Psychiatrists are taking issue with psychoactive drug classifications

By Joe Hannan | Medically reviewed by Amanda Zeglis, DO, MBA
Published October 13, 2022

Key Takeaways

  • A study indicates that psychiatrists believe that the drug schedule does not reflect the evidence-based safety and efficacy of compounds such as psilocybin and ketamine.

  • Rescheduling these compounds is essential for further research, as well as easing patient access—a critical factor amid an ongoing mental health epidemic.

  • Mental health clinicians can stay abreast of emerging research to better understand the reality of these compounds, which may pave the way toward rescheduling.

The laws governing certain psychoactive drugs may not reflect scientific reality.

That’s according to an August 2022 research paper published in the International Journal of Drug Policy, which highlighted a need to reform these laws.[]

Inside the study findings

Researchers surveyed 181 psychiatrists who said that the safety, abuse potential, and therapeutic potential of a set of psychoactive drugs are not aligned with their schedules under the Controlled Substances Act.

Participants in this online survey received one of four possible clinical vignettes. These hypothetical scenarios depicted patients with depression who indicated that self-administered psychoactive drugs were providing relief from their symptoms. The patients said they used one of the following compounds:

  • Psilocybin (Schedule I)

  • Methamphetamine (Schedule II)

  • Ketamine (Schedule III)

  • Alprazolam (Schedule IV)

Participants answered questions about these scenarios, rating them for therapeutic and abuse potential, as well as safety. For comparison purposes, they did the same for alcohol.

Overall, psychiatrists were more accepting of patients using psilocybin and ketamine than methamphetamine and alprazolam.

They also said that methamphetamine and alprazolam were more dangerous and had a lower likelihood of therapeutic benefit and greater likelihood of abuse.

The safety and abuse/therapeutic potential of methamphetamine and alprazolam were on par with alcohol, and the psychiatrists felt that all three were more hazardous than ketamine and psilocybin.

Analyzing the findings

According to lead author Adam Levin, MD, a psychiatrist and third-year resident at the Ohio State University College of Medicine, this finding was noteworthy but not surprising, given the nature of psychiatric practice.

“One of the interesting findings was that alcohol had a higher abuse potential than psilocybin and ketamine, and was equivalent to methamphetamine and ketamine, in terms of abuse potential,” he said. “If you’re a psychiatrist who works in an emergency department, you’re seeing people coming in with methamphetamine or alcohol. It’s very rare that you ever see someone coming in with ketamine or a psychedelic.”

By comparison, he said US hospitals are filled with the consequences of alcohol and tobacco use, whether those consequences are immediate or long-term.

Dr. Levin also found the psilocybin findings noteworthy.

"I think the thing that was most surprising was that psilocybin was rated as having the lowest abuse potential."

Adam Levin, MD

"I did not expect psychiatrists to perceive that, even though I do think it’s true based on the evidence," he added.

Need for reform

Ultimately, the study indicated that US clinicians and patients face a drug schedule that may not reflect the reality of these compounds.

“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,” the researchers concluded.

That incoherence creates challenges for patients and providers, Dr. Levin said. Amid a mental-health crisis, clinicians need as many safe, effective tools at their disposal as possible.

“If there are tools that can have an impact—and there does seem to be an impact, based on the evidence—I think there’s a lot of frustration with the inability to access those tools,” Dr. Levin said. “In terms of toxicology, there’s no known lethal dose for a lot of these compounds. So as a psychiatrist, when you’re seeing people coming into the emergency department overdosing on drinking alcohol or opioids, that’s very striking.”

Dr. Levin hopes that his research, which is part of a growing body of evidence on the safety and efficacy of psychedelics, will ultimately lead to regulatory changes that ease access and increase research.

"It’s really important that our policies reflect the evidence."

Adam Levin, MD

“A lot of these decisions were made in the absence of any clear scientific evidence in the 1970s,” he continued. “As we move forward through this second renaissance in research, it’ll be important to get these policies right when we do reschedule.”

Easing access

Access to these treatments will remain an issue until insurers get on board. Dr. Levin called the collaboration between the Multidisciplinary Association for Psychedelic Studies (MAPS) and the Department of Veterans Affairs a step in the right direction.

MAPS is enrolling participants for a phase 2 study of MDMA-assisted therapy for veterans with PTSD in the Bronx, New York.[]

A similar phase 2 study is also proceeding in Portland, OR, after a partial clinical hold by the FDA, which was concerned about a perceived need for overnight stays at the trial location.[]

This was subsequently addressed by MAPS, which submitted safety data from a phase 3 sub-study.

Dr. Levin said that once VA insurance covers these procedures, private insurers are more likely to follow suit, paving the way for affordability and greater access.

But government wheels turn slowly, and it will likely be a while before rescheduling takes effect and payers begin to cover these drugs. Until then, Dr. Levin said that clinicians can keep an eye on emerging research and data—and advise patients accordingly.

"If you can be someone who says, ‘I reviewed the data here, this has therapeutic potential, and the abuse potential is relatively low,’ then I think individual psychiatrists can be really informed and helpful for their patients."

Adam Levin, MD

What this means for you

This study indicated an attitude shift in psychiatry toward compounds such as ketamine and psilocybin. Psychiatrists are attuned to the evidence that demonstrates safety and efficacy, and many want to see these drugs rescheduled to allow ease of access, and better assist patients.

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