In 1971, President Nixon initiated a battle that would reshape the United States: The War on Drugs. As a key part of that campaign, he enacted the Controlled Substances Act (CSA), which authorized the Drug Enforcement Administration (DEA) to categorize modern-day controlled substances into 5 “schedules” based on their “medical use, potential for abuse, and safety or dependence liability.” They range from Schedule I, which are substances with no accepted medical use and the highest risks, to Schedule V, which are relatively low-risk substances with wide medical applications. What began as an attempt to protect American society is now overdue for reform in how we view and regulate drugs. First, the U.S. drug scheduling system fails to meet its own standards of safety and medical use based on our current understanding of these drugs. Second, it creates a cyclic problem that actively hinders research and the development of potentially life-saving treatments. Not only should many of these drugs be scheduled differently, but the “accepted medical use” standard should be eliminated from the CSA.
The U.S. drug schedules are outdated and inconsistent with the current body of research, leading to mismatched risk and benefit profiles, along with a myriad of other problems such as hindering medical research and obstructing innovative treatments. For example, marijuana (a Schedule I drug) has an addiction rate of about 10 percent, meaning that roughly 10 percent of users develop a marijuana use disorder. This is in comparison with cocaine (Schedule II) and benzodiazepines (Schedule IV), which have addiction rates of 20 percent and 44 percent respectively. Psychedelics, many of which are Schedule I (e.g., LSD, psilocybin, peyote), are not even classified as addictive because they have little to no dependence liability. Additionally, when examining safety, psychedelics have an extremely low mortality rate, with the rare fatalities often associated with polydrug use. Marijuana (Schedule I) also has a relatively low isolated mortality rate of 4 percent, rising to 18 percent when combined with other substances. In contrast with Schedule II drugs like fentanyl, which contributed to over 70 percent of drug overdose deaths in 2022, many Schedule I drugs appear to be much safer with lower mortality risks. Even in contrast with unscheduled substances like alcohol, some Schedule I drugs are seemingly safer and less addictive. Clearly, the current scheduling system fails to align with scientific evidence.
There are inconsistencies regarding medical use as well, where the more clinically relevant substances are sometimes ironically more tightly regulated than their less relevant counterparts. Without sufficient evidence, it is difficult to quantitatively evaluate the degree of clinical applications a certain substance has. However, looking at clinical applications broadly, marijuana has various components (e.g., THC and CBD) that are widely used in clinical settings, such as in treatment of seizures, anorexia, chemotherapy-induced nausea and vomiting, and neuropathic pain. There is also mounting evidence that Schedule I psychedelics, namely psilocybin, have therapeutic potential in treating an array of psychiatric disorders like depression, anxiety, and substance use disorders. This stands in contrast with cocaine (Schedule II), for instance, which is not only more hazardous than marijuana and psychedelics (as established previously), but has relatively limited clinical applications. While these drug schedules were originally influenced by social stigmas rather than rigorous science, current evidence highlights their relative risks much more effectively, making these misclassifications unjustifiable.
Arguably, the greatest downside of these drug scheduling standards is that they ultimately create a vicious cycle that actively impedes research and medical innovation. Higher-scheduled drugs face greater research barriers, with labs often struggling to secure approval for their investigation due to their restricted annual production. This particularly limits research into the potential clinical applications and safety of Schedule I drugs, with the consequence that they remain trapped as Schedule I drugs. How can we begin employing psilocybin-assisted therapy in the clinic, if the very thing hindering its clinical use is the fact that we aren’t using it in the clinic in the first place? While many studies are beginning to highlight psilocybin’s therapeutic efficacy, this process has been relatively slow, and still there is seemingly no federal-level discussion of down-scheduling psilocybin or increasing its availability for research. Prior efforts have also been met with federal resistance, despite the ever-increasing evidence of psilocybin’s therapeutic potential. If Schedule I drug research is made more accessible and efficient, even if it results in a mere modest reduction in psychiatric mortality, this effect will accumulate over time, potentially saving many lives. These research restrictions are also why we still understand little about how psychedelic drugs help patients. Knowing their underlying mechanisms of action could potentially pave the way for novel, even more effective therapeutic strategies, which is unfortunately challenging under the current drug scheduling system.
While President Nixon declared drug abuse “public enemy number one,” the real public enemy is the outdated U.S. drug schedules that are in desperate need of reform. There is no question that the DEA must reform the way that drugs are scheduled, and instate a clear, ongoing process for updating them. Furthermore, by removing the “currently accepted medical use” standard and reclassifying drugs in a way that accurately and objectively reflects the current body of literature, we can leverage these substances to treat medical diseases, while simultaneously restricting public access to protect people from possible harm caused by these drugs. This may not only benefit people suffering from psychiatric illnesses, but it may also mitigate some of the stigma associated with mental health and substance use disorders. We must critically examine the flaws of our drug scheduling system, and advocate for evidence-based legislative changes accordingly. Call your representatives, write to your senators, and spread the word that it’s time to ensure our laws reflect science, not stigma. Tell them it’s time to end needless barriers and unleash a new era of scientific research.
I express my gratitude towards Alexandra Beem and Dr. Mim Ari for kindly editing this op-ed.
Artin Asadipooya is a medical student.
