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Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper

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Health and Public Policy to Facilitate Effective Prevention and Treatment of Substance Use Disorders Involving Illicit and Prescription Drugs: An American College of Physicians Position Paper | PDF


The rising number of drug overdose deaths and the changing legal status of marijuana pose new challenges. In this position paper, the American College of Physicians maintains that substance use disorder is a treatable chronic medical condition and offers recommendations on expanding treatment options, the legal status of marijuana, addressing the opioid epidemic, insurance coverage of substance use disorders treatment, education and workforce, and public health interventions.


Substance use disorders pose a heavy societal burden, endangering individual and family health and well-being, tearing through communities, and sapping resources from the health care system. These disorders are common in the general population and occur at even higher rates among those who are incarcerated. Access to care for this condition is limited. In 2014, 22.5 million people in the United States needed treatment for an illicit drug or alcohol use problem but only 18% received any treatment, far below treatment receipt rates for those with hypertension (77%), diabetes (73%), or major depression (71%) (1).

The use of illicit drugs is a drain on the nation's financial resources. In 2007, the indirect and direct cost of illicit drug use was estimated to be about $200 billion related to lost productivity, health care, and law enforcement ($11 billion annually) (2). The medical complications of untreated substance use disorder also drive health care system costs. Hospitalizations for opioid use disorder rose from nearly 302,000 to more than 520,000 from 2002 to 2012, and costs for such care quadrupled to $15 billion in 2012. Charges for hospitalization for opioid use disorder with serious infections also quadrupled over the same time period to $700 million (3). Notably, evidence shows that for every dollar invested in drug prevention and treatment, the nation sees substantial savings (45).

Over the past 40 years, many jurisdictions established rigid punishments for nonviolent drug offenses, including mandatory incarceration. However, there has been growing support for the idea that public policy should be reoriented to emphasize prevention and treatment of substance use disorders through public and individual health interventions rather than excessive reliance on criminalization and incarceration. One example of this shift is the promotion of specialized drug courts by federal, state, and local governments. Drug courts can offer the individual with substance use disorders a path to treatment rather than incarceration, in addition to supporting prevention and early intervention initiatives (6–8).

In addition, the United Nations has called for a health-focused direction to the drug problem (9). The public is also supportive of treatment rather than incarceration for drug users. According to a 2014 survey conducted by the Pew Research Center, 67% of Americans say that “the government should focus more on providing treatment for those who use illegal drugs such as heroin and cocaine” (10).

This document focuses on substance use disorders related to illicit drugs and misuse of prescription drugs, particularly opioids. Although the American College of Physicians (ACP) recognizes that alcohol and tobacco use disorders are a serious public health problem, policies to address such issues are outside the scope of this paper. Recommendation 3 pertains to marijuana and recommendation 4 to opioids, whereas the other recommendations apply to all use disorders associated with illicit and prescription drugs. For purposes of this paper, the term “illicit drug” includes the following categories based on the National Survey on Drug Use and Health: marijuana (including hashish); cocaine (including crack cocaine); heroin; hallucinogens; inhalants; and the nonmedical use of prescription-type pain relievers, stimulants, and sedatives.

Although many states have legalized or decriminalized use and sale of medical and/or recreational marijuana, it is categorized as an illicit drug for the purposes of this paper because its use and possession remain illegal under federal law and in many states. Furthermore, the paper offers public policy recommendations regarding the prevention and treatment of substance use disorders involving illicit and prescription drugs and not on the clinical aspect of preventing and treating these disorders. This executive summary provides a synopsis of the full position paper, which is available in the Appendix.


This policy paper was drafted by the Health and Public Policy Committee of the ACP, which is charged with addressing issues that affect the health care of the U.S. public and the practice of internal medicine and its subspecialties. The authors reviewed available studies, reports, and surveys on the prevention and treatment of substance use disorder from PubMed, Google Scholar, relevant news articles, policy documents, Web sites, and other sources. The authors largely excluded sources that were more than 10 years old, with the exception of several federal government reports that were included for background purposes. Recommendations were based on reviewed literature and input from the ACP's Board of Governors, Board of Regents, Council of Early Career Physicians, Council of Resident/Fellow Members, Council of Student Members, and Council of Subspecialty Societies and nonmember experts in the field. The policy paper and related recommendations were reviewed and approved by the Health and Public Policy Committee in October 2016 and the Board of Regents in February 2017. Financial support for the development of this position paper comes exclusively from the ACP operating budget.



1. Substance use disorder is a chronic medical condition and should be managed as such.

Substance use disorders are treatable chronic medical conditions that should be addressed through expansion of evidence-based public and individual health initiatives to prevent, treat, and promote recovery. ACP supports appropriate and effective efforts to reduce all substance use, including educational, prevention, diagnostic, and treatment efforts. In addition, ACP supports medical research on substance use disorders, including causes and treatment. ACP emphasizes the importance of addressing the stigma surrounding substance use disorders among the health care community and the general public.

2. ACP supports the implementation of treatment-focused programs as an alternative to incarceration or other criminal penalties for persons with substance use disorders found guilty of the sale or possession of illicit substances. 

Treatment for substance use disorders should be made available in a timely manner, including for those in the criminal justice system as an alternative to incarceration and other criminal penalties.

3. Stakeholders should assess the risks and benefits of removing or reducing criminal penalties for nonviolent offenses involving illicit drugs.

ACP calls for policymakers and researchers to carefully assess the arguments and evidence for amending criminal justice laws to remove or reduce criminal penalties (decriminalization, legalization, or offer of treatment as an alternative to criminal justice penalties) for nonviolent users of drugs, including assessing the following:

a. The relative risk that such drugs pose for the individual health of the users, the potential for misuse, and the potential effect on the overall health of the population that might result from decriminalization or legalization

b. Whether criminalization acts as a barrier to preventing and treating substance use disorders and recurrence of such disorders

c. The consequences of criminalization on the person with a substance use disorder, including disproportionate adverse effects on persons based on racial, socioeconomic, and ethnic characteristics

d. Whether decriminalization or legalization leads to more or fewer substance use disorders and the health consequences associated with them

ACP also calls for research on the individual and public health effects in states that have legalized or decriminalized the use of marijuana and the effectiveness of regulatory structures in those states that may minimize any adverse health impacts especially on children and adolescents.

4. Multiple stakeholders should cooperate to address the epidemic of prescription drug misuse, including the following strategies: implementation of evidence-based guidelines for pain management; expansion of access to naloxone to opioid users, law enforcement, and emergency medical personnel; expansion of access to medication-assisted treatment of opioid use disorders; improved training in the treatment of substance use disorders, including buprenorphine-based treatment; establishment of a national prescription drug monitoring program (PDMP); and improvement of existing monitoring programs.

ACP believes that physicians should work with other stakeholders, including medical and behavioral health care professionals, public health officials, government programs, patient advocacy groups, insurance plans, and law enforcement, to address the prescription drug use disorder epidemic.

To help address the prescription drug use epidemic, ACP makes the following recommendations:

a. Physicians are obligated by the standards of medical ethics and professionalism to practice evidence-based, conscientious pain management that prevents illness, reduces patient risk, and promotes health. ACP strongly believes that physicians must become familiar with, and follow as appropriate, clinical guidelines related to pain management and controlled substances, such as prescription opioids, as well as nonopioid pharmacologics and nonpharmacologic interventions.

b. Lift barriers that impede access to medications to treat opioid use disorder (methadone, buprenorphine, and naltrexone) and to medications for overdose prevention (naloxone). The federal government should consider lifting the cap on the number of patients who can receive buprenorphine if a physician has been trained in proper prescribing practices. Public and private insurers should remove onerous limits on medications for overdose prevention and medication-assisted treatment, including burdensome prior authorization rules or lifetime limits on buprenorphine that prevent medically necessary care. Oversight and enforcement efforts should be strengthened to protect against misuse, diversion, and illegal sale of buprenorphine and other opioid treatment drugs. Policymakers should evaluate and consider removing restrictions on office-based methadone treatment provided by trained physicians or other health care professionals.

c. Funding should be allocated to distribute naloxone to individuals with opioid use disorder to prevent overdose deaths and train law enforcement and emergency medical personnel in its use. Legal protections (that is, Good Samaritan laws) should be established to encourage use of naloxone and the reporting of opioid overdoses in instances where an individual's life is in danger. Physician standing orders to permit pharmacies to provide naloxone to eligible individuals without a prescription should be explored. Insurance and cost-related barriers that limit access to naloxone should be addressed.

d. Pre- and post-buprenorphine training support and education tools and resources should be made available and widely disseminated to assist physicians in their treatment efforts. Physician support initiatives, such as mentor programs, shadowing experienced providers, and telemedicine, can help improve education and support efforts around substance use treatment.

ACP reiterates its support for the establishment of a national PDMP. Until such a program is implemented, ACP supports efforts to standardize state PDMPs through the federal National All Schedules Prescription Electronic Reporting program. The College strongly urges prescribers and dispensers to check PDMPs in their own and neighboring states (as permitted) before writing and filling prescriptions for medications containing controlled substances. All PDMPs should maintain strong protections to assure confidentiality and privacy. Efforts should be made to facilitate the use of PDMPs, such as by linking information with electronic medical records and permitting other members of the health care team to consult PDMPs.

5. Health insurance should be required to cover mental health conditions, including the evidence-based treatment of substance use disorders, and abide parity rules.

ACP strongly supports parity of mental health and substance use disorders and the coverage of comprehensive evidence-based treatment of substance use disorders. Strong oversight must be applied to ensure adequate coverage of medication-assisted treatment components, counseling, and other items and services. Components of comprehensive drug addiction treatment should also be extended to those in need, including medical services, mental health services, educational services, HIV/AIDS services, legal services, family services, and vocational services.

6. The workforce of professionals qualified to treat substance use disorders should be expanded.

ACP supports policies to increase the professional workforce engaged in treatment of substance use disorders. Loan forgiveness programs, mentoring initiatives, and increased payment may encourage more individuals to train and practice as behavioral health professionals.

7. Training in the treatment of substance use disorders should be embedded throughout the continuum of medical education.

Training in screening and treatment of substance use disorders should be embedded in the continuum of medical education. Continuing medical education providers should offer courses to train physicians in addiction medicine, medication-assisted therapy, evidence-based prescribing, and the identification and treatment of substance use disorders.

8. The effectiveness of public health interventions to combat substance use disorders and associated health problems should be studied.

Public health-based substance use disorder interventions, such as syringe exchange programs and safe injection sites, that connect the user with effective treatment programs should be explored and tested.


Substance use disorders have been regarded as a moral failing for centuries, a mindset that has helped establish a harmful and persistent stigma affecting how the medical community confronts addiction. We now know more about the nature of addiction and how it affects brain function, which has led to broader acceptance of the concept that substance use disorder is a disease, like diabetes, that can be treated.

Communities across the country are confronting an opioid epidemic that has taken tens of thousands of lives, leading physicians to take a more active role in managing the condition and spurring policymakers to reassess the nation's drug control policy. Physicians can help guide their patients toward recovery by becoming educated about substance use disorders, proper prescribing practices, consulting prescription drug monitoring programs to reduce opioid misuse, and assisting patients in their treatment. Policymakers can mitigate the effects of drug use by permitting harm reduction strategies, such as syringe exchange programs; supporting initiatives to increase the behavioral health workforce; testing evidence-based prevention and stigma-reduction programs; and encouraging treatment of substance use disorders among the incarcerated and diversion programs for those with nonviolent drug arrests.
 Appendix: Definition of Substance Use Disorders
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition, combines the terms “substance abuse disorder” and “substance dependence” under an umbrella term, “substance use disorders,” and establishes a continuum of mild, moderate, and severe designations (11). Within this category are specific subcategories, including alcohol use disorder and stimulant use disorder. Severity is determined by the number of criteria met by the individual. For example, an individual who meets 6 of the opioid use disorder criteria is diagnosed with severe opioid use disorder (12).

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), “Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home” (13). The American Society of Addiction Medicine maintains that it is important to differentiate between at-risk or harmful substance use and addiction. The Society has defined the spectrum of unhealthy substance use as including addiction, harmful use when addiction is not present but use has already led to health consequences, and at-risk or hazardous use only when use increases the risk or likelihood of health consequences that have not occurred and addiction is not present (14).

What Is the Current Science on Addiction or Severe Substance Use Disorder?

Historically, addiction has been considered by some to be a moral disorder or character defect; this thinking informed policies that emphasized punishment rather than treatment of drug addiction. As behavioral science and neuroscience advanced, a different theory about drug addiction emerged. In 1956, the American Medical Association described alcohol as an illness and in 1987 officially called addiction a disease (15). Alan Leshner of the National Institute on Drug Abuse initiated a “paradigm shift” by establishing that addiction was a chronic, relapsing brain disease, with a genetic component that affects behavior, and that long-term use could lead to altered brain structure and function (1617). A 2008 National Institute on Drug Abuse report summarizes the evolution in thinking:

When scientists began to study addictive behavior in the 1930s, people addicted to drugs were thought to be morally flawed and lacking in willpower. Those views shaped society's responses to drug abuse, treating it as a moral failing rather than a health problem, which led to an emphasis on punishment rather than prevention and treatment. Today, thanks to science, our views and our responses to addiction and other substance use disorders have changed dramatically. Groundbreaking discoveries about the brain have revolutionized our understanding of compulsive drug use, enabling us to respond effectively to the problem (18).

By establishing that addiction was a disease with consequences for individual and public health, Leshner reasoned, the response to drug addiction should not be incarceration but rather should be treatment and management of the disease, even if the initial decision to use the drug was a voluntary one (19). In 1998, ACP (then the American College of Physicians–American Society of Internal Medicine) released the position paper “Illegal Drug Abuse and National Drug Policy,” which included the following position: “Drug abuse should be accepted by health care practitioners, insurers, and employers as a chronic condition and illness, rather than a character weakness” (20). Other authors note that the understanding of addiction as a brain disease has tempered the severity of drug policies (21).

The brain disease paradigm has been criticized by some who believe it absolves the addict from accountability, is less substantiated because the disease lacks a biological marker, or distances the problem from the social context (22). Others pose that addictive behavior is a series of choices, rather than a disease-triggered impulse (2324). Research also reflects the role of genetics, and its interplay with social exposure, as an important component in the manifestation of this condition (25).

Leshner acknowledged that addiction is “not just a brain disease” and that other factors may play a role in whether a user becomes an addict, using the oft-cited example of low heroin relapse rates among Vietnam veterans upon their return to the United States. Once removed from the environment where heroin was readily available and its use was relatively common, most veterans maintained their abstinence from the drug. Leshner said that “not only must the underlying brain disease be treated, but the behavioral and social cue components must also be addressed” (19). The American Society of Addiction Medicine, in recognition that addiction must be viewed in a broader perspective than solely a brain disease, reflects a biopsychosocial perspective in its current definition of addiction (26).

Trends in Illicit Drug Use and Substance Use Disorders 

According to SAMHSA's 2014 National Survey on Drug Use and Health, 27 million people (10.2%) aged 12 years and older used an illicit drug in the past 30 days, a percentage higher than in each year from 2002 to 2013. Of current illicit drug users, 22.2 million are current marijuana users and 4.3 million report current nonmedical use of prescription pain medication. The growth in illicit drug use is mainly the result of rising marijuana use rates; the 2014 rate of nonmedical use of prescription drugs was lower compared with most years in the 2002–2012 period but was similar to the rate in 2013. About 22.5 million people aged 12 years or older needed treatment for a substance use disorder in the past year, with alcohol use disorder being the most common. Less than 20% of this population received any form of substance use disorder treatment, while about 10% received treatment at a specialty treatment facility (hospitals [inpatient only], drug or alcohol rehabilitation facilities [inpatient or outpatient], or mental health centers) (28).