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Primary care physicians play an integral role in the identification and management of alcohol use disorder, which has implications for the safety and physical and mental health of patients, their families, and the public. Screening to identify risky drinking behavior is recommended by the US Preventive Services Task Force but is not always performed consistently or correctly in primary care. When alcohol use disorder is identified, collaboration with patients is essential to determine an appropriate treatment approach. Abstinence may not always be the answer. Approximately one-half of patients with alcohol use disorder experience symptoms of alcohol withdrawal syndrome when decreasing alcohol use abruptly or substantially. Physicians must be adept at recognizing and managing signs of alcohol withdrawal. They should be aware of the range of management options and recognize that pharmacotherapy has been underused.

The number one cause of preventable disease, disability, and death in the United States is tobacco use. According to data from the National Health Interview Survey, 18.7% of US adults (46 million people) currently use a tobacco product. Smoking causes lung, laryngeal, hepatocellular, and colorectal cancers and possibly breast cancer. Nicotine is the highly addictive component of tobacco that releases dopamine when it binds to alpha-4 beta-2 nicotinic acetylcholine receptors in the brain. This produces reward sensations that become associated with specific behaviors and relieves stress and negative emotions. Public policy changes, behavioral interventions, and pharmacologic approaches have been shown to reduce tobacco use. Combining behavior therapy with pharmacotherapy increases cessation rates. The US Food and Drug Administration has approved five nicotine replacement therapies and two no-nicotine oral medications to assist with smoking cessation. Medications are categorized as controllers or relievers based on their pharmacokinetics. Nicotine replacement therapy delivers lower amounts of nicotine and needs to be titrated to alleviate patient cravings. Varenicline is a selective partial agonist at the alpha-4 beta-2 nicotinic acetylcholine receptor and is recommended over bupropion for smoking cessation.

Most overdose deaths in the United States involve opioids. Identification and management of opioid use disorder by primary care physicians is a critical need in health care. Substance use disorders share neurobiological dysregulation of the central motivation and reward pathway (powered by dopamine) that manifests as a cycle of addiction driven by impulse and compulsion. It is important that concern for opioid use disorder does not disrupt appropriate treatment of pain and that analgesic narcotic use is adequately monitored, especially in patients at risk of opioid use disorder. Most patients with opioid use disorder do not receive treatment. Those who do receive treatment will experience uncomfortable, but not life-threatening, symptoms of withdrawal. These symptoms can be managed with alpha2-adrenergic and opioid agonists that also reduce the reinforcement of drug use and help prolong recovery. The 2023 Mainstreaming Addiction Treatment Act removed the waiver requirement for buprenorphine prescribing, which closes the substantial gap in access to medication for opioid use disorder existing across gender, racial, and socioeconomic groups. Treatment plans that include medication for opioid use disorder have been shown to substantially reduce mortality.

Practice guidelines consistently encourage short-term use of benzodiazepines for the management of common medical conditions. However, these medications are often prescribed long-term for unclear or variable indications. These prescribing patterns may be attributed to perceived low risk and low rate of benzodiazepine use disorders (0.2% of US adults). Compared with other addictive substances, benzodiazepines may have less overall risk and fewer adverse outcomes. Benzodiazepines have limited accessibility compared with alcohol and tobacco. When used alone, benzodiazepines have less risk of lethal overdose than when they are coprescribed with opioids. Although benzodiazepine use for pain management is declining, this use often co-occurs with opioid analgesics, which is associated with greater risk of adverse events. Physician prescribing patterns have a tremendous impact on benzodiazepine use disorder and misuse. Primary care physicians play a vital role in preventing these conditions and in the management of benzodiazepine withdrawal. Effective management of benzodiazepine use disorder and misuse relies on targeted screening and intervention. Concomitant conditions associated with benzodiazepine misuse (eg, chronic pain, anxiety, insomnia) should be adequately addressed in treatment planning. Due to questionable effectiveness of alternative medications in managing benzodiazepine withdrawal, intervention should entail a gradual dose reduction that is facilitated by patient-centered tapering schedules.

Exposures to pollutants and contaminants can occur through water or soil, which can be contaminated naturally or through human activities. The toxicity and adverse health effects of these substances depend on exposure route, quantity, and duration. Mechanisms of water contamination include runoff, flooding, infrastructure failures, and contamination from air and surface water pollution. Pesticides and organophosphates commonly are used in agricultural and residential applications, frequently cause water contamination, and commonly cause poisoning in agricultural workers and gardeners. Soil contamination disproportionately affects minority and low-income populations because they are more likely to live in proximity to a pollution source. Fetuses, children, and individuals with preexisting medical conditions are more vulnerable to adverse health effects of soil contamination compared with healthy adults. Some of the most common soil pollutants are heavy metals, pesticides, and polychlorinated biphenyls. Preventing exposure to contaminated soil involves avoidance of historically contaminated sites and ingestion of soil. Approaches to cleanup depend on the extent of contamination, location, and planned future use of the land. Remediation strategies include containment, bioremediation, chemical oxidation, soil washing, and thermal treatment.

Heavy metals are naturally occurring, high-density elements such as arsenic, cadmium, chromium, lead, and mercury. These five metals are the most common causes of heavy metal poisonings. Zinc is also of concern. Heavy metals are widely distributed in the environment and can be toxic even at low concentrations. Exposure commonly occurs via ingestion, inhalation, or skin absorption. Occupational exposures are common and can occur in mining, refining, and smelting operations. Lead exposure disproportionately affects lower-income, inner-city communities due to older housing stock and historical industrial contamination. Adverse health effects of exposure to heavy metals vary by type and form of metal, exposure factors (eg, route, dose, duration), and individual patient characteristics (eg, age, sex). Toxicity management includes supportive treatments, decontamination, chelation, and/or surgery depending on the clinical situation and metal involved. For some types of heavy metal toxicity, there are no definitive treatments. Acute poisoning with arsenic and chromium can be fatal. Pregnant and breastfeeding patients and young children are particularly vulnerable to heavy metal exposure due to its effects on fetal and child development. In cases of suspected exposure, patients should be evaluated with a thorough history, including detailed occupational and social histories, and a physical examination, with laboratory tests and imaging as needed.

Endocrine-disrupting chemicals (EDCs) increasingly have been a subject of concern and study in the past few decades. These chemicals can interfere directly or indirectly with normal physiology of endocrine system organs or organs under the influence of hormones. EDCs have been shown to cause a range of adverse effects, such as developmental abnormalities, abnormal growth patterns in children, reproductive abnormalities, hormone-sensitive cancers, and alterations in immune function. Some have been shown to contribute to obesity. Most EDCs are synthetically developed compounds that are ubiquitous in food packaging, consumer products, and the environment. They are found in pesticides, herbicides, plastics, solvents, flame retardants, and in the environment as industrial byproducts and waste. These substances are poorly regulated and exposures are not tracked. It is virtually impossible to avoid contact with EDCs in everyday life. Populations at greatest risk of adverse health effects include fetuses, newborns, and pregnant individuals. Comprehensive preconception and prenatal care can help family members and caregivers identify sources of and minimize EDC exposure in newborns and infants. For individuals, the clinical significance of these exposures is unknown and there is no current role for testing. For patients with possible exposure, a pertinent history should be taken and counseling provided to help minimize exposure.

Poisoning is the leading cause of death due to unintentional injury in the United States. Each year, between 2,000,000 and 4,000,000 US poison exposures occur. Poison control centers (PCCs), health departments, and family physicians work at different levels of the health care system to identify, manage, and prevent poisoning. PCCs provide assistance to the public and to clinicians and health care facilities, with expert consultation in identification, diagnosis, and treatment of poison exposures. They also provide education for clinicians and support primary prevention activities. State, tribal, and local health departments have been established by law to address public health in their jurisdictions. For patients exposed to a poison, family physicians are often the first point of contact with the health care system. Patients who present with undifferentiated symptoms, such as headache, rash, or respiratory symptoms, may have had an unknown exposure. A comprehensive history, including detailed occupational and social histories, and physical examination are often the first steps in identifying an exposure. Family physicians performing an initial assessment of symptoms can call the PCC if they suspect a toxic exposure or are unable to identify a cause.