, only methadone (an opioid agonist) was available, but now clinicians have buprenorphine (a partial agonist used alone or in combination with naloxone) and naltrexone (an opioid antagonist with both oral and extended-release injectable formulations) as pharmacologic options for MAT. In addition, adjunctive medications such as clonidine, nonsteroidal anti-inflammatory medications and others are used in the treatment of specific opioid withdrawal symptoms.53 Prior to the Drug Addiction Treatment Act of 2000, medications for the treatment of substance abuse were available only via federally approved opioid treatment programs. In OTPs, personnel specifically trained in addiction medicine would dispense certain Schedule II medications (methadone and levo-alpha-acetylmethadol) on a daily basis. In 2000, DATA 2000 was passed, allowing qualified physicians to get a waiver to prescribe or dispense approved Schedule III, IV or V medications for the treatment of opioid dependence (buprenorphine products and naltrexone) outside of an OTP.54 However, as of December 2022, clinicians are no longer required to obtain a DATA waiver (X-waiver) to prescribe buprenorphine or naltrexone to treat OUD,55 which allows for much better integration of MAT into primary care. With the relaxing of the waiver requirement, family physicians are especially well-positioned to provide MAT to their patients.
With the increase in opioid misuse over the past several decades and the passage and implementation of DATA 2000, various federal and state authorities and professional organizations have produced guidelines to help providers treat OUDs. Since 2001, the SAMHSA has updated the Federal Guidelines for Opioid Treatment Programs, which outlines specific recommendations for the administrative and organizational structure and function of an OTP.56 SAMHSA also published the Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction, which outlines the elements of OBOT utilizing buprenorphine.57 The American Society of Addiction Medicine National Practice Guideline for the Treatment of Opioid Use Disorder provides a comprehensive strategy for OUD management that encompasses elements of OTPs and OBOT.58 Similar to the SAMHSA guidelines, it details the initial assessment and evaluation of the patient who has an OUD, offers recommendations for managing opioid withdrawal and describes and contrasts all of the available pharmacologic options for the treatment of OUDs. It concludes with a discussion of psychosocial therapy used in conjunction with pharmacologic treatments and provides guidance in caring for special populations (e.g., pregnant women and adolescents).
Clearly, the DATA 2000 waiver was a barrier for providers and patients. By 2019, only 4% of all U.S. physicians had a valid waiver to prescribe buprenorphine, with the majority of buprenorphine prescribed by primary care physicians and psychiatrists.59 If all the waivered physicians prescribed MAT to the fullest and legal extent possible, they would only be able to treat a fraction of the patients diagnosed with opioid dependence. Studies found that only 11% of patients diagnosed with OUD receive a prescription for MAT, and the situation is even more bleak if patients live in a rural county or are Black.60 Less than one-third of rural Americans have access to a buprenorphine provider in their county, and white patients are four times more likely than Black patients to receive a buprenorphine prescription.
Removing the requirement to obtain a waiver should remove a hurdle for physicians to provide MAT in their practices and open up MAT availability to more patients seeking care. New data are needed to determine if availability has increased since the waiver has been lifted. Examining the characteristics that encourage primary care physicians to prescribe MAT, using team-based primary care models that best support MAT and supporting advanced care practitioners is critical to addressing the demand for trained MAT providers.61,62
Barriers to Providing Office-based Opioid Treatment63
While family physicians can provide OBOT and patients may be amenable to receiving it, most are unaware they could receive MAT from their primary care physicians.64 Despite these barriers, OBOT represents a critical opportunity for family physicians to address the opioid abuse epidemic. By working to reduce these barriers, the AAFP encourages family physicians to incorporate MAT into their practice. Still further, educating the public that family physicians can offer MAT treatments remains an additional barrier to overcome.65
AAFP Efforts to Tackle the Opioid Abuse Epidemic
Policies
The AAFP recognizes the vital role that family physicians and other primary care clinicians play in appropriately managing SUDs, and we have developed policies, programs and partnerships to advocate for and educate family physicians and their communities. The AAFP’s policy on SUDs outlines the organization’s support for training family physicians on the proper diagnosis, treatment and prevention of SUDs.66 This policy also details a comprehensive strategic approach to SUDs, including patient education, partnering with community resources, advocating for legislation and governmental policies and supporting harm reduction strategies, such as bystander naloxone policies and needle exchange programs.
The AAFP also supports continued research into evidence-based guidelines for treating chronic pain. The AAFP supports implementing and using PDMPs and greater physician input into pain management regulation and legislation. The AAFP’s policy is that all students and residents should receive comprehensive education on SUD treatment. This includes recognizing the social inequities that might impact a patient’s capacity to understand and effectively cope with drug-related harm and reducing the stigma often associated with SUD.67 The AAFP supports appropriate training for pain management and has developed a curriculum guideline for teaching residents how to care for patients with chronic pain.68
Education
Since its inception in 1947, the AAFP has been committed to promoting and maintaining high standards in family medicine and improving public health. This is demonstrated by the AAFP’s role in the CME community as an accredited provider — the first of three national, standard-setting, credit-granting systems. While the AAFP opposes mandatory CME for physicians on opioid prescribing,69 it strongly supports educating its members on effective and evidence-based pain management through CME and non-CME activities. Additionally, the AAFP develops and provides multiple certified CME activities to address pain management and SUDs for its members. These CME activities are available in live, online and enduring formats, which allows for increased access by members. The AAFP will continue to support family physicians in enhancing their knowledge, competence and performance when treating patients with pain. We will also continue to provide CME to address the abuse, misuse and safety of opioid prescribing.
Resources and the AAFP's Commitment
The AAFP has collaborated with numerous organizations on issues pertaining to opioids, including the American Medical Association, SAMHSA, State Pain Policy Advocacy Network and American Academy of Pain Medicine. In 2014, the AAFP joined 25 other medical associations and organizations to launch the AMA Opioid Task Force.70 The group has since expanded to 29 associations and organizations, and in 2021, it was rebranded the AMA Substance Abuse and Pain Care Task Force.71 Building on previous work, the task force identifies best practices for combating opioid abuse and recommends the following five practices to be implemented across the country72:
Another initiative that aligns with the AAFP’s position and we support is the HHS National Pain Strategy, which has made the following six recommendations for improving pain management73:
The report from this group highlights opportunities to reduce the overreliance on opioid prescribing. Notably, the strategy calls for better evidence and more research on pain management.
Additionally, the AAFP provides its members with tools and resources for education, advocacy and patient care about pain management and opioid misuse. These resources include a chronic pain management toolkit, CME offerings, office-based tools and resources for community engagement, advocacy, science and education. The AAFP has also formed a member advisory panel that comprises commission members and subject matter experts. This panel will provide input on, and support for, the AAFP’s goals and initiatives related to opioids and pain management.
Effective pain management and care of patients with SUDs require patient-centered approaches and compassion, which are hallmarks of family medicine and family physicians. The AAFP is committed to ensuring that the specialty of family medicine is central to solving ongoing issues about the opioid public health crisis in the health care system. The recommendations and resources outlined in this paper are provided to encourage family physicians to take action on all levels to address the needs of a population struggling with chronic pain and/or OUDs.
(July 2012 BOD) (October 2025 COD)