DEA Drug Schedules

DEA Drug Schedules

• Five schedules classify controlled substances based on their abuse potential and accepted medical use.

• Schedule I drugs exhibit:.

  • No accepted medical use.
  • High potential for abuse
  • Examples: heroin, LSD, MDMA, marijuana, peyote.

• Schedule II drugs possess:

  • High abuse potential.
  • Severe psychological or physical dependence liability.
  • Some therapeutic utility.
  • Examples of Schedule II narcotics: morphine, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone.
  • Stimulants like Ritalin and Adderall are also Schedule II drugs.

• Schedule III drugs include:

  • Stimulants and depressants.
  • Less abuse potential than Schedule I and II drugs.
  • Mixtures of limited codeine quantities with noncontrolled ingredients, ketamine, anabolic steroids, buprenorphine, testosterone.

• Schedule IV drugs exhibit:

  • Less abuse potential than Schedule III drugs.
  • Examples: Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, Ambien, Tramadol.

• Schedule V drugs have:

  • Less abuse potential than Schedule IV drugs.
  • Limited quantities of narcotics/stimulants for antitussive, antidiarrheal, analgesic purposes.
  • Examples: cough preparations with less than 200mg of codeine per 100mL/100g, Lomotil, Motofen, Lyrica, Parepectolin.

Good Samaritan Act

• Most states have Good Samaritan Acts, generally protecting private citizens assisting in emergencies from liability for unintentionally caused injuries.
• Florida's Good Samaritan Act extends additional protections to healthcare providers giving emergency medical treatment.
• Florida Statute 786.13 aims to encourage practitioners to provide emergency care without fear of litigation.
• The statute protects "healthcare practitioners," not limited to emergency medicine specialists, potentially covering physician assistants and nurses.
• A 2003 amendment expanded the Act beyond patients entering through ERs and trauma centers.
• Florida Statute 768.13(2)(a) states healthcare practitioners providing emergency services are not liable for civil damages from care/treatment if acting as a reasonably prudent person.
• The act requires a higher burden of proof, the plaintiff must prove reckless disregard affecting the life/health of another, per Florida Statute 768.13(2)(b).
• Reckless disregard is defined as the provider knowing their actions create an unreasonable risk of injury substantially greater than necessary for negligence, per Florida Statute 768.13(2)(b)(3).
• The Good Samaritan Act's immunity covers any act or omission in providing medical care, diagnosis, or treatment, even before stabilization for non-emergency care.

Rating Scales

• Mental Status rating scales assess impairment level.
  • Mini-Mental State Examination (MMSE)
  • Montreal Cognitive Assessment (MoCA)
  • Mini-Cog
  • St Louis University Mental Status Examination (SLUMS)
• Depression rating scales include:
  • Patient Health Questionnaire 9 (PHQ-9)
  • Edinburgh Postnatal Depression Scale (EPDS)
  • Beck Depression Inventory (BDI)
  • Hamilton Depression Rating Scale (HAM-D)
• Anxiety rating scales include:
  • Zung's Self-Rating Anxiety Scale
  • Hamilton Rating Scale for Anxiety
  • Yale-Brown Obsessive Compulsive Scale
• ADHD rating scales:
  • Conners' Parent and Teacher Rating Scales
  • Vanderbilt ADHD Diagnostic Parent and Teacher Rating Scales
• Schizophrenia scales that measure clinical outcomes:.
  • Positive and Negative Syndrome Scale (PANNS)
  • Brief Psychiatric Rating Scale (BPRS)
  • Scale for Assessment of Positive Symptoms (SAPS)
  • Scale for Assessment of Negative Symptoms (SANS)
• Abnormal movement rating scales:
  • Abnormal Involuntary Movement Scale (AIMS)
  • Dyskinesia Identification System Condensed User Scale (DISCUS)
  • Simpson-Angus Rating Scale (SAS)

Substance Abuse Screening Tools

• The CAGE screening tool is commonly used for alcohol abuse (Cut down, Annoyed, Guilt, Eye-opener).
• AUDIT: Alcohol Use Disorders Identification Test
• S-MAST is a short Michigan Alcoholism Screening Test (or Geriatric Version).
• CRAFFT is a screening tool for children/adolescents younger than 21.
• COWS: The Clinical Opiate Withdrawal Scale.
• The Clinical Institute Withdrawal Assessment for Alcohol is used to assess the likelihood of withdrawal and (DTs). DTs typically occur within 24-72 hours after alcohol cessation.
  • It assesses common withdrawal symptoms like nausea/vomiting, tremors, sweats, anxiety, agitation, tactile/auditory/visual disturbances, headaches, and altered sensorium/orientation.
  • Symptoms are graded on scales; higher scores indicate more severe withdrawal and potential DTs (0-9 = absent/very mild, 10-15 = mild, 16-20 = moderate, 21-67 = severe/possible DTs).

Psychotropic Medications

• Medications for Schizophrenia and other psychotic disorders:
  • Typical Antipsychotics: Haloperidol, Loxapine, Thioridazine, Thiothixene, Fluphenazine, Mesoridazine, Trifluoperazine, Chlorpromazine, Perphenazine
  • Second-Generation Antipsychotics: Clozapine, Ziprasidone, Risperidone, Quetiapine, Olanzapine, Aripiprazole, Paliperidone, Iloperidone, Asenapine, Lurasidone
• Medications for Mood and Bipolar Disorders:
  • Mood Stabilizers: Valproic acid, Divalproex sodium, Lithium carbonate, Lamotrigine, Carbamazepine, Oxcarbazepine
• Medications for Mood, Unipolar Affective and Depressive Disorders:
  • Tricyclics (TCAs): Clomipramine, Amoxapine, Amitriptyline, Desipramine, Nortriptyline, Doxepin, Trimipramine, Imipramine, Protriptyline
  • Serotonin Selective Reuptake Inhibitors (SSRIs): Citalopram, Fluvoxamine, Paroxetine, Fluoxetine, Sertraline, and Escitalopram.
  • Monoamine Oxidase Inhibitors (MAOIs): Phenelzine, Tranylcypromine sulfate, Selegiline transdermal
  • SNRIs and Other Agents: Trazodone, Venlafaxine, Desvenlafaxine, Mirtazapine, Nefazodone, Bupropion, Duloxetine, Vilazodone, Vortioxetine, and Levomilnacipran.
• Medications Used To Treat Anxiety Disorders:
  • Benzodiazepines(BNZs): Lorazepam, Clonazepam, Chlordiazepoxide, Oxazepam, Clorazepate and Alprazolam.
  • Anxiolytics: Buspirone
  • Other Agents: Propranolol and Atenolol.
• Medications Used To Treat ADD & ADHD:
  • Stimulants: Amphetamine/dextroamphetamine, Dexmethylphenidate, Dextroamphetamine, Methylphenidate, Lisdexamfetamine dimesylate
  • Other Agents: Guanfacine, Clonidine, Atomoxetine
  • Other Agents: Certain antidepressants like desipramine, venlafaxine, and bupropion

Personality Disorders

• Genetic loading and dysfunctional family dynamics are risk factors for personality disorders.
• Cluster A presents as pervasive distrust, suspiciousness and odd or unusual behavior.
  • Paranoid Personality Disorder: Pervasive distrust/suspicion of others, hostility, and finding malice in others innocuous comments.
  • Schizoid Personality: Avoids relationships, chooses solitary activities, lacks interest in sexual activity, appears cold and detached, and exhibits affective flattening.
  • Schizotypal Personality: Ideas of reference, odd beliefs, magical thinking, unusual perceptions, paranoid ideation, inappropriate affect, and excessive social anxiety.
• Cluster B includes disorders with pervasive affective and interpersonal disruption, they may require hospitalization during symptom expression or stress.
  • Antisocial Personality: Disregard for social norms, repeated unlawful acts, deceitfulness, impulsivity, recklessness, irresponsibility, and lack of remorse.
  • Borderline Personality: Fear of abandonment, unstable relationships, identity disturbance, impulsivity, suicidal behavior, chronic emptiness, and intense anger
  • Histrionic Personality exhibits uncomfortable behaviour when not at the centre of attention. Interactions may be inappropriate seductive or provocation, shifting and shallow emotional responses, impressionistic speech, and is suggestible and easily influenced. Relationships may be considered more intimate than they are
  • Narcissistic Personality includes having a grandiose sense of self-importance, fantasies of power, success, brilliance, and beauty. As well as a belief of self importance and being special and unique. A need for excessive admiration, unreasonable expectations or sense of entitlement, and a lack of empathy
• Cluster C disorders feature pervasive anxiety and fear.
  • Avoidant Personality: Avoids interpersonal contact due to fear of criticism, restraint in relationships, preoccupied with negative evaluation, views self as inferior, and reluctant to take risks.
  • Dependent Personality: Difficulty with decisions without advice, needs others to assume responsibility, cannot express disagreement, struggles with initiating projects, and seeks nurturance or relationships urgently.
  • Obsessive-Compulsive Personality: Preoccupied with details/rules/order, perfectionistic, devoted to work over relationships, inflexible morality, cannot discard objects, reluctant to delegate, miserly spending, rigid and stubborn.

SSRI Medications

• Fluoxetine (Prozac): Treats MDD, OCD, Bulimia, PD, and can combine with Olanzepine for bipolar depression/treatment-resistant depression. It has a long half-life.
• Sertraline (Zoloft): Used for MDD, OCD, PD, PTSD, SAD, PMDD.
• Paroxetine (Paxil): Treats MDD, OCD, PD, SAD, GAD, PTSD; requires gradual dose reduction.
• Fluvoxamine (Luvox): Treats OCD in children and adults; requires gradual dose reduction.
• Citalopram (Celexa): Treats MDD, dose-dependent QT interval prolongation, doses over 40mg/day not recommended.
• Escitalopram (Lexapro): Treats MDD and GAD in children and adults, useful for people with a tendency toward QT prolongation.
• Vilazodone (Viibryd): Treats MDD, take with food as it helps if for treatment-resistant depression. Careful with bleeding
• Vortioxetine (Trintellix): Treats MDD, may help treatment-resistant depression. Careful with bleeding

SSRIs and Side Effects

• Common side effects: Anxiety, agitation, akathisia, insomnia, nausea, diarrhea, and sexual dysfunction.
• Hyponatremia is more common in older patients.
• Serotonin Syndrome symptoms: Diarrhea, restlessness, agitation, autonomic instability, myoclonus, seizures, hyperthermia, rigidity, delirium, coma, death;
• Discontinuation Syndrome requires tapering to avoid agitation, nausea, disequilibrium, dysphoria.
• All SSRIs carry black box warning for increased suicidality in young individuals with major depression/psychiatric disorders.

Therapeutic Interventions

• CBT involves understanding relationships between cognition and emotion

  • It also targets new/adjusted beliefs, modifies perceptions, decreases negativity, increases internal control, enhances coping, and modifies factors contributing to illness.

• DBT is often used to treating borderline personality disorder and emphasizes treating therapy-interfering behaviours.

• The Transtheoretical Model of Change lists six stages for health behaviour changes:

  • (1) Precontemplation (no intention to change)
  • (2) Contemplation (thinking about change)
  • (3) Preparation (decision made, ready for action)
  • (4) Action (specific overt actions),
  • (5) Maintenance(prevent relapse).

• Motivational interviewing assesses willingness to engage in treatment and facilitate decisions without coercion, meeting individuals where they are.

  • Specific techniques include asking open questions, affirmations reflecting stated/implied feelings, summaries to move ideas forward.

Neurotransmitters in Psychology

• Dopamine is produced in the substantia nigra.
• Norepinephrine is produced in the locus ceruleus of the pons and it is implicated in mood, anxiety, and concentration.
• Serotonin is produced in the raphe nuclei of the brainstem and implicated in mood and anxiety.
• Glutamate is an excitatory neurotransmitter that may be involved in mood disorders/schizophrenia.
• GABA is an inhibitory neurotransmitter that increases the effect of benzodiazepines, alcohol, barbiturates, other CNS depressants.

Levels of Evidence

• Quantitative Hierarchy: RCTs/meta-analysis > evidence-based guidelines > RCTs without randomization > reviews of descriptive/qualitative studies > expert opinion.
• Qualitative Hierarchy: Systematic reviews > qualitative studies > expert opinion/committee> evidence-based guideline based on systematic review of RCTs > well-designed trials without randomization > systematic reviews/meta-analysis > one well-designed RCT

Labs for 2nd Generation Antipsychotics

• Monitor blood glucose/A1c, lipid panel, blood pressure, weight/BMI/waist circumference, ECG for QT prolongation risk, and metabolic effects.

Ethical Principles

• Justice involves fairness in care.
• Beneficence encourages well-being and doing good.
• Nonmaleficence dictates doing no harm.
• Fidelity is being true and loyal.
• Autonomy is acting for oneself.
• Veracity involves truth telling.
• Respect for people's humanity involves treating everyone with equal respect.

Schizophrenia Symptoms

• Positive symptoms respond well to antipsychotics which are excesses/distortions in normal functioning, triggered by increased mesolimbic dopamine.
  • Examples: Hallucinations, delusions, referential thinking, disorganized behavior, hostility, grandiosity, mania, suspiciousness.
• Negative symptoms respond well to atypical antipsychotics, meaning that they represent a decrease/loss in function, triggered by decreased mesocortical dopamine.
  • Examples: Affective flattening, alogia, avolition, apathy, abstract-thinking problems, anhedonia, attention deficits.

Intoxication Symptoms

• Cocaine intoxication can cause agitation, irritability, impaired judgement, impulsive sexual behaviour, aggression, increased psychomotor, mania as well as increased tachycardia, hypertension and myadriasis.
• Marijuana intoxication results in distorted perceptions, increased relaxation/sensitivity, and loss of coordination.
  • Common physical effects include red eyes, mild tachycardia, increased appetite, dry mouth, and orthostatic hypotension.
  • Chronic use may cause controversial effects like chronic respiratory disease, lung cancer, cerebral atrophy, seizures, chromosomal damage, birth defects, immune reactivity, testosterone/menstrual alterations.

ADHD

• Characterized by inattention, hyperactivity, and impulsivity, treated with stimulants and therapy.

Clozapine (Clozaril)

• It is exclusively for treatment-resistant schizophrenia, requires enrollment in REMS program, and monitoring ANC (weekly/biweekly/monthly). This may be influenced by the duration of treatment and if ANC normal.
  • ANC level is 500-999/µl interrupt treatment, check ANC daily and resume once ANC normalizes to > 1000 μι
  • ANC levels less than 500/µl suspend drug
• Regular monitoring for myocarditis, dose-related seizures, weight gain/diabetes, hyperprolactinemia, lipids/glucose, cardiovascular history are needed.

Lithium

• Its use for manic episodes, requires monitoring serum levels/kidney function due to toxicity. Toxicity can be increased Level greater than 1.2 mEq/L
  • Therapeutic range is .5 - 1.2 mEq/L.
• Baseline labs before initiation of lithium to ensure safety and efficacy: Thyroid panel Serum creatinine Blood urea nitrogen (BUN) Pregnancy test (Epstein anomaly) ECG for clients older than age 50
• Concurrent use of NSAIDs and ACE inhibitors may double lithium level
• Diet and hydration status may contribute to fluctuating lithium concentrations and decrease if the user takes in high amounts of sodium.
• Short acting forms include alprazolam and lorazepam, intermediate-acting include temazepam and long-acting include clonazepam and diazepam.

Motivational Interviewing Techniques

• Allows practitioners to tailor communication based on patient phase of change.
  • Includes Open questions that are questions that cannot be answered with a yes or no or with short answer, affirmations for strengths and efforts, and mirroring feelings.

Yalom`s Therapeutic Factors

• Put a theoretical perspective on group work and identified 10 therapeutic factors differentiate group therapy from individual therapy

• • Instillation of hope: Participants develop hope for creating a different life.

• Members are at different levels of growth; thus, they gain hope

• from others that change is possible.

• Universality: Participants discover that others have similar problems,thoughts, or feelings and that they are not alone.

• Altruism: This results from sharing oneself with another and helping another.

• Increased development of socialization skills: New social skills are learned, and maladaptive social behaviors are corrected. The group can

• provide a "natural laboratory.” 5. Imitative behaviors: Participants are able to increase their skills by imitating the behaviors of others.

• Interpersonal learning: Interacting with others increases adaptive

• interpersonal relationships.

• Group cohesiveness: Participants develop an attraction to the group

• and other members as well as a sense of belonging.

• Catharsis: Participants experience catharsis as they openly express

• their feelings, which were previously suppressed.

• Existential factors: Groups enable participants to deal with the

• meaning of their own existence.

• Corrective refocusing: Participants re-experience family conflicts in the group, which allows them to recognize and change behaviors that may be problematic.

Crisis Assessment

• Used to evaluate individual's risk of harm to self/others via mental state and support systems.
• The Mini Mental State Exam or MMSE, is used to thoroughly assess the mental status.
• The maximum score is of 30 is and a score of 23 indicates cognitive impairment. Possible cut off points on the MMSE are: (1) 25-30 questionable significance, (2) 20-25 mild impairment, (3) 10-20 moderate impairment, (4) 10 or lower severe impairment.

Levels of Prevention

• Aims to decrease new cases of mental disorders by avoiding stressors in order to cope more adaptively. The following would be helpful in prevention of high risk events: Stress management, classes for graduate students, DARE and REAL for middle / elementary school.

• Secondary prevents number of cases and is found with: Finding early on, screening, and prompt treatment. Ex. Telephone hotlines, crisis intervention, disaster responses

• Tertiary occurs in the reduction f the severity of the disease in a mental disorder. This can be avoided by: : Day, treatment programs, case management for physical, housing, or vocational needs; social skills training

This lesson explains the DEA's drug scheduling system. It categorizes controlled substances into five schedules. The classification depends on their abuse potential and accepted medical use.