Experts on Psychoactive Drugs Contrary to US Policy

Psychiatrists’ perceptions of the safety, therapeutic value, and abuse potential of psychoactive drugs are inconsistent with current drug policies, a new survey shows.

Adam Levin, MD

“The consensus among experts, including psychiatrists, about specific drugs is not consistent or congruent with the schedule of these drugs” in the United States, lead author Adam Levin, MD, 3rd year psychiatry, Ohio State University, Columbus, and associate scientist with the Center for Psychedelic Drug Research and Education, Ohio State College of Social Work, told Medscape Medical News.

Levin emphasized the importance of appropriate drug planning to improve access to treatments such as psilocybin (psychedelic mushrooms) and 4-methylenedioxy methamphetamine (MDMA), which are now being tested for psychiatric disorders.

“We are in the midst of a mental health crisis, so it would be very important to have new tools,” he said.

The research results were: published online August 11 in the International Journal of Drug Policy.

Five drug schedules

The Controlled Substances Act of 1970 created five “schemes” that organized drugs from most to least dangerous (Schedule IV). However, Levin said the schedules do not accurately reflect the harm or therapeutic benefits of the various drugs.

Some drugs in lower, less restrictive schedules have a greater potential for harm than those in higher schedules, he noted. For example, methamphetamine, which has been recalled in multiple formulations due to concerns about abuse and limited medical use, remains a Schedule II drug.

In addition, several Schedule I drugs, including psilocybin and MDMA that are considered dangerous and have no medical value, have shown therapeutic potential and a low rate of abuse, addictionor physical injury, the researchers note.

In fact, the US Food and Drug Administration (FDA) has granted breakthrough therapy status to psilocybin for drug-resistant depression and major depressive disorder (MDD) and for MDMA for posttraumatic stress disorder. This has positioned these drugs for potential FDA approval within the next few years.

Access to Schedule I drugs for research purposes is strictly controlled. “Once psilocybin was put on schedule 1, there was a huge drop in research funding and the amount of research, and we’re just now beginning to understand the potential therapeutic value of this drug,” Levin said.

Even with a recent resurgence in research, most studies are funded by charitable donations or for-profit companies because of continued hesitation on the part of grant-giving organizations, he added.

Apparent contradictions

Given the pending approval of several Schedule I drugs and the escalating misuse of drugs in lower schedules, there is a growing need to understand physicians’ attitudes around apparent drug schedule contradictions, the researchers note.

Their study included a geographically diverse group of 181 mostly middle-aged psychiatrists (65.2% males) with an average of 16.2 years of practice after their stay.

Participants were randomly assigned to respond to a vignette depicting a clinical scenario in which a patient wants one of four medications to help treat major depression: psilocybin, a Schedule I drug; methamphetamine (Desoxyn), a Schedule II drug; ketamine, a Schedule III drug; or alprazolam (Xanax), a Schedule IV drug.

Each of these therapies has been found to have antidepressant properties, but none are FDA-approved for the treatment of MDD. Recently, however, an intranasal formulation of the ketamine enantiomer Spravato (esketamine) has been approved for treatment-resistant depression.

There were significant differences between the groups presented with different vignettes. Participants warned more often about repeated use and development of a new psychiatric problem with methamphetamine and alprazolam compared to psilocybin or ketamine.

Respondents were most concerned about increased suicide risk following the nonprescription use of alprazolam compared to psilocybin and ketamine.

Compared to all other drugs, ketamine was more likely to be integrated into treatment plans.

Therapeutic value, abuse potential

The participants were also asked to rate the safety, therapeutic value and abuse potential of the four drugs, as well as alcohol, an unscheduled legal drug, if correct or as prescribed.

Respondents considered psilocybin and ketamine to be equally safe — and safer than methamphetamine and alprazolam. They considered ketamine to have the highest therapeutic potential, followed by psilocybin, then alprazolam and methamphetamine. “The last one was alcohol, which we expected because alcohol isn’t used therapeutically,” Levin said.

People who completed the survey rated methamphetamine, alprazolam, and alcohol as having similar high abuse potential, and ketamine as having moderate abuse potential. Psilocybin was rated with the lowest potential for abuse, “which is the exact opposite of what’s implied by schedule 1 status,” Levin noted.

The results provide evidence that these drugs are “misplanned,” he said.

“This suggests that the scheme does not reflect current evidence, which I think is very important to understand because there are ramifications to the drug scheme,” including criminal and investigative ramifications, he added.

Levin pointed out that possession of drugs in more harmful schemes is linked to sometimes long prison terms.

Psychiatrists’ perceptions of the drugs “overlap quite significantly” with recent surveys from other mental health professionals, including psychologists and addiction experts, he noted.

The study was funded by the Drug Enforcement and Policy Center, Moritz College of Law and Ohio State University. Levin reported no relevant financial relationships.

Int J Drug Policy. Published online August 11, 2022. Full article

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