Substance use disorders (SUD) are complex health and societal problems. SUD involve a problematic pattern of substance use leading to clinically significant impairment or distress and ranges from mild to severe addiction. 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 SUD and the comorbidities and mortality related to their misuse. Education in the treatment of all aspects of these complex disorders, including screening, knowledge, community resources and use of evidence-based strategies, should be a required 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:
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, “ Opioid Use and Misuse, A Public Health Concern” for further information.
Heroin, which can be used intranasally, intravenously, subcutaneously, and intramuscularly, 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 its low cost, relative ease of production, higher potency, and high addictive potential fentanyl is often 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 and advocate for the wide availability of naloxone to reverse overdose deaths.
Multiple avenues of treatment are available for opioid use disorder (OUD), including medication assisted treatment (MAT) and behavioral counseling. The Food and Drug Administration has approved three drugs for the treatment of OUD: buprenorphine, methadone, and naltrexone. The AAFP encourages the training of family physicians regarding proper assessment, treatment, and referral for treatment of OUD, including incorporating MAT with buprenorphine and/or naltrexone 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.
Healthcare organizations, including hospitals, should treat OUD as a chronic disease. Patients with OUD 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.
Cannabis
The American Academy of Family Physicians (AAFP) acknowledges that cannabinoids may have therapeutic benefits but also recognizes that cannabis use may have negative public health and patient health outcomes. High-quality research on the effects of cannabis use on special populations, public health and the environment is limited. Therefore, the AAFP advocates for further research into the overall safety and health effects of cannabis use.
The AAFP recognizes that many states have legalized the possession and use of cannabis products and supports the decriminalization of cannabis possession. In addition, the AAFP recognizes the importance of intervention and treatment for cannabis misuse in lieu of incarceration for all people, including youth. The AAFP advocates for further research regarding the effects of cannabis regulation on patient, community, and environmental health.
Alcohol Use
Alcohol misuse is defined as a spectrum of behaviors, including risky (excessive) alcohol use, binge drinking, and alcohol use disorder (AUD). 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 4-5 drinks per day for men or more than 4 drinks per day for women), or excess total consumption (more than 15 drinks per week for men or more than 8 drinks per week for women), or both. 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 people, 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, potential medication management, community resources, and family support under expert guidance. A family physician has a key role in supporting sustained sobriety. 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 and use non-stigmatizing language. The AAFP encourages its members to document AUD and alcohol related disease in the medical record and encourages members to document AUD on death certificates when implicated as a contributing cause of illness, injury or death.
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 use disorder and alcohol-impaired 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 has 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:
Substance Use Disorder Advocacy
Family physicians should be aware of community resources and regulation for the treatment of SUD 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.
Substance Use in Adolescents
The AAFP favors age 21 as the minimum legal age to purchase or consume alcohol.
The AAFP recommends that all youth do not consume alcohol. Although overall alcohol consumption by adolescents has decreased modestly over the past decade, alcohol use and misuse remains a significant public health concern for that population. Alcohol use in adolescents is associated with increased risk in mental health 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 Underage Alcohol Use.
The AAFP recognizes the prevalence of substance use among adolescents in the United States and the risk of use to development. Adolescents with untreated or undertreated SUD are at risk for adverse outcomes into adulthood, including criminal involvement, sexually transmitted infections, unintended pregnancy, co-occurring mental health disorders, and is associated with violence and unintentional injury.
The AAFP supports integrated and comprehensive early intervention implemented by primary care physicians to identify, reduce, and prevent substance use in adolescents. As physicians across the lifespan, family physicians are uniquely positioned to provide screening and referral to treatment to adolescents during annual exams, and should be familiar with the Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach.
Substance Use During Pregnancy
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 the use of drug testing or laboratory testing in pregnant or postpartum people without explicit informed consent, except for emergency medical circumstances.
The AAFP opposes imprisonment or other criminal sanctions of those who are pregnant solely for substance use during pregnancy and strongly encourages timely access to substance use treatment in pregnancy.
Abstinence Syndrome
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 risk of congenital anomalies, prematurity, growth impairment, and adverse developmental outcomes associated with substance use in pregnancy, these newborns will also be monitored for and may experience Neonatal Abstinence Syndrome (NAS). NAS encompasses all substance exposed newborns, although it is most often used for opioid-exposed newborns. Family physicians involved in caring for these newborns should be aware of and educated on the two main management systems used to monitor for NAS – Finnegan Scoring System and Eat Sleep Console (ESC). The decision of which management system to be used should be individualized to the family physician’s institution guidelines.
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 increased significantly from 1999 to 2023, particularly overdose deaths involving opioids. 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 advocates broadly for co-location of naloxone where automated external defibrillators are also required, and that naloxone be stored with on-site emergency kits in primary care facilities.
The AAFP encourages primary care facilities to implement overdose preparedness protocols that include naloxone storage with on-site emergency kits and all-clinic staff training in naloxone administration.
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.
Parity
SUD 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 SUD treatment in health care plans.
(2003) (October 2025 COD)