DEA Drug Schedules: I-V

DEA and Schedule Drug/Substance Levels

• There are five "schedules" of controlled substances based on their abuse potential and accepted medical use.
• Substances in Schedule I have a high abuse potential and no accepted medical use in the United States such as heroin, LSD, MDMA, marijuana, and peyote.
• Schedule II drugs have a high abuse potential, may lead to psychological or physical dependence, but have therapeutic utility like morphine, codeine, fentanyl, stimulants (Ritalin and Adderall).
• Schedule III drugs have less abuse potential than Schedules I and II and include limited quantities of codeine mixtures (Tylenol with codeine), ketamine, and anabolic steroids.
• Schedule IV drugs have less abuse potential than Schedule III and include Xanax, Soma, Valium, Ativan, Talwin, Ambien, and Tramadol.
• Schedule V drugs have the least abuse potential and include preparations containing limited quantities of certain narcotics/stimulants for antitussive, antidiarrheal, and analgesic purposes such as cough preparations with codeine, Lomotil, and Lyrica.

Good Samaritan Statute

• All 50 states have passed some version of the Good Samaritan Act to protect people from legal repercussions when assisting in emergency situations.
• Florida's Good Samaritan Act protects healthcare providers and encourages them to provide emergency care.
• Florida Statute 786.13 states the legislature's intent to encourage healthcare practitioners to provide necessary healthcare to all persons without fear of litigation.
• The statute protects healthcare practitioners and extends to physician assistants, nurses, and other extenders providing emergent care.
• An amendment in 2003 made it so the act is no longer only for people who entered through the emergency room.
• Under Florida Statute 768.13(2)(a)), healthcare practitioners providing emergency services are not liable for civil damages as a result of care/treatment.
• The act requires a high burden of proof, the health care provider acted with "reckless disregard for the consequences so as to affect the life or health of another".
• Reckless disregard includes conduct that a health care provider knew or should have known that it created an unreasonable risk of injury.
• Immunity extends to any act/omission of providing medical care, treatment, or diagnosis and care given before patient stabilization.

Rating Scales

• There are a variety of rating scales that can be used to assess and monitor mental health conditions

Mental Status (level of impairment)

• Mini-Mental State Examination (MMSE)
• Montreal Cognitive Assessment (MoCA)
• Mini-Cog
• St Louis University Mental Status Examination (SLUMS)

Depression

• Patient Health Questionnaire 9 (PHQ-9)
• Edinburgh Postnatal Depression Scale (EPDS)
• Beck Depression Inventory (BDI)
• Hamilton Depression Rating Scale (HAM-D)

Anxiety

• Zung's Self-Rating Anxiety Scale
• Hamilton Rating Scale for Anxiety
• Yale-Brown Obsessive Compulsive Scale

ADHD

• Conners' Parent and Teacher Rating Scales
• Vanderbilt ADHD Diagnostic Parent and Teacher Rating Scales

Schizophrenia

• Clinical outcome measures such as Positive and Negative Syndrome Scale (PANNS).
• Bief Psychiatric Rating Scale (BPRS)
• Scale for Assessment of Positive Symptoms (SAPS)
• Scale for Assessment of Negative Symptoms (SANS)

Assessment of abnormal movement rating scales

• Abnormal Involuntary Movement Scale (AIMS)
• Dyskinesia Identification System Condensed User Scale(DISCUS)
• Simpson-Angus Rating Scale (SAS)

Substance abuse

• CAGE - Screening tool in order to asses alcohol abuse (Cut down, Annoyed, Guilt, Eye-opener)
• AUDIT: Alcohol Use Disorders Identification Test
• S-MAST: Short Michigan Alcoholism Screening Test (or Geriatric Version)
• CRAFFT: Used for children and adolescents under 21 years of age
• COWS: The Clinical Opiate Withdrawal Scale
• CIWA is a tool used to determine likelihood of withdrawal (delirium tremens). Likelihood typically occurs in the first 24-72 hours from alcohol cessation.
• Assesses 10 common withdrawal symptoms (nausea/vomiting, tremors, paroxysmal sweats, anxiety, agitation, tactile disturbances, auditory disturbances, visual disturbances, headaches, altered sensorium)

Psychotropic Medications

• Be familiar with different categories and classes

Medications used to treat Schizophrenia and other psychotic disorders

• This class of drugs can be broken down into typical and second generation antipsychotics.

Typical Antipsychotics

• Haloperidol (Haldol), haloperidol decanoate (Haldol Decanoate)
• Loxapine (Loxitane)
• Thioridazine (Mellaril)
• Thiothixene (Navane)
• Fluphenazine (Prolixin), fluphenazine decanoate (Prolixin Decanoate)
• Mesoridazine (Serentil)
• Trifluoperazine (Stelazine)
• Chlorpromazine (Thorazine)
• Perphenazine (Trilafon)

Second-Generation Antipsychotics

• Clozapine (Clozaril)
• Ziprasidone (Geodon)
• Risperidone (Risperdal)
• Quetiapine (Seroquel)
• Olanzapine (Zyprexa)
• Aripiprazole (Abilify)
• Paliperidone (Invega)
• Iloperidone (Fanapt)
• Asenapine (Saphris)
• Lurasidone (Latuda)

Medications used to treat mood disorders and bipolar affective disorders

• Mood Stabilizers (Valproic acid (Depakene), Divalproex sodium (Depakote), Lithium carbonate, Lamotrigine (Lamictal))
• Treats Carbamazepine (Tegretol) & Oxcarbazepine (Trileptal; off-label)

Medications used to treat mood disorders, unipolar affective disorders, and depressive disorders

• Tricyclics (TCAS) (Clomipramine (Anafranil), Amoxapine (Asendin), Amitriptyline (Elavil)
• Treats Desipramine (Norpramin), Nortriptyline (Pamelor), Doxepin (Sinequan), Trimipramine (Surmontil) & Imipramine (Tofranil)
• Serotonin Selective Reuptake Inhibitors (SSRIs) (Citalopram (Celexa) Fluvoxamine (Luvox), Paroxetine (Paxil), Paroxetine mesylate (Pexeva))
• Treats Fluoxetine (Prozac), Sertraline (Zoloft), Escitalopram (Lexapro)

Monoamine Oxidase Inhibitors (MAOIs)

• Phenelzine (Nardil)
• Tranylcypromine sulfate (Parnate)
• Selegiline transdermal (EMSAM)

SNRIs and Other Agents

• Trazodone (Desyrel)
• Venlafaxine (Effexor)
• Desvenlafaxine (Pristiq)
• Mirtazapine (Remeron)
• Nefazodone (Serzone)
• Bupropion (Wellbutrin, Forfivo, Aplenzin)
• Duloxetine (Cymbalta)
• Vilazodone (Viibryd)
• Vortioxetine (Brintellix)
• Levomilnacipran (Fetzima)

Medications used to treat anxiety disorders

• Benzodiazepines (BNZs) (Lorazepam (Ativan), Clonazepam (Klonopin), Chlordiazepoxide (Librium))
• Treats Oxazepam (Serax), Clorazepate (Tranxene), & Alprazolam (Xanax) Treats Buspirone (BuSpar).
• Other Agents
• Propranolol (Inderal). and Atenolol (Tenormin)

Medications used to treat Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder

• Stimulants (Amphetamine/dextroamphetamine (Adderall), Dexmethylphenidate (Focalin), Dextroamphetamine (Dexedrine))
• Treats Methylphenidate (Ritalin), Methylphenidate (Concerta), & Lisdexamfetamine dimesylate (Vyvanse) Treats Guanfacine (Intuniv) Other Agents (Clonidine (Kapvay), and Atomoxetine (Strattera)
• Antidepressants like desipramine (Norpramin), venlafaxine (Effexor), and bupropion (Wellbutrin) are also used sometimes.

Personality disorders

• Risk Factors
• Genetic loading
• Dysfunctional family of origin

Cluster A

• Pervasive distrust, suspiciousness, odd behavior
• Paranoid personality disorder (persistent, inappropriate suspiciousness and distrust of others)
• Schizoid personality disorder (Neither desires nor enjoys close relationships, Chooses solitary activities, Shows little to no interest in sexual activity with another person)
• Schizotypal personality disorder (Magical thinking, Unusual perceptual experiences, & Paranoid ideation)

Cluster B

• Cluster B = Patterns of interpersonal disruption, hospitalization possible during symptom expression
• Antisocial personality disorder (Failure to conform to social norms, Repeated acts that are grounds for arrest, Lack of remorse)
• Borderline personality disorder (Pattern of unstable, intense interpersonal relationships, Impulsivity (self-damaging behavior), & Recurrent suicidal behavior)
• Histrionic personality disorder (Uncomfortable in center of attention, inappropriate behavior, shallow emotions)
• Narcissistic personality disorder (Sense of self-importance, preoccupied with power, belief of self-importance)

Cluster C = Patterns of pervasive anxiety and fear

• Avoidant personality disorder (Avoidance of activities because of fear of disapproval, Preoccupation with being criticized)
• Dependent personality disorder (Difficulty disagreeing, Needing others to assume responsibility)
• Obsessive-compulsive personality disorder (Preoccupation with order, perfection, Overly conscientious)

SSRIs

• Fluoxetine (Prozac) (Useful with Olanzepine for acute depressive episodes in Bipolar I Disorder and treatment resistant depression)
• Sertraline (Zoloft) - Treats (MDD), (OCD), (PD), (PTSD), (SAD), (PMDD)
• Paroxetine (Paxil) - Treats (GAD) + (OCD), (PD), (SAD), (GAD), (PTSD). Short half life.
• Fuvoxamine (Luvox) - Treats OCD in children/adults. Short half life as well
• Citalopram (Celexa) - Dose-dependent QT prolongation
• Escitalopram (Lexapro) - Treats MDD and GAD
• Vilazodone (Viibryd)
• Vortioxetine (Trintellix)

SSRIs Side Effects

• anxiety, agitation, akathisia, insomnia, nausea, diarrhea, sexual dysfunction and hyponatremia (low sodium)

Serotonin and Discontinuation Syndrome.

• Serotonin Syndrome: Restlessness, agitation.
• Discontinuation Syndrome: flu like symptoms

Blackbox warnings for SSRIs

• Blackbox warnings for increased suicidality risk in children, adolescents, and young adults

CBT, DBT, Motivational Interviewing

CBT (Cognitive Behavior Therapy): Increase understanding of relationships between cognition and emotion, Decrease negativity

• DBT (Dialectical Behavior Therapy), focuses on emotional regulation, distress, management skills,
• Mindfulness, all emphasis of interfering behaviors.
• Transtheoretical Model of Change: Health behaviors occur in 6 stages.
• Precontemplation: no intention to change
• Contemplation: thinking about change, is aware
• Preparation: decision to change is made
• Action: specific actions to change
• Maintenance: prevent relapse
• • Motivational interviewing: assess a person's willingness to engage in treatment.

Guiding to focus on"Change thinking"

• Focused, goal-directive therapy
• Builds on the Transtheoretical Model of Change= Motivational with client, and Non-confrontational.

Neurotransmitters

• Dopamine produced in the S. Nigra (substantia nigra)
• Norepinephrine produced in the locus ceruleus of pons, implicated in mood+Anxiety, in concentration disorders.
• Serotonin also from raphe nuclei of brainstem
• Glutamate Universal + Excitatory=Major ,and involved in process of kindling and epilepsy
• GABA Universal + Inhibitory= Site of action of benzodiazepine.

level with evidence

• Randomized controlled trials (RCT)
• Meta/systematic reviews

Labs to Monitor for 2nd Generation antipsychotic

• Blood glucose, Cholesterol
• Potential ECG, for long QT, with weight gain.

Ethical principles

• • principles providing a foundation in decision-making in: Justice, Beneficence, Nonmaleficence Autonomy

Justice

• Doing what is fair within all aspects of care

Beneficence

• Well-being and doing good

Nonmaleficence

• Doing no harm

Fidelity

• Being true/loyal

Autonomy

• Doing for self

Varacity

• Truth telling

Respect

• Treating within equal respect

Schizophrenia

• Schizophrenia has + negative outcomes

Positive symptoms

• Relate to antipsychotic medication Caused by increased-dopamine
• Symptoms include:
• Hallucinations
• Delusions
• Referential thinking
• Disorganized behavior
• Hostility
• Suspisciousness

Negative symptoms

• Responds better to atypical antipsychotic medications. Cause=Decreased dopamine
• Symptoms include:
• Affective flattening
• Poverty of speech
• Avolition
• Apathy
• Abstract thinking difficulty
• Anhedonia
• Attention Deficits

Cocaine

With HIGH doses=Agitation+sexual behavior

Physical Effects of Cannabis Use

• (Common) red dilated conjunctival vessels + increased appetite

• (Heavy chronic use)= Impaired reactivity

• Attention hyper-activity= Neurodevelopmental disorder.

Clozapine (Clozarill)

• For treatment resistant schizophrenia
• Must be enrolled in Clozapine REMS program
• Assessed in the ANC Absolute Neutrophil Count
• Levels 500-999/uL interrupt treatment, check ANC during and resume one ANC >1000UL
• Monitor for weight, circumference, sugar
• Monitor for family/personal history of + cardio

Lithium

• Gold standard for + treatment of manic episodes
• Mood + stabilizer, that treats for bi-polar disorder
• Potential toxicity, with serum levels + regular kidney function
• Narrow therepetuic

Levels > 1.2 increase risk for toxic side effects

Labs= Thyroid panel (creatinine and BUN)

• Pregnancy test (Epstein anomaly. ECG for >50. DO NOT MIX W/NSAID Hyponatremia can cause dehydration, + lithium concentration

• Can Decrease serum Lithium concentrations by administering + sodium

Benzodiazepines (Schedule IV)

• Short Term: (Alprazolam + Loreazepam). Class is anxiolytic medications with Gaba affects

Ml provides

Ways for + practitioners to communication.

• OPEN question : questions cant answer yes or no with short answers
• Affirmations: comments and strenghts
• Refflections: statements with content of feelings

Explanation of the DEA's drug scheduling system. Controlled substances are categorized into five schedules based on abuse potential and medical use. Schedule I has the highest potential for abuse, while Schedule V has the lowest.