Substance Use Disorders

Substance use disorders (SUD) are complex health and societal problems.Substance use disorders involve a problematic pattern of substance use leading to clinically significant impairment or distress and ranges from mild to severe. These disorders are prevalent, increasing in incidence, and can have significant implications for individuals, families, and communities.

The American Academy of Family Physicians (AAFP) promotes a society which is free of alcohol, drug and substance misuse. The AAFP strongly urges its members to be involved in the diagnosis, treatment and prevention of substance use disorders as well as the secondary diseases related to their use. Education in the treatment of all aspects of these complex disorders, including knowledge and usage of evidence-based strategies, should be a defined part of medical school and family medicine residency curricula.

To better care for patients with such disorders, a comprehensive strategy should be adopted by physicians that includes:

  1. Recognition of the gravity, extent, and broad-based nature of substance use disorders in our society;
  2. Inclusion of substance use disorders in patient education;
  3. Early diagnosis, treatment and referral of those diagnosed with substance use disorder;
  4. Recognizition of the effects of substance use disorders on family members and community members and offering support and treatment for impacted individuals;
  5. Partnering with community resources in the prevention, education and treatment of substance use disorder.
  6. Advocating for inclusion of and parity for substance use disorder treatment in all health care plans;
  7. Advocating for legislation and governmental policies facilitating the prevention, diagnosis and treatment of substance use disorders, including funding for further research;
  8. Reinforcement of laws and strategies to limit exposure of the population, particularly adolescents and children, to the misuse of these substances;
  9. Supporting harm reduction strategies such as bystander naloxone programs, needle-syringe exchange programs, patient education, program and policy initiatives to prevent the secondary diseases associated with substance use disorders.

Opioids

Concurrent with the increased use of opioid analgesics for pain control has been an explosive growth in the rate of abuse, misuse and overdose of these prescription medications. The AAFP recognizes the vital role that family physicians and other primary care clinicians have in the proper provision of pain management services including prescribing opioid analgesics. The AAFP supports the training of family physicians regarding the proper assessment, referral and treatment of chronic pain patients in an effort to lessen the diversion, misuse of opioid pain relievers. The AAFP also supports further research into evidence-based guidelines for the treatment of chronic pain syndromes, implementation of prescription drug monitoring programs nationwide and greater physician input into pain management regulation and legislation. Please see the AAFP position paper, “Chronic Pain Management and Opioid Misuse, A Public Health Concern” for further information.

Heroin

Heroin, which can be used intranasally, intravenously, subcutaneously, and intracuscularly, is experiencing a rebound in usage, partially related to efforts to reduce the misuse of prescription pain relievers. With increased usage there has been a corresponding increase in overdose related deaths. Fentanyl is a potent synthetic opioid. Due to low cost and relative ease of production, fentanyl is mixed with other illicit substances and may be taken without the knowledge of the person using those substances. Synthetic opioids like fentanyl are now the most common drug associated with overdose deaths. The AAFP encourages its members to be aware of this and other trends in substance use.

Multiple avenues of treatment are available for opioid use disorders, including medication assisted treatment (MAT) and behavioral counseling. The Food and Drug Administration has approved three drugs for the treatment of opioid use disorder: buprenorphine, methadone, and naltrexone. The AAFP encourages the training of family physicians regarding the proper assessment, treatment, and referral for treatment of opioid use disorder, including obtaining the MAT waiver to prescribe MAT in their practice. The AAFP advocates for removal of barriers to the access of MAT. The AAFP recognizes that the need for continuing MAT should be individualized and some patients may require indefinite or lifelong treatment. The AAFP opposes regulation that places lifetime limits on MAT treatment.

Healthcare organizations, including hospitals, should treat opioid use disorder as a chronic disease. Patients who have an opioid use disorder should be accurately identified, regardless of their point of entry into the healthcare system, as early identification can aid in effective treatment and recovery. The AAFP encourages the use of evidence-based treatment options in the outpatient, inpatient, obstetric, peri-operative, and emergency department settings with the establishment of appropriate discharge plans to ensure continuity of care.

Family physicians should be aware of community resources and regulation for the treatment of substance use disorders in their state. The AAFP supports increased access to trauma-informed, culturally competent, patient centered inpatient and outpatient SUD treatment services. The AAFP supports effective care models and legislation that reduces the workforce shortage of physicians capable of treating SUD, eliminates stigma around SUD, ensures robust insurance coverage for MAT and other treatment modalities, and provides support for families and communities.

Marijuana

The AAFP opposes the recreational use of marijuana. However, the AAFP supports decriminalization of the possession of marijuana. The AAFP recognizes the benefits of intervention and treatment for the recreational use of marijuana, in lieu of incarceration, for all individuals, including youth. The AAFP also recognizes that several states have passed laws approving limited recreational use and/or possession of marijuana. Therefore, the AAFP advocates for further research into the overall safety and health effects of recreational use, as well as the effects of those laws on patient and societal health.

Risky Alcohol Use

Alcohol misuse is defined as a spectrum of behaviors, including risky (excessive) alcohol use, binge drinking, and alcohol use disorder. Risky or excessive alcohol use can lead to an increased risk of poor health and social consequences. It is defined as excess daily consumption (more than 4 drinks per day for men or more than 3 drinks per day for women), or excess total consumption (more than 14 drinks per week for men or more than 7 drinks per week for women), or both. A significant portion of the population, approximately 30%, misuses alcohol, and the majority of these persons engages in risky or excessive alcohol use. Alcohol use in pregnancy is the cause of fetal alcohol spectrum disorders (FASDs), a range of lifelong conditions that include physical and behavioral problems, as well as intellectual disabilities. Family physicians are in an ideal position to facilitate the prevention of untimely morbidity and mortality associated with risky alcohol use. All adults, including pregnant women, should be screened for risky use, using an evidence-based screening tool and provide a brief behavioral intervention to patients screening positive for risky alcohol use, to help them make healthier choices around their drinking. Detoxification is only the beginning of treatment and must be followed by adequate rehabilitation under expert guidance. Education in the treatment of all aspects of this complex disease should be a defined part of medical school and family medicine residency curricula.

The AAFP recommends that hospitals not discriminate against the admission and treatment of patients with alcohol-related illness or injury. The AAFP encourages its members to document alcohol abuse and alcohol related disease in the medical record and encourages members document alcohol abuse on death certificates when implicated as a contributing cause of illness, injury or death.

Alcohol Use in Adolescents

The AAFP recommends that all youth not consume alcohol. Although overall alcohol consumption by adolescents has decreased modestly over the past decade, alcohol use and abuse remains a signficant public health concern for that population. Alcohol use in adolescents is associated with increased risk in mental heatlh disorders, injury, and unsafe sexual behaviors. The AAFP urges its members to educate themselves and the public regarding the recognition, prevention and treatment of this medical problem in our nation's youth. Please also see the AAFP position paper, "Alcohol Advertising and and Underage Alcohol Use."

Standardized Drinking Age

The AAFP favors age 21 as the minimum legal age to purchase or consume alcohol.

Taxes on Alcohol Beverages

The AAFP, along with other professional and public health organizations advocates for the strong support for increased taxes on beer, wine, and distilled spirits equally based on alcohol content with a substantial portion of that revenue earmarked for the prevention and treatment of alcohol abuse and drunk driving.

Drinking While Driving

 

The AAFP supports efforts to reduce the number of alcohol and substance impaired drivers on
our roads. Significant reduction in morbidity and mortality have been widely reported when laws
provide a strong deterrence to driving while impaired and the AAFP recommends the adoption
of such laws in the interest of public safety. The AAFP recognizes the impaired driver as having
a medical problem and recommends that impaired drivers receive appropriate referral and
treatment for their condition. The AAFP supports the following recommendations:

  1. Reduction of the legal blood alcohol concentration (BAC) for drivers to 0.04 gm/dl.;
  2. State legislation to fund comprehensive alcohol-impaired driving prevention and treatment programs;
  3. State legislation to immediately confiscate drivers' licenses for those found to be above the legal BAC while driving (this is known as administrative license revocation);
  4. Increased enforcement of drinking and driving laws and expanded use of sobriety checkpoints;
  5. Support of state and federal messaging regarding alcohol and substance abuse and its effects on driving.

Parity

Substance use disorders are treatable medical illnesses that, if left untreated or inadequately treated, incur undue costs for the individual and for society as a whole. Treatment of substance use disorders is often long-term and may be lifelong for some individuals. Therefore, the AAFP supports full parity for substance use disorder treatment in health care plans.

Pregnant Women, Substance Use by

The AAFP recognizes that the literature does not support any lower limit of substance use at which potential fetal harm is reduced. As such, the AAFP supports public and individual education about the risks of any substance use during pregnancy.

The AAFP opposes imprisonment or other criminal sanctions of pregnant women solely for substance use during pregnancy, but encourages facilitated access to an established drug and alcohol rehabilitation program for such women.

Neonatal Drug Withdrawal

As described in the preceding section, no level of substance use during pregnancy is noted in which fetal harm is reduced. In addition to the congenital anomalies, prematurity, and growth impairment associated with substance use, family physicians involved in newborn care are increasingly noting the problem of neonatal drug withdrawal or neonatal abstinence syndrome. The AAFP encourages the education of all its members providing newborn care on the recognition, diagnosis and treatment of this syndrome.

Harm Reduction

The AAFP supports a comprehensive public health policy to prevent infectious diseases and other complications associated with injection drug use.

The AAFP supports effective harm reduction strategies to prevent the spread of HIV, hepatitis C, and Hepatitis B; reduce the risk of death from opioid overdose and engage individuals in treatment for substance use disorders. Needle-syringe exchange programs and safe injection sites reduce the transmission of disease, do not increase the rate of substance use, and increase the likelihood that individuals will enter drug treatment programs. Such strategies may also provide additional health and preventive services to vulnerable and high-risk populations. Physicians should be knowledgeable
about their states’ statutes regarding such harm reduction strategies. Additionally, the AAFP recommends that physicians and other healthcare workers counsel patients who are injecting substances about using sterile needles and syringes while simultaneously educating those patients about the harms of continued drug use and their treatment options.

Drug overdose deaths have significantly increased since 1999, particularly overdose deaths involving opioids and benzodiazepines. The AAFP supports education of the lay public and medical community about prevention, early recognition and treatment of overdoses. Effective strategies to decrease substance use disorder and overdose death require interdisciplinary coalitions, often including law enforcement, legislators, educators, jurisdictional leaders, and other community resources.

The AAFP supports efforts to promote naloxone kits for lay public usage as part of overdose prevention programs and the implementation of legislation which protects any individuals who administer naloxone from prosecution for practicing medicine without a license. The AAFP supports policies which promote the provision of naloxone to patients using opioids or other individuals in close contact with those patients, including personnel at safe injection sites. The AAFP supports the implementation of programs
which allow first responders and non-medical personnel to possess and administer naloxone in emergency situations.

The AAFP promotes the passage of 911 Good Samaritan Immunity laws to exempt the lay public from prosecution when contacting emergency medical services (EMS) to report overdoses and physicians from treating an overdose at a safe injection site.

(2003) (2019 COD)