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Substance Misuse in Adults: A Primary Care Approach

Alicia Kowalchuk, DO
Sandra J. Gonzalez, PhD, LCSW
Roger J. Zoorob, MD, MPH

American Family Physician. 2024;109(5):430-440.

Author disclosure: No relevant financial relationships.

Substance misuse and substance use disorder continue to be major causes of morbidity and mortality, and family physicians are well positioned to provide evidence-based prevention and management for these conditions. Of people 12 years and older, 13% reported using a nonprescribed controlled substance in the past month, and 24% had at least one episode of binge drinking of alcohol, defined as five or more drinks for men and four or more drinks for women on one occasion. Benzodiazepines are used by 12% of the U.S. population. Clinicians should incorporate standardized screening and brief intervention for use of alcohol and other substances into routine care of adult patients, as well as referral to specialized treatment services when indicated. Use of nonstigmatizing, person-first language has been shown to positively affect care for patients with substance use disorders. Alcohol screening and brief intervention have been shown to reduce excessive drinking by 40% in patients at 6 months postintervention. Office-based treatment of alcohol use disorder with medications approved by the U.S. Food and Drug Administration, such as acamprosate and naltrexone, remains underutilized, presenting another opportunity for family physicians to positively affect the health of their patients and communities. With elimination of the X-waiver, any clinician with Schedule III prescriptive authority can treat opioid use disorder with buprenorphine in their office-based practice. Opioid overdose education and naloxone coprescribing are other tools family physicians can employ to combat the overdose crisis.

The medical approach to substance use has significantly changed over the past decade. Decreases in opioid prescribing and increases in synthetic opioid availability have fueled a crisis of overdose deaths, exceeding 100,000 U.S. deaths annually.1 In response, research and funding priorities have shifted, and the medical profession has adopted new tools for prevention, screening, assessment, and treatment. The American Academy of Family Physicians strongly supports family physicians and residents incorporating diagnosis, treatment, and prevention of substance use disorders (SUDs) into their routine clinical practices.2,3 For purposes of this article, “substance use disorder” indicates that an individual meets the specicfic Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), criteria for a substance use disorder 4; substance misuse indicates not meeting those criteria for the disorder and using in hazardous situations or above limits for low-risk alcohol use. This article shares key updates in the primary care field and focuses on adult care. An article focusing on adolescents has been previously published in American Family Physician.5

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Screen for unhealthy alcohol use in patients 18 years and older using brief, validated questionnaires; provide brief behavior counseling intervention for those who screen positive.28,29 B U.S. Preventive Services Task Force recommendation and clinical trials showing decreased risky drinking and functional improvement over standard care
Routinely screen for unhealthy drug use in patients 18 years and older with brief, validated questionnaires when an appropriate continuum of care is available.31,33,34 C U.S. Preventive Services Task Force recommendation and clinical trials; the American Academy of Family Physicians found insufficient evidence to support screening for substances other than opioids
Daily oral naltrexone (Revia) and monthly extended-release intramuscular naltrexone (Vivitrol) are recommended for treating alcohol use disorder.52 A Consistent evidence from randomized controlled trials
Buprenorphine is recommended for treating OUD and now requires only a standard U.S. Drug Enforcement Administration registration to prescribe.62 A Consistent evidence from randomized controlled trials
Overdose education and naloxone distribution are recommended for all patients with OUD, whether active or in recovery, and for any patients taking chronic opioid therapy to reduce overdose risk.70 B Nonrandomized study showing decreased morbidity and mortality with few and minor adverse effects

OUD = opioid use disorder.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

ALICIA KOWALCHUK, DO, is an associate professor in the Department of Family and Community Medicine at Baylor College of Medicine, Houston, Tex.

SANDRA J. GONZALEZ, PhD, LCSW, is an associate professor in the Department of Family and Community Medicine at Baylor College of Medicine.

ROGER J. ZOOROB, MD, MPH, FAAFP, is the Richard M. Kleberg, Senior Professor and Chair of the Department of Family and Community Medicine at Baylor College of Medicine.

Address correspondence to Alicia Kowalchuk, DO, Baylor College of Medicine, 3701 Kirby Dr., Ste. 600, Houston, TX 77098 (aliciak@bcm.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial relationships.

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