Published in the International Journal of Drug Policy this month, major new survey results from over 180 psychiatrists across the United States have revealed a significant and concerning inconsistency between current drug schedules and what health professionals deem safe and therapeutically beneficial.
A Disparity Between Health Science and US Drug Schedules
Under the Controlled Substances Act (CSA), US law organizes drugs into five distinct schedules according to their therapeutic value and potential for abuse.
The purpose of the CSA is to ensure public health. Yet, many of these drugs’ schedules in no way accurately reflect scientific evidence about their benefits and harms. As such the over-prescription of harmful lower-schedule substances has resulted in epidemics of prescription drug abuse, with worrying numbers of hospitalizations and overdoses increasing each year.
Benzodiazepines, currently used to treat anxiety, are a key example. Despite being classified as Schedule IV, with low harm and abuse potential, the over-prescribing of these drugs resulted in 41,500 US overdose-related deaths between 2019-2020 alone. Accounting for nearly 17% of all fatal overdoses that year.
On the flip side, psychedelic drugs, such as psilocybin (the active ingredient in magic mushrooms) and MDMA (ecstasy), remain Schedule I, regardless of the wealth of evidence for their long-lasting benefits and relatively low physical harm and addiction risk.
As professionals directly impacted by medical schedules in their daily work, the first-hand experience of psychiatrists places them in an ideal position to assess the risks and benefits of different drugs. However, until recently, no formal investigations of their perspectives have been carried out.
Marking of-it’s-kind study, researchers from the Ohio State University, Columbus, collected data from 181 psychiatrists’ across the US about their attitudes towards four drugs from different schedules and assessed whether they were in line with current CSA law.
In descending order from Schedule I to IV, the drugs considered in the study included psilocybin, methamphetamine, ketamine, and alprazolam (Xanex).
Firstly, the psychiatrists were presented with a scenario of a depressed patient using one of the four drugs as an off-label treatment.
In their responses, the psychiatrists expressed that they would be more likely to warn against the patient using methamphetamine and alprazolam compared to the other drugs. In this context, they also valued ketamine and psilocybin as more acceptable, less concerning, and less likely to cause unwanted psychological effects.
The psychiatrists were then asked to rate their perceived safety, therapeutic value, and abuse potential for each drug and also alcohol.
Again, the responses conflicted with current licensing laws. Despite psilocybin having the strictest regulatory ban and alcohol none at all, the psychiatrists viewed psilocybin with the least abuse potential and alcohol the most. They also viewed ketamine and psilocybin as more therapeutically beneficial and safe.
Finally, the researchers asked the psychiatrists general questions about US drug policy.
In response, a quarter of all participants reflected that US drug policy contributes to substance use disorders and one-fifth that drug policy increases the difficulty of treating such disorders.
One quarter additionally mentioned that policy creates drug-related stigma and influences psychiatry training. Furthermore, 28% expressed some form of criticism against current licensing laws.
“Our findings add to a growing consensus among experts in addiction and mental health that the current drug policy is not scientifically coherent with regard to specific drugs,” quoted Adam Levin, an Affiliate Scholar in Ohio State University’s Center for Psychedelic Drug Research and Education and lead author of the study.
Current Scheduling Law Creates Barriers to Psychedelic Research
The disparity between the therapeutic value of drugs and their scheduling, as demonstrated by the study, is one of the greatest barriers in psychedelic research today.
The strict regulatory barriers, time-consuming applications, and huge costs involved discourage many research institutions from studying psychedelic drugs. So much so that from the years 2006-2020, the National Institute of Health directly funded no psychedelic trials at all.
However, the psychiatrist’s positive perspectives around psilocybin show how the ongoing growing evidence for psychedelics in mental health has begun to shape professional attitudes.
As quoted by Dr. Levin:
“It is worth noting that, although all drugs [included in the study] have some evidence for efficacy in the treatment of depression, many of the studies investigating benzodiazepines and psychostimulants for depression were published in the 1990s, while ketamine and psilocybin are under active investigation for the treatment of depression. It is likely that psychiatrists are more familiar with this recent literature and, therefore, more likely to view ketamine and psilocybin as therapeutic in this context.
Even with this caveat, our results, and other recent surveys, point to a growing realization among mental health clinicians of the potential of psilocybin in treating psychiatric disorders.“
In line with this shift, a recent letter by the Biden administration predicts regulatory approval of MDMA and psilocybin for PTSD and depression in the next two years.
Nonetheless, the widescale federal bans on psychedelic drugs mean patients with hard-to-treat debilitating treatments will likely have to wait years until the possibility of accessing these potentially transformative treatments.
Moreover, the “outsized influence” of the US in determining international drug policy means the FDA Schedule system is mirrored far and wide across the globe. Placing other countries on similar trajectories in regard to patient access.
Attitudes toward ketamine and psilocybin expressed by the psychiatrists emphasize the call to make these drugs more accessible in terms of treatment and research.
Their concerns around methamphetamine and alprazolam, and the alluded-to impact of CSA laws on psychiatrists’ training, also highlight the necessity for a more sensible drug policy so that harmful and addictive prescription drugs aren’t as readily distributed.
As mediators between the scheduling system and real-life patient action, more campaign groups and governmental organisations may look to consider the perspectives of psychiatrists, both to expand evidence for reform and help shape the future of drug laws.
Martha is a freelance writer and co-director of the Psychedelic Society, where she curates and facilitates events relating to altered states. With a background in Neuroscience, she frequently publishes about the applications of psychedelics in mental health, as well as discussing the cultural contexts in which psychedelic therapies are emerging today. Tweets @PsychedelicsUK.