Controlled Substances Act

Long title	An Act to amend the Public Health Service Act and other laws to provide increased research into, and prevention of, drug abuse and drug dependence; to provide for treatment and rehabilitation of drug abusers and drug dependent persons; and to strengthen existing law enforcement authority in the field of drug abuse.
Acronyms(colloquial)	CSA
Enacted by	the 91st United States Congress
Effective	May 1, 1971
Citations
Public law	91-513
Statutes at Large	84 Stat.1236a.k.a. 84 Stat. 1242
Codification
Titles amended	21 U.S.C.: Food and Drugs
U.S.C. sections created	21 U.S.C.ch. 13 § 801 et seq.
Legislative history
Introduced in the Houseas H.R. 18583 byHarley O. Staggers (D–WV) on September 10, 1970 Committee consideration byInterstate and Foreign Commerce Committee and Senate Judiciary Committee Passed the House on September 24, 1970 (342–7) Passed the Senate on October 7, 1970 (54–0) Reported by the joint conference committee on October 13, 1970; agreed to by the House on October 14, 1970 (passed) and by the Senate on October 14, 1970 (passed) Signed into law by PresidentRichard Nixonon October 27, 1970
Major amendments
Hillory J. Farias and Samantha Reid Date-Rape Prevention Act of 2000
United States Supreme Court cases
United States v. Oakland Cannabis Buyers' Cooperative Gonzales v. Raich McFadden v. United States

The Controlled Substances Act (CSA) is the statute establishing federalU.S. drug policy under which the manufacture, importation, possession, use, and distribution of certain substances is regulated. It was passed by the 91st United States Congress as Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970 and signed into law by President Richard Nixon.^[1] The Act also served as the national implementing legislation for the Single Convention on Narcotic Drugs.

The legislation created five schedules (classifications), with varying qualifications for a substance to be included in each. Two federal agencies, the Drug Enforcement Administration (DEA) and the Food and Drug Administration (FDA), determine which substances are added to or removed from the various schedules, although the statute passed by Congress created the initial listing. Congress has sometimes scheduled other substances through legislation such as the Hillory J. Farias and Samantha Reid Date-Rape Prevention Act of 2000, which placed gamma hydroxybutyrate (GHB) in Schedule I and sodium oxybate (the isolated sodium salt in GHB) in Schedule III.^[2][3] Classification decisions are required to be made on criteria including potential for abuse (an undefined term),^[4][5] currently accepted medical use in treatment in the United States, and international treaties.

• 1History
• 5Schedules of controlled substances

History[edit]

Regulation of therapeutic goods in the United States
Prescription drugs Over-the-counter drugs
Federal Food, Drug, and Cosmetic Act Comprehensive Drug Abuse Prevention and Control Act of 1970 Controlled Substances Act Prescription Drug Marketing Act Drug Price Competition and Patent Term Restoration Act Hatch-Waxman exemption Marihuana Tax Act
Department of Health and Human Services Food and Drug Administration Department of Justice Drug Enforcement Administration
Drug discovery Drug design Drug development New drug application Investigational new drug Clinical trial (Phase I, II, III, IV) Randomized controlled trial Pharmacovigilance Abbreviated New Drug Application Fast track approval Off-label use
International Conference on Harmonisation of Technical Requirements for Registration of Pharmaceuticals for Human Use Uppsala Monitoring Centre World Health Organization Council for International Organizations of Medical Sciences Single Convention on Narcotic Drugs
Institute of Medicine Research on Adverse Drug events And Reports NORML

The nation first outlawed addictive drugs in the early 1900s and the International Opium Convention helped lead international agreements regulating trade.^[6][7][8] The Food and Drugs Act of 1906 was the beginning of over 200 laws concerning public health and consumer protections.^[9] Others were the Federal Food, Drug, and Cosmetic Act (1938), and the Kefauver Harris Amendment of 1962.^[10][11]

In 1969, PresidentRichard Nixon announced that the Attorney General, John N. Mitchell, was preparing a comprehensive new measure to more effectively meet the narcotic and dangerous drug problems at the federal level by combining all existing federal laws into a single new statute. With the help of White House Counsel head, John Dean; the Executive Director of the Shafer Commission, Michael Sonnenreich; and the Director of the BNDD, John Ingersoll creating and writing the legislation, Mitchell was able to present Nixon with the bill.^[12]

The CSA not only combined existing federal drug laws and expanded their scope, but it also changed the nature of federal drug law policies and expanded Federal law enforcement pertaining to controlled substances.Title II, Part F of the Comprehensive Drug Abuse Prevention and Control Act of 1970 established the National Commission on Marijuana and Drug Abuse^[13]—known as the Shafer Commission after its chairman, Raymond P. Shafer—to study cannabis abuse in the United States.^[14] During his presentation of the commission's First Report to Congress, Sonnenreich and Shafer recommended the decriminalization of marijuana in small amounts, with Shafer stating,

[T]he criminal law is too harsh a tool to apply to personal possession even in the effort to discourage use. It implies an overwhelming indictment of the behavior which we believe is not appropriate. The actual and potential harm of use of the drug is not great enough to justify intrusion by the criminal law into private behavior, a step which our society takes only with the greatest reluctance.^[15]

Rufus King notes that this stratagem was similar to that used by Harry Anslinger when he consolidated the previous anti-drug treaties into the Single Convention and took the opportunity to add new provisions that otherwise might have been unpalatable to the international community.^[16] According to David T. Courtwright, 'the Act was part of an omnibus reform package designed to rationalize, and in some respects to liberalize, American drug policy.' (Courtwright noted that the Act became, not libertarian, but instead repressionistic to the point of tyrannical, in its intent.) It eliminated mandatory minimum sentences and provided support for drug treatment and research.^[17] King notes that the rehabilitation clauses were added as a compromise to Senator Jim Hughes, who favored a moderate approach. The bill, as introduced by Senator Everett Dirksen, ran to 91 pages. While it was being drafted, the Uniform Controlled Substances Act, to be passed by state legislatures, was also being drafted by the Department of Justice; its wording closely mirrored the Controlled Substances Act.^[16]

Amendments,1970-2017[edit]

Since its enactment in 1970, the Act has been amended numerous times:

1. The 1976 Medical Device Regulation Act.^[18]
2. The Psychotropic Substances Act of 1978 added provisions implementing the Convention on Psychotropic Substances.^[19]
3. The Controlled Substances Penalties Amendments Act of 1984.
4. The 1986 Federal Analog Act for chemicals 'substantially similar' in Schedule I and II to be listed
5. The 1988 Chemical Diversion and Trafficking Act (implemented August 1, 1989 as Article 12) added provisions implementing the United Nations Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances that went into force on November 11, 1990.
6. 1990 The Anabolic Steroids Act, passed as part of the Crime Control Act of 1990, which placed anabolic steroids into Schedule III^[20]:30
7. The 1993 Domestic Chemical Diversion and Control Act (effective on April 16, 1994) in response to methamphetamine trafficking.
8. The 2008 Ryan Haight Online Pharmacy Consumer Protection Act^[21]
9. The 2010 Electronic Prescriptions for Controlled Substances (EPCS) .
10. The 2010 Secure and Responsible Drug Disposal Act (effective on October 12, 2010), to allow pharmacies to operate take-back programs for controlled subtance medications in response to the US opioid epidemic.^[22]
11. The 2017 Protecting Patient Access to Emergency Medications Act (PPAEMA) amended Section 33 of the CSA to include DEA registration for Emergency Medical Service (EMS) agencies, approved uses of standing orders, and requirements for the maintenance and administration of controlled substances used by EMS agencies.^[23]

Content[edit]

The Controlled Substances Act consists of 2 subchapters. Subchapter I defines Schedules I-V, lists chemicals used in the manufacture of controlled substances, and differentiates lawful and unlawful manufacturing, distribution, and possession of controlled substances, including possession of Schedule I drugs for personal use; this subchapter also specifies the dollar amounts of fines and durations of prison terms for violations. Subchapter II describes the laws for exportation and importation of controlled substances, again specifying fines and prison terms for violations.^[24]

Enforcement authority[edit]

The Drug Enforcement Administration was established in 1973, combining the Bureau of Narcotics and Dangerous Drugs (BNDD) and Customs' drug agents.^[25] Proceedings to add, delete, or change the schedule of a drug or other substance may be initiated by the DEA, the Department of Health and Human Services (HHS), or by petition from any interested party, including the manufacturer of a drug, a medical society or association, a pharmacy association, a public interest group concerned with drug abuse, a state or local government agency, or an individual citizen. When a petition is received by the DEA, the agency begins its own investigation of the drug.

The DEA also may begin an investigation of a drug at any time based upon information received from laboratories, state and local law enforcement and regulatory agencies, or other sources of information. Once the DEA has collected the necessary data, the Deputy Administrator of DEA,^[26]:42220 requests from HHS a scientific and medical evaluation and recommendation as to whether the drug or other substance should be controlled or removed from control. This request is sent to the Assistant Secretary of Health of HHS. Then, HHS solicits information from the Commissioner of the Food and Drug Administration and evaluations and recommendations from the National Institute on Drug Abuse and, on occasion, from the scientific and medical community at large. The Assistant Secretary, by authority of the Secretary, compiles the information and transmits back to the DEA a medical and scientific evaluation regarding the drug or other substance, a recommendation as to whether the drug should be controlled, and in what schedule it should be placed.

The HHS recommendation on scheduling is binding to the extent that if HHS recommends, based on its medical and scientific evaluation, that the substance not be controlled, then the DEA may not control the substance. Once the DEA has received the scientific and medical evaluation from HHS, the DEA Administrator evaluates all available data and makes a final decision whether to propose that a drug or other substance be controlled and into which schedule it should be placed. Under certain circumstances, the Government may temporarily schedule^[27] a drug without following the normal procedure. An example is when international treaties require control of a substance. In addition, 21 U.S.C.§ 811(h) allows the Attorney General to temporarily place a substance in Schedule I 'to avoid an imminent hazard to the public safety'. Thirty days' notice is required before the order can be issued, and the scheduling expires after a year; however, the period may be extended six months if rulemaking proceedings to permanently schedule the drug are in progress. In any case, once these proceedings are complete, the temporary order is automatically vacated. Unlike ordinary scheduling proceedings, such temporary orders are not subject to judicial review.

The CSA also creates a closed system of distribution^[28] for those authorized to handle controlled substances. The cornerstone of this system is the registration of all those authorized by the DEA to handle controlled substances. All individuals and firms that are registered are required to maintain complete and accurate inventories and records of all transactions involving controlled substances, as well as security for the storage of controlled substances.

Treaty obligations[edit]

The Congressional findings in 21 USC §§ 801(7), 801a(2), and 801a(3) state that a major purpose of the CSA is to 'enable the United States to meet all of its obligations' under international treaties. The CSA bears many resemblances to these Conventions. Both the CSA and the treaties set out a system for classifying controlled substances in several schedules in accordance with the binding scientific and medical findings of a public health authority. Under 21 U.S.C.§ 811 of the CSA, that authority is the Secretary of Health and Human Services (HHS). Under Article 3 of the Single Convention and Article 2 of the Convention on Psychotropic Substances, the World Health Organization is that authority.

The domestic and international legal nature of these treaty obligations must be considered in light of the supremacy of the United States Constitution over treaties or acts and the equality of treaties and Congressional acts. In Reid v. Covert the Supreme Court of the United States addressed both these issues directly and clearly holding:

[N]o agreement with a foreign nation can confer power on the Congress, or on any other branch of Government, which is free from the restraints of the Constitution.

Article VI, the Supremacy Clause of the Constitution, declares:

'This Constitution, and the Laws of the United States which shall be made in Pursuance thereof, and all Treaties made, or which shall be made, under the Authority of the United States, shall be the supreme Law of the Land; . . .'

There is nothing in this language which intimates that treaties and laws enacted pursuant to them do not have to comply with the provisions of the Constitution. Nor is there anything in the debates which accompanied the drafting and ratification of the Constitution which even suggests such a result. These debates, as well as the history that surrounds the adoption of the treaty provision in Article VI, make it clear that the reason treaties were not limited to those made in 'pursuance' of the Constitution was so that agreements made by the United States under the Articles of Confederation, including the important peace treaties which concluded the Revolutionary War, would remain in effect. It would be manifestly contrary to the objectives of those who created the Constitution, as well as those who were responsible for the Bill of Rights—let alone alien to our entire constitutional history and tradition—to construe Article VI as permitting the United States to exercise power under an international agreement without observing constitutional prohibitions. In effect, such construction would permit amendment of that document in a manner not sanctioned by Article V. The prohibitions of the Constitution were designed to apply to all branches of the National Government, and they cannot be nullified by the Executive or by the Executive and the Senate combined.

There is nothing new or unique about what we say here. This Court has regularly and uniformly recognized the supremacy of the Constitution over a treaty. For example, in Geofroy v. Riggs, 133 U. S. 258, 133 U. S. 267, it declared:

'The treaty power, as expressed in the Constitution, is in terms unlimited except by those restraints which are found in that instrument against the action of the government or of its departments, and those arising from the nature of the government itself and of that of the States. It would not be contended that it extends so far as to authorize what the Constitution forbids, or a change in the character of the government, or in that of one of the States, or a cession of any portion of the territory of the latter, without its consent.'

This Court has repeatedly taken the position that an Act of Congress, which must comply with the Constitution, is on a full parity with a treaty, and that, when a statute which is subsequent in time is inconsistent with a treaty, the statute to the extent of conflict renders the treaty null. It would be completely anomalous to say that a treaty need not comply with the Constitution when such an agreement can be overridden by a statute that must conform to that instrument.^[29]

According to the Cato Institute, these treaties only bind (legally obligate) the United States to comply with them as long as that nation agrees to remain a state party to these treaties. The U.S. Congress and the President of the United States have the absolute sovereign right to withdraw from or abrogate at any time these two instruments, in accordance with said nation's Constitution, at which point these treaties will cease to bind that nation in any way, shape, or form.^[30]

A provision for automatic compliance with treaty obligations is found at 21 U.S.C.§ 811(d), which also establishes mechanisms for amending international drug control regulations to correspond with HHS findings on scientific and medical issues. If control of a substance is mandated by the Single Convention, the Attorney General is required to 'issue an order controlling such drug under the schedule he deems most appropriate to carry out such obligations,' without regard to the normal scheduling procedure or the findings of the HHS Secretary. However, the Secretary has great influence over any drug scheduling proposal under the Single Convention, because 21 U.S.C.§ 811(d)(2)(B) requires the Secretary the power to 'evaluate the proposal and furnish a recommendation to the Secretary of State which shall be binding on the representative of the United States in discussions and negotiations relating to the proposal.'

Similarly, if the United Nations Commission on Narcotic Drugs adds or transfers a substance to a schedule established by the Convention on Psychotropic Substances, so that current U.S. regulations on the drug do not meet the treaty's requirements, the Secretary is required to issue a recommendation on how the substance should be scheduled under the CSA. If the Secretary agrees with the Commission's scheduling decision, he can recommend that the Attorney General initiate proceedings to reschedule the drug accordingly. If the HHS Secretary disagrees with the UN controls, however, the Attorney General must temporarily place the drug in Schedule IV or V (whichever meets the minimum requirements of the treaty) and exclude the substance from any regulations not mandated by the treaty, while the Secretary is required to request that the Secretary of State take action, through the Commission or the UN Economic and Social Council, to remove the drug from international control or transfer it to a different schedule under the Convention. The temporary scheduling expires as soon as control is no longer needed to meet international treaty obligations.

This provision was invoked in 1984 to place Rohypnol (flunitrazepam) in Schedule IV. The drug did not then meet the Controlled Substances Act's criteria for scheduling; however, control was required by the Convention on Psychotropic Substances. In 1999, an FDA official explained to Congress:

Rohypnol is not approved or available for medical use in the United States, but it is temporarily controlled in Schedule IV pursuant to a treaty obligation under the 1971 Convention on Psychotropic Substances. At the time flunitrazepam was placed temporarily in Schedule IV (November 5, 1984), there was no evidence of abuse or trafficking of the drug in the United States.^[31]

The Cato Institute's Handbook for Congress calls for repealing the CSA, an action that would likely bring the United States into conflict with international law, were the United States not to exercise its sovereign right to withdraw from and/or abrogate the Single Convention on Narcotic Drugs and/or the 1971 Convention on Psychotropic Substances prior to repealing the Controlled Substances Act.^[30] The exception would be if the U.S. were to claim that the treaty obligations violate the United States Constitution. Many articles in these treaties—such as Article 35 and Article 36 of the Single Convention—are prefaced with phrases such as 'Having due regard to their constitutional, legal and administrative systems, the Parties shall . . .' or 'Subject to its constitutional limitations, each Party shall . . .' According to former United Nations Drug Control Programme Chief of Demand Reduction Cindy Fazey, 'This has been used by the USA not to implement part of article 3 of the 1988 Convention, which prevents inciting others to use narcotic or psychotropic drugs, on the basis that this would be in contravention of their constitutional amendment guaranteeing freedom of speech'.^[32]

Schedules of controlled substances[edit]

There are five different schedules of controlled substances, numbered I–V. The CSA describes the different schedules based on three factors:

1. Potential for abuse: How likely is this drug to be abused?
2. Accepted medical use: Is this drug used as a treatment in the United States?
3. Safety and potential for addiction: Is this drug safe? How likely is this drug to cause addiction? What kinds of addiction?

The following table gives a summary of the different schedules.^[33]

Potential for Abuse	Accepted Medical Use?	Potential for Addiction
Schedule I	High	None	Drug is not safe to use, even under medical supervision
Schedule II	High	Yes; sometimes allowed only with 'severe restrictions'	Abusing the drug can cause severe physical and mental addiction
Schedule III	Medium[a]	Yes	Abusing the drug can cause severe mental addiction, or moderate physical addiction
Schedule IV	Low[b]	Yes	Abusing the drug may lead to mild mental or physical addiction
Schedule V	Lowest[c]	Yes	Abusing the drug may lead to mild mental or physical addiction

Placing a drug or other substance in a certain schedule or removing it from a certain schedule is primarily based on 21 USC §§ 801, 801a, 802, 811, 812, 813, and 814. Every schedule otherwise requires finding and specifying the 'potential for abuse' before a substance can be placed in that schedule.^[34] The specific classification of any given drug or other substance is usually a source of controversy, as is the purpose and effectiveness of the entire regulatory scheme.

The term 'controlled substance' means a drug or other substance, or immediate precursor, included in schedule I, II, III, IV, or V of part B of this subchapter. The term does not include distilled spirits, wine, malt beverages, or tobacco, as those terms are defined or used in subtitle E of the Internal Revenue Code of 1986.

Some have argued that this is an important exemption, since alcohol and tobacco are two of the most widely used drugs in the United States.^[36][37] Also of significance, the exclusion of alcohol includes wine which is sacramentally used by many major religious denominations in the United States.

Schedule I controlled substances[edit]

Schedule I substances are described as those that have the following findings:

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1. The drug or other substance has a high potential for abuse.
2. The drug or other substance has no currently accepted medical use in treatment in the United States.
3. There is a lack of accepted safety for use of the drug or other substance under medical supervision.^[38]

No prescriptions may be written for Schedule I substances, and such substances are subject to production quotas which the DEA imposes.

Under the DEA's interpretation of the CSA, a drug does not necessarily have to have the same 'high potential for abuse' as heroin, for example, to merit placement in Schedule I:

[W]hen it comes to a drug that is currently listed in schedule I, if it is undisputed that such drug has no currently accepted medical use in treatment in the United States and a lack of accepted safety for use under medical supervision, and it is further undisputed that the drug has at least some potential for abuse sufficient to warrant control under the CSA, the drug must remain in schedule I. In such circumstances, placement of the drug in schedules II through V would conflict with the CSA since such drug would not meet the criterion of 'a currently accepted medical use in treatment in the United States.' 21 USC 812(b). (emphasis added)^[39]

Drugs listed in this control schedule include:

• αMT (alpha-methyltryptamine), a psychedelic, stimulant, and entactogendrug of the tryptamine class that was originally developed as an antidepressant by workers at Upjohn in the 1960s.
• BZP (benzylpiperazine), a synthetic stimulant once sold as a designer drug. It has been shown to be associated with an increase in seizures if taken alone.^[40] Although the effects of BZP are not as potent as MDMA, it can produce neuroadaptations that can cause an increase in the potential for abuse of this drug.^[41]
• Cathinone, an amphetamine-like stimulant found in the shrub Catha edulis (khat).
• DMT (dimethyltryptamine), a naturally occurring psychedelic drug that is widespread throughout the plant kingdom and endogenous to the human body. DMT is the main psychoactive constituent in the psychedelic South American brew, ayahuasca, for which the UDV are granted exemption from DMT's schedule I status on the grounds of religious freedom.
• Etorphine, a semi-synthetic opioid possessing an analgesic potency approximately 1,000–3,000 times that of morphine.
• GHB, a general anesthetic and treatment for narcolepsy-cataplexy and alcohol withdrawal with a limited safe dosage range and poor ability to control pain when used as an anesthetic (severely limiting its usefulness).^[42] It was placed in Schedule I in March 2000 after widespread recreational use led to increased emergency room visits, hospitalizations, and deaths.^[43] A specific formulation of this drug is also listed in Schedule III for limited uses, under the trademark Xyrem.
• Heroin (diacetylmorphine), which is used in some European countries as a potent pain reliever in terminal cancer patients, and as second option, after morphine; it is about twice as potent, by weight, as morphine and, indeed, becomes morphine upon injection into the bloodstream.
• Ibogaine, a naturally occurring psychoactive substance found in plants in the Apocynaceae family. Some countries use ibogaine as an alternative medicine treatment for drug addiction. Ibogaine is also used for medicinal and ritual purposes within African spiritual traditions of the Bwiti.
• LSD (lysergic acid diethylamide), a semi-syntheticpsychedelic drug famous for its involvement in the counterculture of the 1960s.
• Marijuana and its cannabinoids. Pure (–)-trans-Δ9-tetrahydrocannabinol is also listed in Schedule III for limited uses, under the trademark Marinol. Ballot measures in several states such as Colorado, Washington, California, Florida, Massachusetts, Oregon and others have made allowances for recreational and medical use of marijuana and/or have decriminalized possession of small amounts of marijuana – such measures operate only on state laws, and have no effect on Federal law.^[39][44] Whether such users would actually be prosecuted under federal law is a separate question.
• MDMA ('ecstasy'), a stimulant, psychedelic, and entactogenic drug which initially garnered attention in psychedelic therapy as a treatment for post-traumatic stress disorder (PTSD). The medical community originally agreed upon placing it as a Schedule III substance, but the government denied this suggestion, despite two court rulings by the DEA's administrative law judge that placing MDMA in Schedule I was illegal. It was temporarily unscheduled after the first administrative hearing from December 22, 1987 – July 1, 1988.^[45]
• Mescaline, a naturally occurring psychedelic drug and the main psychoactive constituent of peyote (Lophophora williamsii), San Pedro cactus (Echinopsis pachanoi), and Peruvian torch cactus (Echinopsis peruviana).
• Methaqualone (Quaalude, Sopor, Mandrax), a sedative that was previously used for similar purposes as barbiturates, until it was rescheduled.
• Peyote (Lophophora williamsii), a cactus growing in nature primarily in northeastern Mexico; one of the few plants specifically scheduled, with a narrow exception to its legal status for religious use in Native American churches.
• Psilocybin and psilocin, naturally occurring psychedelic drugs and the main psychoactive constituents of psilocybin mushrooms.
• Controlled substance analogs intended for human consumption, as defined by the Federal Analog Act.

Schedule II controlled substances[edit]

Schedule II substances are those that have the following findings:

1. The drug or other substances have a high potential for abuse
2. The drug or other substances have currently accepted medical use in treatment in the United States, or currently accepted medical use with severe restrictions
3. Abuse of the drug or other substances may lead to severe psychological or physical dependence.^[38]

Except when dispensed directly to an ultimate user by a practitioner other than a pharmacist, no controlled substance in Schedule II, which is a prescription drug as determined under the Federal Food, Drug, and Cosmetic Act (21 USC 301 et seq.), may be dispensed without the written prescription of a practitioner, except that in emergency situations, as prescribed by the Secretary by regulation after consultation with the Attorney General, such drug may be dispensed upon oral prescription in accordance with section 503(b) of that Act (21 USC 353 (b)). With exceptions, an original prescription is always required even though faxing in a prescription in advance to a pharmacy by a prescriber is allowed.^[46] Prescriptions shall be retained in conformity with the requirements of section 827 of this title. No prescription for a controlled substance in Schedule II may be refilled.^[47] Notably no emergency situation provisions exist outside the Controlled Substances Act's 'closed system' although this closed system may be unavailable or nonfunctioning in the event of accidents in remote areas or disasters such as hurricanes and earthquakes. Acts which would widely be considered morally imperative remain offenses subject to heavy penalties.^[48]

These drugs vary in potency: for example fentanyl is about 80 times as potent as morphine (heroin is roughly two times as potent). More significantly, they vary in nature. Pharmacology and CSA scheduling have a weak relationship.

Because refills of prescriptions for Schedule II substances are not allowed, it can be burdensome to both the practitioner and the patient if the substances are to be used on a long-term basis. To provide relief, in 2007, 21 C.F.R.1306.12 was amended (at 72 FR64921) to allow practitioners to write up to three prescriptions at once, to provide up to a 90-day supply, specifying on each the earliest date on which it may be filled.^[49]

Drugs in this schedule include:

• Amphetamine drugs including Adderall, Dextroamphetamine (Dexedrine), Lisdexamfetamine (Vyvanse): treatment of ADHD, narcolepsy, severe obesity (limited use, dextroamphetamine only), binge eating disorder (lisdexamfetamine only). Originally placed in Schedule III, but moved to Schedule II in 1971.
• Barbiturates (short-acting), such as pentobarbital
• Cocaine: used as a topical anesthetic and to stop severe epistaxis
• Codeine (pure) and any drug for non-parenteral administration containing the equivalent of more than 90 mg of codeine per dosage unit;
• Diphenoxylate (pure)
• Fentanyl and most other strong pure opioid agonists, i.e.levorphanol
• Hydrocodone in any formulation as of October 2014 (Examples include Vicodin, Norco, Tussionex). Prior to October 2014, formulations containing hydrocodone and over-the-counter analgesics such as Acetaminophen and Ibuprofen were Schedule III.^[50]
• Hydromorphone (semi-synthetic opioid; active ingredient in Dilaudid, Palladone)
• Methadone: treatment of heroin addiction, extreme chronic pain
• Methamphetamine: treatment of ADHD (rare), severe obesity (limited use)
• Methylphenidate (Ritalin, Concerta), Dexmethylphenidate (Focalin): treatment of ADHD, narcolepsy
• Nabilone (Cesamet) – A synthetic cannabinoid. An analogue to dronabinol (Marinol) which is a Schedule III drug.
• Opium tincture (Laudanum): a potent antidiarrheal
• Oxycodone (semi-synthetic opioid; active ingredient in Percocet, OxyContin, and Percodan)
• Oxymorphone (semi-synthetic opioid; active ingredient in Opana)
• Nembutal (Pentobarbital) – barbiturate medication originally developed for narcolepsy; primarily used today for physician assisted suicide and euthanasia of animals.
• Pethidine (USAN: Meperidine; Demerol)
• Phencyclidine (PCP)
• Secobarbital (Seconal)
• Tapentadol (Nucynta) – A drug with mixed opioid agonist and norepinephrine re-uptake inhibitor activity.

Schedule III controlled substances[edit]

Schedule III substances are those that have the following findings:

1. The drug or other substance has a potential for abuse less than the drugs or other substances in Schedules I and II.
2. The drug or other substance has a currently accepted medical use in treatment in the United States.
3. Abuse of the drug or other substance may lead to moderate or low physical dependence or high psychological dependence.^[38]

Except when dispensed directly by a practitioner, other than a pharmacist, to an ultimate user, no controlled substance in Schedule III or IV, which is a prescription drug as determined under the Federal Food, Drug, and Cosmetic Act (21 USC 301 et seq.), may be dispensed without a written or oral prescription in conformity with section 503(b) of that Act (21 USC 353 (b)). Such prescriptions may not be filled or refilled more than six months after the date thereof or be refilled more than five times after the date of the prescription unless renewed by the practitioner.^[47] A prescription for controlled substances in Schedules III, IV, and V issued by a practitioner, may be communicated either orally, in writing, or by facsimile to the pharmacist, and may be refilled if so authorized on the prescription or by call-in.^[46] Control of wholesale distribution is somewhat less stringent than Schedule II drugs. Provisions for emergency situations are less restrictive within the 'closed system' of the Controlled Substances Act than for Schedule II though no schedule has provisions to address circumstances where the closed system is unavailable, nonfunctioning or otherwise inadequate.

Drugs in this schedule include:

• Anabolic steroids (including prohormones such as androstenedione); the specific end molecule testosterone in many of its forms (Androderm, AndroGel, Testosterone Cypionate, and Testosterone Enanthate) are labeled as Schedule III while low-dose testosterone when compounded with estrogen derivatives have been exempted (from scheduling) by the FDA^[51]
• Intermediate-acting barbiturates, such as talbutal or butalbital
• Buprenorphine (semi-synthetic opioid; active in Suboxone, Subutex)
• Dihydrocodeine when compounded with other substances, to a certain dosage and concentration.
• Ketamine, a drug originally developed as a safer, shorter-acting replacement for PCP (mainly for use as a human anesthetic) but has since become popular as a veterinary and pediatric anesthetic;
• Xyrem, a preparation of GHB used to treat narcolepsy. Xyrem is in Schedule III but with a restricted distribution system. All other forms of GHB are in Schedule I.
• Marinol, synthetically prepared tetrahydrocannabinol (officially referred to by its INN, dronabinol) used to treat nausea and vomiting caused by chemotherapy, as well as appetite loss caused by AIDS.
• Paregoric, an antidiarrheal and anti-tussive, which contains opium combined with camphor (which makes it less addiction-prone than laudanum, which is in Schedule II).
• Phendimetrazine Tartrate, a stimulant synthesized for use as an anorexiant.
• Benzphetamine HCl (Didrex), a stimulant designed for use as an anorexiant.
• Fast-acting barbiturates such as secobarbital (Seconal) and pentobarbital (Nembutal), when combined with one or more additional active ingredient(s) not in Schedule II (e.g., Carbrital (no longer marketed), a combination of pentobarbital and carbromal).
• Ergine (lysergic acid amide), listed as a sedative but considered by some to be psychedelic.^[52][53] An inefficient precursor to its N,N-diethyl analogue, LSD, ergine occurs naturally in the seeds of the common garden flowers Turbina corymbosa, Ipomoea tricolor, and Argyreia nervosa.

Schedule IV controlled substances[edit]

'Placement on schedules; findings requiredSchedule IV substances are those that have the following findings:

1. The drug or other substance has a low potential for abuse relative to the drugs or other substances in Schedule III
2. The drug or other substance has a currently accepted medical use in treatment in the United States
3. Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in Schedule III^[38]

Control measures are similar to Schedule III. Prescriptions for Schedule IV drugs may be refilled up to five times within a six-month period. A prescription for controlled substances in Schedules III, IV, and V issued by a practitioner, may be communicated either orally, in writing, or by facsimile to the pharmacist, and may be refilled if so authorized on the prescription or by call-in.^[46]

Drugs in this schedule include:

• Benzodiazepines, such as alprazolam (Xanax), chlordiazepoxide (Librium), clonazepam (Klonopin), diazepam (Valium), and Lorazepam (Ativan), as well as:
  • temazepam (Restoril) (note that some states require specially coded prescriptions for temazepam)
  • flunitrazepam (Rohypnol) (note that flunitrazepam is not used medically in the United States)
• The benzodiazepine-likeZ-drugs: zolpidem (Ambien), zopiclone (Imovane), eszopiclone (Lunesta), and zaleplon (Sonata) (zopiclone is not commercially available in the U.S.)
• Chloral hydrate, a sedative-hypnotic
• Long-acting barbiturates such as phenobarbital
• Some partial agonist opioid analgesics, such as pentazocine (Talwin)
• The eugeroic drug modafinil (sold in the U.S. as Provigil) as well as its (R)-enantiomer armodafinil (sold in the U.S. as Nuvigil)
• Difenoxin, an antidiarrheal drug, such as when combined with atropine (Motofen) (difenoxin is 2–3 times more potent than diphenoxylate, the active ingredient in Lomotil, which is in Schedule V)
• Tramadol (Ultram)
• Carisoprodol (Soma) has become a Schedule IV medication as of 11 January 2012^[54]

Schedule V controlled substances[edit]

Schedule V substances are those that have the following findings:

1. The drug or other substance has a low potential for abuse relative to the drugs or other substances in schedule IV
2. The drug or other substance has a currently accepted medical use in treatment in the United States
3. Abuse of the drug or other substance may lead to limited physical dependence or psychological dependence relative to the drugs or other substances in schedule IV.^[38]

No controlled substance in Schedule V which is a drug may be distributed or dispensed other than for a medical purpose.^[47] A prescription for controlled substances in Schedules III, IV, and V issued by a practitioner, may be communicated either orally, in writing, or by facsimile to the pharmacist, and may be refilled if so authorized on the prescription or by call-in.^[46]

Drugs in this schedule include:

• Cough suppressants containing small amounts of codeine (e.g., promethazine+codeine);
• Preparations containing small amounts of opium or diphenoxylate (used to treat diarrhea);
• Some anticonvulsants, such as pregabalin (Lyrica), lacosamide (Vimpat) and retigabine (ezogabine) (Potiga/Trobalt);
• Pyrovalerone (used to treat chronic fatigue and as an appetite suppressant for weight loss);
• Some centrally-acting antidiarrheals, such as diphenoxylate (Lomotil) when mixed with atropine (to make it unpleasant for people to grind up, cook, and inject). Difenoxin with atropine (Motofen) has been moved to Schedule IV. Without atropine, these drugs are in Schedule II.
• Cannabidiol, only in a marijuana-derived pharmaceutical formulation marketed by GW Pharmaceuticals as Epidiolex. Cannabidiol derived from industrial hemp remains Schedule 1.^[55]

Regulation of precursors[edit]

The Controlled Substances Act also provides for federal regulation of precursors used to manufacture some of the controlled substances. The DEA list of chemicals is actually modified when the United States Attorney General determines that illegal manufacturing processes have changed.

In addition to the CSA, due to pseudoephedrine (PSE) and ephedrine being widely used in the manufacture of methamphetamine, the U.S. Congress passed the Methamphetamine Precursor Control Act which places restrictions on the sale of any medicine containing pseudoephedrine. That bill was then superseded by the Combat Methamphetamine Epidemic Act of 2005, which was passed as an amendment to the Patriot Act renewal and included wider and more comprehensive restrictions on the sale of PSE-containing products. This law requires^[56] customer signature of a 'log-book' and presentation of valid photo ID in order to purchase PSE-containing products from all retailers.^[57]

Additionally, the law restricts an individual to the retail purchase of no more than three packages or 3.6 grams of such product per day per purchase – and no more than 9 grams in a single month. A violation of this statute constitutes a misdemeanor. Retailers now commonly require PSE-containing products to be sold behind the pharmacy or service counter. This affects many preparations which were previously available over-the-counter without restriction, such as Actifed and its generic equivalents.

Criticism[edit]

There has been criticism against the schedule classifications of the listed drugs and substances in the CSA, citing undefined terms.^[4][5]Some criticism has arisen due to research that has found several substances on the list of Schedule I substances to have actual accepted medical uses and low abuse potential, despite the requirement for a Schedule I listing mandating that any substance so scheduled have both a high potential for abuse and no accepted medical use.^[58][59][60] One such example is the legalization of marijuana in some capacity in currently 33 states.^[61]

See also[edit]

• Single Convention on Narcotic Drugs (1961)
• Treaty Clause and Head Money Cases

Similar legislation outside of the United States:

• Controlled Drugs and Substances Act (Canada)
• Misuse of Drugs Act 1971 (United Kingdom)

Notes[edit]

1. ^Less than the drugs in Schedule I and Schedule II
2. ^When compared with the drugs in Schedule III
3. ^When compared with the drugs in Schedule IV

References[edit]

1. ^Pub.L.91–513, 84 Stat.1236, enacted October 27, 1970, codified at 21 U.S.C.§ 801 et. seq.
2. ^'2000 - Addition of Gamma-Hydroxybutyric Acid to Schedule I'. US Department of Justice via the Federal Register. March 13, 2000.
3. ^'William J. Clinton: Statement on Signing the Hillory J. Farias and Samantha Reid Date-Rape Drug Prohibition Act of 2000'. February 18, 2000.
4. ^ ^abGovernment Regulations Docket ID: DEA-2009-0013 in BASIS FOR THE RECOMMENDATION TO CONTROL 5-METHOXY-DIMETHYLTRYPTAMINE (5-MeO-DMT) IN SCHEDULE I OF THE CONTROLLED SUBSTANCES ACT The term 'abuse' is not defined in the CSA.
5. ^ ^ab'[D]rug abuse may refer to any type of drug or chemical without regard to its pharmacologic actions. It is an eclectic concept having only one uniform connotation: societal disapproval. .. The Commission believes that the term drug abuse must be deleted from official pronouncements and public policy dialogue. The term has no functional utility and has become no more than an arbitrary codeword for that drug use which is presently considered wrong.' – Second Report of the National Commission on Marihuana and Drug Abuse; Drug Use In America: Problem In Perspective (March 1973), p.13
6. ^'Illegal Drugs in America: A Modern History'. DEA Museum & Visitors Center. Archived from the original on December 4, 2004.
7. ^'The 1912 Hague International Opium Convention'. Public Policy Options. Canadian Senate Special Committee on Illegal Drugs. 3. Schaffer Library of Drug Policy.
8. ^Musto, David F. 'History of Legislative Control Over Opium, Cocaine, and Their Derivatives'. Schaffer Library of Drug Policy.
9. ^'Legislation'. U.S. Food and Drug Administration. July 2, 2015.
10. ^'Medical Device Amendments'. Rx-wiki. Parsons Printing Press. Retrieved December 30, 2012.
11. ^'50 Years: The Kefauver-Harris Amendment'. FDA. Retrieved July 7, 2016.
12. ^Strength of the Pack: The Personalities, Politics and Espionage Intrigues. Douglas Valentine. November 15, 2010. ISBN9781936296910. Retrieved May 13, 2018.
13. ^91st United States Congress (1970), 'Part F—Advisory Commission: Establishment of Commission on Marihuana and Drug Abuse', An Act to amend the Public Health Service Act and other laws to provide increased research, into, and prevention of, drug abuse and drug dependence; to provide for treatment and rehabilitation of drug abusers and drug dependent persons; and to strengthen existing law enforcement authority in the field of drug abuse, U.S. Government Publishing Office, pp. 1280–1281.Pub.L.91–513, 84 Stat.1236, enacted October 27, 1970
14. ^National Commission on Marihuana and Drug Abuse (March 1973). Drug Use In America: Problem In Perspective, Second Report of the National Commission on Marihuana and Drug Abuse (Report).
15. ^'NORML - Working to Reform Marijuana Laws'. norml.org. Retrieved May 15, 2018.
16. ^ ^abKing, Rufus. 'The 1970 Act: Don't Sit There, Amend Something'. The Drug Hang Up, America's Fifty-Year Folly. Schaffer Library of Drug Policy.
17. ^Courtwright, David T. (October 5, 2004). 'The Controlled Substances Act: how a 'big tent' reform became a punitive drug law'. Drug and Alcohol Dependence. 76 (1): 9–15. doi:10.1016/j.drugalcdep.2004.04.012. PMID15380284.
18. ^'S.510 - An Act to amend the Federal Food, Drug, and Cosmetic Act to provide for the safety and effectiveness of medical devices intended for human use, and for other purposes'. Congress.Gov. Library of Congress. Retrieved August 31, 2016.
19. ^'S.2399 - Psychotropic Substances Act'. Congress.Gov. Library of Congress. Retrieved August 31, 2016.
20. ^Steven B. Karch. Pathology, Toxicogenetics, and Criminalistics of Drug Abuse. CRC Press, 2007 ISBN9781420054569
21. ^Ryan Haight Online Pharmacy Consumer Protection Act of 2008. 2009 – via Wikisource.
22. ^'S.3397 - 111th Congress (2009-2010): Secure and Responsible Drug Disposal Act of 2010'. Congress.Gov. Library of Congress. Retrieved March 26, 2019.
23. ^'CDC - The Protecting Patient Access to Emergency Medications Act of 2017 - Publications by Topic - Public Health Law'. www.cdc.gov. February 22, 2019. Retrieved April 24, 2019.
24. ^'Title 21 United States Code (USC) Controlled Substances Act'. Drug Enforcement Administration: Office of Diversion Control. United States Department of Justice.
25. ^'State and Local Task Forces'. Drug Enforcement Administration. United States Department of Justice. Retrieved December 30, 2012.
26. ^Drug Enforcement Administration (August 21, 2009). 'Schedules of Controlled Substances: Placement of 5-Methoxy-N,N-Dimethyltryptamine Into Schedule I of the Controlled Substances Act'. Federal Register. 74 (161): 42217–42220. Under the authority vested in the Attorney General by section 201(a) of the CSA (21 USC 811(a)), and delegated to the Administrator of DEA by Department of Justice regulations (28 CFR 0.100), and redelegated to the Deputy Administrator pursuant to 28 CFR 0.104… 74 FR42217
27. ^'Final Order: Temporary Placement of Five Synthetic Cannabinoids Into Schedule I'. Drug Enforcement Administration: Office of Diversion Control. United States Department of Justice. Retrieved December 30, 2012.
28. ^Abood, Richard R. (November 21, 2012). 'The Closed System of Controlled Substance Distribution'. Pharmacy Practice and the Law. Jones & Bartlett. p. 184. ISBN978-1-4496-8691-8. Retrieved December 30, 2012.
29. ^'Reid v. Covert, 354 U. S. 1 at pp 17–19'. Justia Law. Retrieved October 30, 2014.
30. ^ ^ab'The War on Drugs'(PDF). Cato Handbook for Congress: Policy Recommendations for the 108th Congress. Cato Institute. 2003. pp. 171–178. Retrieved October 20, 2012.
31. ^'Date Rape' DrugsArchived 2006-05-16 at the Wayback Machine
32. ^fuoriluogo.it – aprile 2003Archived April 23, 2015, at the Wayback Machine
33. ^21 U.S.C. § 812 – Schedules of controlled substances.
34. ^'21 U.S. Code Chapter 13 - Drug Abuse Prevention and Control'. LII / Legal Information Institute.
35. ^'21 U.S. Code § 802 - Definitions'. LII / Legal Information Institute.
36. ^'Appendix C: Measurement of Dependence, Abuse, Treatment, and Treatment Need – 2000 NHSDA – Substance Dependence, Abuse, and Treatment'. National Household Survey on Drug Abuse. SAMHSA, Office of Applied Studies. 2000. Archived from the original on February 21, 2013.
37. ^'InfoFacts – Cigarettes and Other Tobacco Products'. Retrieved October 30, 2014.
38. ^ ^abcde21 U.S.C.§ 812 – Schedules of controlled substances
39. ^ ^abMarshall, Donnie (March 20, 2001). 'Notice of denial of petition to reschedule marijuana'. Federal Register. Drug Enforcement Administration. 66 (75): 20038–20076. Retrieved June 13, 2013.
40. ^Gee, Paul; Gilbert, Mark; Richardson, Sandra; Moore, Grant; Paterson, Sharon; Graham, Patrick (2008). 'Toxicity from the Recreational Use of 1-benzylpiperazine'. Clinical Toxicology. 46 (9): 802–07. doi:10.1080/15563650802307602. PMID18821145.
41. ^Brennan, K.; Johnstone, A.; Fitzmaurice, P.; Lea, R.; Schenk, S. (2007). 'Chronic Benzylpiperazine (BZP) Exposure Produces Behavioral Sensitization and Cross-sensitization to Methamphetamine (MA)'. Drug and Alcohol Dependence. 88 (2–3): 204–13. doi:10.1016/j.drugalcdep.2006.10.016. PMID17125936.
42. ^Tunnicliff, G. (1997). 'Sites of action of gamma hydroxybutyrate (GHB)--A neuroactive drug with abuse potential'. Clinical Toxicology. 35 (6): 581–590. doi:10.3109/15563659709001236.
43. ^Okun, M. S.; Boothy, L. A.; Bartfield, R. B.; Doering, P. L. (2001). 'GHB: An important pharmacologic and clinical update'. Journal of Pharmacy and Pharmacological Science. 4 (=2): 167–175.
44. ^See United States v. Angelos, 433 F.3d 738 (10th Cir. 2006) (55 years for three sales of marijuana).
45. ^'MAPS Legal History of MDMA'. Retrieved October 30, 2014.
46. ^ ^abcd'Manuals – Practitioner's Manual – SECTION V'. Retrieved 2014-01-07
47. ^ ^abc'21 U.S. Code § 829 - Prescriptions'. LII / Legal Information Institute.
48. ^'21 U.S. Code Part D - Offenses and Penalties'. LII / Legal Information Institute.
49. ^'Issuance of Multiple Prescriptions for Schedule II Controlled Substances'. U.S. DEA, U.S. DOJ. November 2007. Retrieved September 3, 2014.
50. ^Federal Register / Vol. 79, No. 163 / Pgs. 49661 - 49682 / Aug 22, 2014 DEA-Final Rule, Effective October 6, 2014 Text (162 KB)PDF (242 KB)
51. ^Exempt Anabolic Steroids (21 CFR § 1308.33 and 21 CFR § 1308.34) 05 February 2015 Drug Enforcement Administration Office of Diversion Control Drug and Chemical Evaluation Section
52. ^Halpern, J.H. (2004). 'Hallucinogens and dissociative agents naturally growing in the United States'. Pharmacology & Therapeutics. 102 (2): 131–138. doi:10.1016/j.pharmthera.2004.03.003. PMID15163594.
53. ^Schultes, R.E. and Hofmann, A., 1980. The botany and chemistry of hallucinogens, Charles C. Thomas, Springfield, IL.
54. ^[Federal Register Volume 76, Number 238 (Monday, December 12, 2011)] [Rules and Regulations] [Pages 77330-77360]
55. ^Mitchell, Thomas (September 28, 2018). 'Why This Colorado Law Firm Is Upset Over DEA's Rescheduling of CBD Medication'. Westword.
56. ^'Federal Pseudoephedrine Law'(PDF). doh.state.fl.us. Florida Department of Health, Division of Medical Quality Assurance. October 5, 2006. Archived from the original(PDF) on July 30, 2012. Retrieved October 20, 2012.
57. ^'General Information Regarding the Combat Methamphetamine Epidemic Act 2005'. Drug Enforcement Administration, Office of Diversion Control. Retrieved October 20, 2012.
58. ^'Drug Scheduling'. Drug Enforcement Administration, United States Department of Justice.
59. ^Nutt, David J.; King, Leslie A.; Phillips, Lawrence D.; Independent Scientific Committee on Drugs (November 6, 2010). 'Drug harms in the UK: A multicriteria decision analysis'. The Lancet. 376 (9752): 1558–1565. CiteSeerX10.1.1.690.1283. doi:10.1016/S0140-6736(10)61462-6. PMID21036393.
60. ^'DrugFacts: Is Marijuana Medicine?'. National Institute on Drug Abuse. National Institutes of Health; U.S. Department of Health and Human Services. July 2015.
61. ^'State Marijuana Laws in 2018 Map'. www.governing.com.

External links[edit]

The naturally occurring opiates (plant alkaloids derived from the opium poppy) as well as synthetic (man-made) and semisynthetic opioids are considered to be narcotic drugs, which include both legally prescribed and illicit varieties. Opioids not only diminish the perception of pain signaling in the central nervous system but also produce rewarding, euphoric effects, making them targets for abuse and highly addictive.

Commonly Abused Narcotics & Opioids

Below is a brief list of some of the more widely-known narcotics and opioids drugs:

• Opium
• Heroin
• Codeine
• Oxycodone
• Hydrocodone
• Tramadol
• Morphine
• Hydromorphone
• Carfentanil

The United States is in the midst of an opioid epidemic. The American Society of Addiction Medicine (ASAM) indicates that close to 3 million people battled opioid addiction (to either heroin or prescription painkillers) in 2015. More than 60 percent of the record-high overdose deaths in 2015 involved an opioid drug, and 91 people in the US die from an opioid overdose daily, the Centers for Disease Control and Prevention (CDC) reports. Also in 2015, roughly 300 million prescriptions were dispensed for narcotic pain medications around the world, and Americans consumed 80 percent of them.

Opioid abuse, addiction, and overdose are considered serious public health concerns in the United States. Here we’ll provide more detail about some of the more commonly discussed prescription painkillers and illicit narcotic drugs.

Learn About Specific Narcotics & Related Drugs

For years, opium was a widely-used drug derived from the crude botanical extract extruded from the opium poppy plant. With minimal processing, opium consisted of a mixture of naturally-occurring opiate alkaloids—substances that serve as the building blocks for the synthesis of many modern opioid drugs. Opium was sometimes distributed as a liquid or solid, but most commonly encountered as a brownish powder, according to the DEA. Opium was most commonly smoked but could also be pressed into pill form or dissolved into a tincture or other solution for oral use or injection.

The opioid alkaloids contained in opium extracts (e.g., codeine, morphine, thebaine) are used to synthesize many prescription narcotics (like morphine, codeine, oxycodone, etc.). Heroin is also made from raw materials obtained from the opium poppy plant. Opium is not as common a drug of abuse in the United States as other opioids are, and outside of limited use as an anti-diarrheal agent, has no medical use in its traditional form.

Heroin

An illegal, semi-synthetic opiate, heroin is classified as a Schedule I controlled substance in the United States, as it has no approved medical uses and a high potential for abuse and addiction. Opioids like heroin dull pain but can also impair cognition, increase sedation, and slow certain autonomic functions such as those that control respiratory rate. Heroin may be distributed as a brown or white powder or a sticky black substance called “black tar heroin.” The drug can be snorted, smoked, or injected. Heroin creates an intense and rapid “high” or “rush,” and individuals often cycle between an awake and unconscious state, called being “on the nod.”

More than 400,000 Americans reported past-month heroin use on the 2014 National Survey on Drug Use and Health (NSDUH). The CDC reports that heroin use is increasing across most demographics in the US in recent years.

As prescription opioids become costlier and less accessible, individuals may be opting for cheaper options like heroin. The CDC reports that three out of four people who initiate heroin use began by abusing a prescription opioid, close to half of those who use heroin are addicted to prescription opioids, and nine out of 10 also abuse another drug.

Overdose is a major risk of abuse. The rate of heroin overdose deaths increased by nearly 20 percent from 2015 to 2016, and close to 15,500 people died from drug overdoses involving heroin in 2016. Heroin overdose symptoms may include markedly constricted pupils, difficulties breathing, respiratory arrest, stupor, sluggish movements, confusion, clammy and cold skin, slow heart rate and low blood pressure, a bluish tinge to the nails and lips, and a potential loss of consciousness. Heroin overdose is a medical emergency; if an overdose is suspected, call 911 immediately.

ASAM reports that more than 600,000 people battled heroin addiction in 2015. Heroin and other opioid drugs increase dopamine activity in the brain. This surge in dopamine accompanies the burst of pleasure that is associated with opioid use and strongly reinforces continued, compulsive use of these drugs.

One of the most popular and arguably one of the most controversial drugs in recent history, OxyContin is an extended-release formulation of oxycodone that has made more than $35 billion in sales for Purdue Pharma since it burst onto the market with aggressive marketing strategies in 1995, Forbes reports. Purdue has paid out millions for its alleged role in the opioid addiction epidemic currently sweeping across America.

OxyContin and other opioids containing oxycodone are effective painkillers for moderate to severe pain; however, they can quickly lead to the development of physical dependence and addiction with regular use or abuse. In its various formulations, oxycodone is dispensed as both immediate and extended-release tablets intended for oral use. Oxycodone is also available in several combination formulations that include analgesic pain relievers such as acetaminophen and aspirin.

Oxycodone is a Schedule II controlled substance, which means that it does have accepted medical use; however, it is also commonly abused for its mind-altering effects and can also lead to addiction. OxyContin and other oxycodone products contain a black-box warning regarding their high diversion, abuse, dependence, addiction, and overdose potential.

People may crush, grind, or dissolve oxycodone tablets in an attempt to bypass those with an extended-release mechanism prior to snorting, smoking, or injecting the drug. This greatly increases the odds for overdose as the full dose intended for a timed release is delivered much more quickly. Oxycodone is one of the most prescribed prescription pain relievers and also one of the most common drugs involved in prescription opioid overdose fatalities.

In 2007, OxyContin was reformulated to make it more abuse-deterrent. When crushed, the result is now a gooey substance that is more difficult to abuse. Even so, the drug can still be abused by swallowing and taking higher doses at one time. The Pharmaceutical Journal reports that while the reformulation of OxyContin did decrease abuse rates, individuals may be turning to the illicit drug heroin as a replacement.

Hydrocodone is the top-prescribed and most regularly diverted and abused opioid drug, according to the DEA. Americans consume around 99 percent of the world’s supply of hydrocodone, which became more tightly regulated in 2014. Hydrocodone and its many combination products are now classified as a Schedule II controlled substances.

In addition to being an effective painkiller, hydrocodone has some cough suppressant (antitussive) properties and is a component of some prescription cold and cough formulations. Prescribed as tablets or oral solution, hydrocodone products are intended for oral administration, but some may attempt to misuse them by snorting, smoking, or injecting the drug. Nearly 3 percent of high school seniors reported misusing Vicodin (hydrocodone/acetaminophen) in 2015.

The DEA warns that hydrocodone is one of the drugs most frequently involved in prescription opioid overdose deaths, and it is considered highly addictive.

Morphine (MS Contin and Kadian)

Morphine is a natural opiate alkaloid derived directly from the opium poppy plant. Pharmaceutical morphine is used as a narcotic analgesic for both acute and chronic pain management, and also to provide sedation before surgical procedures. Morphine continues to be one of the most widely utilized pain medications in hospital settings, where it was once administered almost entirely as an injectable solution.

Today, it is available in other forms, including both immediate- and extended-release tablets, oral solutions, and rectal suppositories. Those dependent on morphine may prefer to inject the drug as it provides a more rapid onset of effects than taking it orally.

Morphine typically remains active in the bloodstream for 4-6 hours, and dependence can develop rapidly. The Global Information Network about Drugs (GINAD) reports that between 1990 and 2010, the US consumed over half of the world’s morphine, and an estimated 10 percent of Americans have abused an opioid drug (including morphine) at least one time in their lives. Many synthetic and semisynthetic narcotics are derived from morphine.

Another Schedule II narcotic opioid, hydromorphone available as an injectable solution, an oral solution, and as both immediate release and controlled release tabs. According to the DEA, there were close to 4 million prescriptions dispensed for hydromorphone products.

Though indispensable as a powerful agent for pain control in hospitals and other clinical settings, hydromorphone is commonly diverted after being obtained through “doctor shopping,” forged prescriptions, questionable prescribers, and pharmacy and nursing home theft. When misused, people may attempt to smoke, snort, or inject the crushed tablets. It is a semi-synthetic opioid derived from morphine that is very potent, highly addictive, and has a high potential for overdose when abused. The Drug Abuse Warning Network estimated that, in 2011, nearly 20,000 people received care in an emergency department (ED) for the misuse of hydromorphone.

Fentanyl (Actiq, Fentora, Duragesic, Subsys, Abstral, and Lazanda)

Fentanyl is prescribed to treat chronic and severe pain in those who are tolerant to opioids. Fentanyl is a Schedule II drug that is 50-100 times more potent than morphine.

Overdose rates for synthetic opioids (including drugs like fentanyl) increased 100 percent between 2015 and 2016. Fentanyl was involved in nearly 3,000 overdose deaths in the second half of 2016. Given the startling prevalence of fentanyl overdoses throughout the country, numerous warnings regarding the danger of this drug have been issued.

The DEA reports that 6.5 million prescriptions for fentanyl were dispensed in 2015. Fentanyl is available as lozenges, sublingual tablets, buccal tablets, as well as metered nasal and sublingual sprays. It may be abused by freezing and cutting up the patches to suck or chew on them, or by scraping the gel off for injecting or oral ingestion.

The drug is capable of eliciting an intense and rapid rush of euphoria, making it extremely addictive. Due to its small molecular size, fentanyl is able to be absorbed through the skin on contact and can be lethal in relatively small doses due to its potent effects.

When extracted from the opium poppy, codeine can be used to directly manufacture pharmaceutical formulations for prescription use. However, much of the codeine used for medicinal use is actually manufactured using a synthetic process that relies on morphine as a chemical building block. In the United States, codeine is only available in generic form or in combination products, such as Tylenol with codeine (e.g., Tylenol 3).

Around 10,000 people received emergency care for misusing codeine in 2011, according to the DAWN report. It is generally thought to be less addictive and habit-forming than more potent narcotics; however, it still carries a risk for abuse, dependence, addiction, and overdose.

Methadone (Dolophine and Methadose)

Methadone is one of the longer acting opioid agonists, staying active in the bloodstream for close to a full day, meaning that it can be prescribed in lower doses less often in order to keep opioid withdrawal symptoms at bay. Methadone is still an opioid agonist drug though; therefore, it does have the potential to be abused and also lead to the development of physical dependence and addiction. More than 66,000 people were treated in EDs for the misuse of methadone in 2011, per the DAWN report. It is also one of the most common drugs found in prescription opioid overdose fatalities.

Meperidine (Demerol)

Even when taking Demerol as directed and with a necessary prescription, a person can become dependent on it and suffer withdrawal symptoms when the drug wears off. When physical dependence becomes significantly severe, it can become difficult to stop taking Demerol, which may lead to continued, compulsive misuse and addiction.

Meperidine may be prescribed as a tablet or syrup. In cases of significant physiological dependence, people may benefit from a slow tapering and other medical detox interventions to avoid severe withdrawal at the start of the recovery period.

Opana is a powerful painkiller for the treatment of severe pain. It is usually prescribed when alternative treatments are ineffective or when a person is already tolerant to other opioids. It is roughly twice as powerful as OxyContin, and its maker, Endo Pharmaceuticals, reported nearly $400 million in sales in 2011.

In 2010, OxyContin was reformulated to make it more difficult to misuse, and this change may have actually opened the door to the abuse of Opana. At the time, the extended-release tablet form of Opana (now discontinued) could be crushed and then snorted or injected for an intense high. In 2012, Opana was itself reformulated to deter abuse. While the new coating did decrease the rate of intranasal abuse of Opana, it is still possible to crush and inject the drug. Repeated oxymorphone use can easily lead to physical dependence, and it is extremely addictive.

Tramadol (Ultram, Ultracet, and Ryzolt)

Tramadol has generally been considered to have a relatively low abuse and dependence potential, the Primary Care Companion to the Journal of Clinical Psychiatry reports; however, the DEA classified tramadol as a controlled substance in 2014, as over 3 million Americans were reported to have abused it in their lifetime by the year 2012. Tramadol is most often abused by people who are opioid-dependent already, by healthcare providers, and by chronic pain sufferers. While it may be less addictive than other opioid narcotic drugs, it still may lead to physical dependence and addiction, especially when misused.

Carfentanil

A fentanyl analog, carfentanil is a powerful opioid narcotic developed for use in veterinary medicine as a general anesthetic for large animals. This so-called “elephant tranquilizer” is roughly 100 times more potent than fentanyl, 5,000 times more potent than heroin, and as much as 10,000 times more potent than morphine, the DEA warned in a 2016 alert to the public and police in response to the increasingly common presence of carfentanil in illicit drug samples.

The drug is often encountered in a form that may resemble powdered heroin or cocaine, but it is much more dangerous and may be lethal in exceedingly small doses. It may be being added to heroin, used to “cut” or stretch the drug, or passed off as a different drug. In addition to having a very high potential for fatal overdose, it is also highly addictive.

Buprenorphine

Buprenorphine is a partial opioid agonist used as an analgesic as well as an FDA-approved treatment medication for opioid dependence. It is available in different forms under brand names such as Buprenex, Butrans, and Probuphine. In combination with the opioid antagonist drug naloxone, buprenorphine is available as Suboxone, Zubsolv, and Bunavail.

In 2012, more than 9 million buprenorphine prescriptions were dispensed in the United States. Though widely used as a treatment medication for managing opioid dependence, it may still be abused and has some dependence liability of its own.

The introduction of naloxone in combination products was made to deter some of the inherent abuse potential or buprenorphine, as naloxone is an opioid antagonist drug. The naloxone component is poorly absorbed when used orally, allowing the buprenorphine component to remain active when taken as directed for therapeutic use. However, when buprenorphine combination products are intentionally misused via injection routes, the naloxone effectively blocks some of the opioid effects, and can furthermore precipitate the immediate onset of uncomfortable opioid withdrawal symptoms.

Despite the progress made with the safeguards of the combination products, some forms of buprenorphine are still abused. The DAWN report includes an estimate of more than 20,000 people receiving ED treatment for buprenorphine abuse in 2011.

Signs a Loved One Is Abusing a Narcotic Drug

Narcotic drugs can be incredibly dangerous and have a high risk for potentially life-threatening overdose. More than 42,000 opioid-related deaths were reported in the United States in 2016, amounting to more than 66% of all drug overdose deaths that year. In addition to the undeniable risk of overdose, chronic opioid misuse can lead you or a loved one toward a compulsive cycle of physical dependence, withdrawal, and other opioid addiction associated health effects.

Early intervention is key, as overdose is preventable, and opioid addiction is treatable. There are several things to watch out for when abuse of a narcotic is suspected, such as:

• Mood swings
• Erratic sleep patterns
• Changes in appetite and weight
• Slurred speech, uncoordinated movements, euphoria, sedation, shallow breathing, face flushing, pinpoint pupils, droopy eyes, itching of the arms, calmness, and dry mouth, which can all indicate opioid intoxication
• Unexplained medication bottles or pills
• Presence of drug paraphernalia
• Withdrawal from friends and family
• Increased secrecy and time spent online in drug forums or chat rooms
• Lack of interest in recreational and other activities that were once a priority
• Financial strain
• Potential legal and/or criminal entanglements
• Trying to get prescription refills when they are not needed or early

• Taking more pills at a time than prescribed
• Going to multiple doctors, or “doctor shopping,” for additional prescriptions
• Altering medications (e.g., chewing or crushing them)
• Asking friends and peers for their medications
• Increased pain sensitivity
• Lack of motivation
• Difficulties concentrating and issues with short-term memory functions
• Decline in personal hygiene and care over personal appearance
• Drop in work/school attendance and production
• Inattention to normal obligations
• Tolerance and taking more medication to feel its effects
• Drug dependence and withdrawal symptoms that are physically similar to the flu and that emotionally include depression, anxiety, insomnia, irritability, and drug cravings

Narcotic drug abuse and addiction are treatable with behavioral therapies, counseling services, medications, detox services, and supportive care. There are many different forms of treatment available to choose from; the key is to reach out for help as soon as possible.