Even Schedule VI medications can have addictive potential, especially for patients with a history of substance abuse.
While most physicians know that controlled substances are regulated by state and federal law and are broken down into designated "schedules," the purpose and meaning of each schedule can often confuse even the most seasoned clinician.
Federal law categorizes controlled substances into five schedules:
- Schedule I: Illegal drugs such as LSD and heroin
- Schedule II: Drugs with significant addictive potential, including narcotics such as oxycodone and meperidine
- Schedule III: Drugs which have some potential for abuse, such as hydrocodone
- Schedule IV: Drugs which have low potential for abuse but may lead to physical or psychological dependence, including the benzodiazepines
- Schedule V: Drugs that have been determined to have low abuse potential, and have been designated for regulation by individual states or localities, such as buprenorphine
Massachusetts designates an additional category of controlled substances. This sixth category includes all prescription medications that are not already covered in Federal Schedules I – V: Schedule VI: Medications such as penicillin, cimetidine, and even ibuprofen.
Most physicians familiar with the scheduling system view Schedule VI drugs as having little or no addictive potential. However, this is not always the case. Therefore it is important to consider the medication itself — not only its schedule categorization — when prescribing for a patient.
For example, it is necessary to exercise caution when prescribing the drugs tramadol (Ultram) and butalbital with acetaminophen (Fioricet). While tramadol was initially promoted as a low addiction-potential analgesic, there is anecdotal evidence that patients with a history of substance dependence can experience significant addictive symptoms with this drug. Yet these are the very patients who may be receiving this medication simply because it has been categorized as a Schedule VI.
A revised drug insert now includes a warning about the potential for addiction with some patients who use tramadol. However, the schedule has not been revised, and the drug remains a Schedule VI substance. Fioricet contains the same active ingredient (butalbital) as Fiorinal with aspirin, which is a Schedule III controlled substance. However, since Fioricet is a Schedule VI controlled substance, its addictive potential may be overlooked. In addition, physician offices often maintain samples of both Fioricet and tramadol, allowing for easy access to the medication.
While a schedule is certainly an important factor in determining a medication's addictive qualities, it should not be the sole factor.
For additional guidelines on prescribing, contact Physician Health Services at (781) 434-7404.
