Table 1. Drug Schedules I-V Established by the Controlled Substances Act
Schedule
Risk Level
Medical Use Status
Prescriptions
Refills allowed
Examples
I
Highest risk for SUD and misuse
No currently accepted medical use
No
N/A
Heroin LSD Mescaline MDMA Methaqualone Marijuana Amphetamine
Lack of accepted safety for medical use
II
High potential for SUD and misuse (less than Schedule I)
Currently accepted medical use
Paper
No*
Electronically transmitted with strict requirements Phone only in emergencies with written prescription to follow within 7 days
Opioids: Codeine Fentanyl Hydrocodone Hydromorphone Meperidine Morphine Methadone Opium Oxycodone
Methylphenidate Pentobarbital ACET with codeine
III
Less potential for SUD and misuse than Schedules I or II
Currently accepted medical use
Paper
Up to 5 refills within 6 months
Electronically transmitted
Anabolic steroids
Phone, fax
Buprenorphine
Ketamine
IV
Low potential for SUD and misuse relative to Schedule III**
Currently accepted medical use
Paper
Up to 5 refills within 6 months
Benzodiazepines: Alprazolam Clonazepam Diazepam
Electronically transmitted
Phone, fax
Lorazepam Midazolam Temazepam Triazolam
Carisoprodol
V
Low potential for SUD and misuse relative to Schedule IV
Currently accepted medical use
Paper
No limits, except partial refills must occur within 6 months of issue date
Cough preparations with codeine
Electronically transmitted
Ezogabine
Phone, fax
SUD = Substance-use disorder LSD = Lysergic acid diethylamide MDMA = Methylenedioxymethamphetamine ACET = Acetaminophen *See exceptions under “Federal Restrictions Regarding Refills” **Benzodiazepines carry risks of substance dependence and respiratory depression, particularly in combination with other substances that also depress respiration. 21,22
These drugs, which include alprazolam, diazepam, and lorazepam, are frequently mentioned in overdose statistics involving opioids, and expert guidance urges caution in their use and taper and particularly discourages the combination with opioids unless deemed necessary. 13,20,21 Schedule V contains drugs with limited quantities of opioids that include cough preparations, containing no more than 200 milligrams of codeine per 100 milliliters or per 100 grams. Although this lower schedule has less misuse danger relative to other schedules, patients prescribed any CS still must be managed with care.
Part of the role of the DEA is to ensure medications are not diverted for misuse. Table 2 contains common terms associated with the use and misuse of opioids and other prescription drugs that are categorized under CS schedules. 5 The DEA provides manuals for HCPs and other practitioners to keep abreast of federal requirements in implementing the CSA. 22 As of this writing, the DEA Diversion Control Division is currently updating all manuals but did issue an updated pharmacist’s manual as of 2020.
The Purpose of a Prescription in Legitimate Medical Practice The DEA tracks the flow of CS from manufacture to ultimate use and enforces the CSA, including the tenets of lawful prescribing. 12 In order to be legal, a CS prescription must be issued for a legitimate medical purpose in the course of professional practice. 23 In general, this means HCPs must practice in accordance with medical standards recognized and accepted in the United States. 22 The totality of circumstances particular to each HCP and patient must be evaluated on its own merits.
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