In this chapter, we will discuss the clinical utility and growing public health concern surrounding benzodiazepines, a widely prescribed class of medications used for anxiety, seizures, insomnia, and sedation. While effective, benzodiazepines pose significant risks when misused, especially when combined with other substances and central nervous system depressants like opioids. This article reviews the history of benzodiazepines, in addition to their mechanism of action. It also examines current epidemiological data, showing misuse rates in the United States in addition to demographic factors. Psychiatric and other factors that drive misuse such as overprescription are explored.
Elecronic cigarettes (e-cigarettes), initially marketed as a safer smoking alternative, have gained widespread use, especially among adolescents and young adults who did not previously smoke. While our understanding of long-term risks is still emerging, vaping carries significant concerns for adolescents, including nicotine dependence, increased risk of substance use disorders and mood disorders, and potential cardiovascular and pulmonary harm. Primary care clinicians should routinely screen for e-cigarette use in adolescents and young adults and counsel patients on associated risks, emphasizing that safer doesn't mean safe.
As medical cannabis becomes more widely legalized, clinicians face growing pressure to advise patients amid limited, inconsistent evidence. This article explores the evolving role of cannabis in treating multiple conditions while highlighting known risks like psychosis, cannabinoid hyperemesis syndrome, and cannabis use disorder. Attention is given to drug-drug interactions, challenges in clinical decision making, and racial disparities. With appropriate screening, monitoring, and clinician education, cannabis may serve as a valuable adjunct in patient-centered harm reduction care but demands thoughtful and evidence-informed use.
Primary care providers (PCPs) are often tasked to care for those with stimulant use, both prescribed and illicit. The increasing use of stimulants across all age graphics has become more prevalent over the last several decades. The challenges of managing use and misuse are becoming more common for those in an office-based setting. With a wide range of uses including behavioral modification, narcolepsy and weight management, it is without doubt that a PCP may encounter stimulant use on a regular basis.
People who use drugs (PWUD) are at higher risk for sexually transmitted infections, hepatitis, overdoses, and medication interactions. The increased morbidity and mortality due to substance use can be prevented with harm reduction strategies. Primary care clinicians are best positioned to implement harm reduction as they are the focal point of care, see patients regularly, and know their comprehensive history. When caring for PWUD, clinicians should be mindful of increased risks that each substance poses, and offer screening, prophylaxis, testing, and vaccination. Outside of the clinic, clinicians should be aware of community resources for harm reduction.
Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based, scalable public health intervention designed to identify and address alcohol, prescription, and illicit drug use in primary care. By combining validated screening tools, brief behavioral interventions, and referral to treatment, SBIRT reduces risky substance use, prevents progression to substance use disorders, and improves health outcomes. Evidence supports its effectiveness in adults, adolescents, and older adults, with additional benefits including cost savings through reduced health care utilization, criminal justice involvement, and productivity losses. Implementation requires integration into workflows, staff training, and interprofessional collaboration.
The 2010s saw a dramatic shift in the approach to prescribing opioid medications for chronic pain. Fueled by a growing understanding of abuse potential, the opioid epidemic, and later, a misapplication of the 2016 Centers for Disease Control and Prevention (CDC_ Guideline for Prescribing Opioids for Chronic Pain, many clinicians stopped both initiating opioid treatment and continuing treatment for legacy opioid patients, many of whom had been on high doses for years. Similarly, patients with active or past addiction found limited options for pain treatment, often stigmatized by staff in health care settings, thus increasing their risk of substance use and mental health crisis.
Misuse of noncontrolled prescription medications (NCPMs) is often overlooked with the emphasis on opioids and stimulants. We provide a definition of misuse and describe common categories of NCPMs commonly misused, and through case-based examples we discuss select medications, motives and context for misuse and provide some basic information on clinical management. We also discuss the importance of flexibility in working with these patients and in prescribing or deprescribing NCPMs.
