When is it NOT okay to fill for the monthly ADHD prescriptions?

[swatchgirl]

Patients are usually in their early to mid-twenties, comes to one single pharmacy for a count of 30 or 60 pills a month (they typically fill for generic Adderall, Vyvance, Focalin, etc.)... "regular customers" in the purest sense. The diagnosis is of course, ADHD. Most of these patients pay with insurance, a few pay with cash, and most are never early, so they always come and fill right on time.

Should these prescriptions always be filled without ever questioning the doctors, since the prescriptions are likely legitimate?

Harmful side effects aside, how many of these kids are selling these pills all over their campuses? And as long as the doctor writes for them, we are supposed to continue to fill them?

What is the definition of a "legitimate" script? Could someone please clarify?

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[zelman]

If dose seems appropriate and there are no issues on any PMP you can access, just use the DEA's list of red flags as a guide. It gets tricky when they're on vyvanse 140mg or adderall 150mg, but at normal doses, don't question the diagnosis. That's outside your area of expertise.


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[lane one]

Patients are usually in their early to mid-twenties, comes to one single pharmacy for a count of 30 or 60 pills a month (they typically fill for generic Adderall, Vyvance, Focalin, etc.)... "regular customers" in the purest sense. The diagnosis is of course, ADHD. Most of these patients pay with insurance, a few pay with cash, and most are never early, so they always come and fill right on time.

Should these prescriptions always be filled without ever questioning the doctors, since the prescriptions are likely legitimate?

Harmful side effects aside, how many of these kids are selling these pills all over their campuses? And as long as the doctor writes for them, we are supposed to continue to fill them?

What is the definition of a "legitimate" script? Could someone please clarify?

New grad I'm assuming? Here's what you need to do: Dose correct? Script valid? Not early? Verify it. Forget what they taught you in school. Some people will go on taking ADHD meds forever and ever because they like them. You can call the doc and express your opinion, but its his patient and you know nothing about their visits. Carrying a predisposition that college kids are not using these meds appropriately and selling them to all their friends will not serve you well in retail pharmacy.

 

[swatchgirl]

New grad I'm assuming? Here's what you need to do: Dose correct? Script valid? Not early? Verify it. Forget what they taught you in school. Some people will go on taking ADHD meds forever and ever because they like them. You can call the doc and express your opinion, but its his patient and you know nothing about their visits. Carrying a predisposition that college kids are not using these meds appropriately and selling them to all their friends will not serve you well in retail pharmacy.

My pharmacist manager also said the same thing, and he claims that he will fill these scripts. I get the feeling that the DEA doesn't really care when it comes to ADHD meds, as long as the quantity and dosages are reasonable?

 

[ldiot]

If it's a normal dose and not early there's really no reason to refuse it. You could always use your state reporting system to make sure they aren't using multiple doctors/pharmacies but I don't see any reason to be calling the doctor on these.

Now if you have a certain doctor handing out adderall to every patient he sees like it's candy then sure I would bring this up with my partner.

People are selling them but you'll never know who and there's nothing you can do about it. Just don't fill them early.

 

[zelman]

My pharmacist manager also said the same thing, and he claims that he will fill these scripts. I get the feeling that the DEA doesn't really care when it comes to ADHD meds, as long as the quantity and dosages are reasonable?

The DEA doesn't care about pharmacists who aren't actively scheming to divert drugs until they want to make an example out of someone. Then anyone can have their life destroyed.

 

[RxPreceptor]

If they happen to sell on the side versus being compliant, it's his/her own damn fault when getting busted. You can not control everything in pharmacy. Just have faith in karma in that these dinguses will get what they deserve...eventually

 

[Dr Wario]

Most ADHD scripts are probably fine but my area has had a massive influx of a few local prescribers writing them around the clock along with benzos around the clock. I recently had a 4 hour interview with corporate about our dispensing (mostly bzds but they were also looking heavily into amphetamines) where they pulled 80 scripts and checked into them. The investigators found no scripts that they recommended I not fill as all were from local doctors, regular customers but they had a growing concern about combinations/doses that local doctors were writing.

I am very curious if anyone else has seen this phenomenon where people are getting xanax 1-2mg tid + adderall 10-30mg tid and how you typically handle it. After our interview, I called all the local doctors and told them that our store will have to move away from dispensing this combination and doses need to come down. This is not a personal judgement on their prescribing practices, it is simply a matter of reality in that the DEA is starting to look more heavily at benzos and amphetamines.

Do any psyche doctors want to weigh into this and give clinical justification for giving a stimulant and sedative at the same time? I have no issue with giving a sedative at night to help people sleep when on stimulants during the day, but giving them at the exact same time appears counter-productive to me and seems like a red flag for diversion/abuse.

 

[doublehh03]

Most ADHD scripts are probably fine but my area has had a massive influx of a few local prescribers writing them around the clock along with benzos around the clock. I recently had a 4 hour interview with corporate about our dispensing (mostly bzds but they were also looking heavily into amphetamines) where they pulled 80 scripts and checked into them. The investigators found no scripts that they recommended I not fill as all were from local doctors, regular customers but they had a growing concern about combinations/doses that local doctors were writing.

I am very curious if anyone else has seen this phenomenon where people are getting xanax 1-2mg tid + adderall 10-30mg tid and how you typically handle it. After our interview, I called all the local doctors and told them that our store will have to move away from dispensing this combination and doses need to come down. This is not a personal judgement on their prescribing practices, it is simply a matter of reality in that the DEA is starting to look more heavily at benzos and amphetamines.

Do any psyche doctors want to weigh into this and give clinical justification for giving a stimulant and sedative at the same time? I have no issue with giving a sedative at night to help people sleep when on stimulants during the day, but giving them at the exact same time appears counter-productive to me and seems like a red flag for diversion/abuse.

My friend's store had the same talk with corporate b/c her store was filling a lot of narcotics. They were asking her if she knew how to decline customers b/c a lot they were suspicious of, unlike your case.

To your other point, I would discuss with the doctors about tapering the BZD dose and add another anti-anxiety med like bupsar, hydroxyzine...). I do fill a few scripts from some psych doctors that combine stimulants + but low dose BZD as a sleep aid but adding a non-BZD anxiolytic.

 

[Drugsarefun2350]

Do any of you guys have any success when suggesting therapy changes to the doctors? Blows my mind that this is our job now because boards of medicine won't police their own

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[Sine Cura]

One time I got a prescriber to stop writing for Norco 10/325 #180 and Percocet 10/325 #180 (increased long-acting opioid dose).

Most of the time they make B.S. excuses ("they will re-evaluate next month) or they tell you to GTFO.

Performance evaluations generally don't account for how aggressively you practice "corresponding responsibility" so this is why people come up with tactics like no early refills or blanket refusals or quantity limits or not filling holy trinities, period, and then use the excuse "I am exercising my professional judgment not to fill these scripts." It's too much work to police ****ty prescribers.

It helps if you work for a chain that tells you straight up you can't fill X Y and/or Z

 

[Drugsarefun2350]

One time I got a prescriber to stop writing for Norco 10/325 #180 and Percocet 10/325 #180 (increased long-acting opioid dose).

Most of the time they make B.S. excuses ("they will re-evaluate next month) or they tell you to GTFO.

Performance evaluations generally don't account for how aggressively you practice "corresponding responsibility" so this is why people come up with tactics like no early refills or blanket refusals or quantity limits or not filling holy trinities, period, and then use the excuse "I am exercising my professional judgment not to fill these scripts." It's too much work to police ****ty prescribers.

It helps if you work for a chain that tells you straight up you can't fill X Y and/or Z

I completely agree, way too much work to police it, my store does a pretty decent amount of narcotics, I'd be so behind everyday if I went digging into each of these rxs, lot of shady prescribers in my area of florida, but the Florida board passed a law last year making pharmacists jump through hoops before we can refuse to fill rx

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[knight on horse]

Do any psyche doctors want to weigh into this and give clinical justification for giving a stimulant and sedative at the same time? I have no issue with giving a sedative at night to help people sleep when on stimulants during the day, but giving them at the exact same time appears counter-productive to me and seems like a red flag for diversion/abuse.

Theoretically it will be good for social anxiety and evidently that is indeed the case

The dopamine improves mood, energy, and action, sustains attention and activity, while the sedative tamps down on ideation, anxiety and excitability

Dopamine, like testosterone, will increase combativeness, arrogance, aggression, and determination, and, when beyond the limits of the brain to handle, dopamine furthermore can result in paranoia and psychosis. We wouldn't want our heretofore meek lambs now flush and happy with dopamine and ready to socialize becoming insufferable anxious and angry psychotics as well, being unused to handling the dopamine levels, thereby ruining their jaunts and landing them in the asylum

 

[Dr Wario]

Do any of you guys have any success when suggesting therapy changes to the doctors? Blows my mind that this is our job now because boards of medicine won't police their own

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I agree with this 100%, one office asked me what gives me to right to ask for a diagnosis when their almighty Doctor ordained this sacred prescription. I responded that since prescribers were not able to police themselves, the DEA has charged us pharmacists to do it for you, thanks for that.

 

[ldiot]

Theoretically it will be good for social anxiety and evidently that is indeed the case

The dopamine improves mood, energy, and action, sustains attention and activity, while the sedative tamps down on ideation, anxiety and excitability

Dopamine, like testosterone, will increase combativeness, arrogance, aggression, and determination, and, when beyond the limits of the brain to handle, dopamine furthermore can result in paranoia and psychosis. We wouldn't want our heretofore meek lambs now flush and happy with dopamine and ready to socialize becoming insufferable anxious and angry psychotics as well, being unused to handling the dopamine levels, thereby ruining their jaunts and landing them in the asylum

Whether or not amphetamines are involved should Xanax really be used long term for mild/moderate social anxiety to begin with? Panic disorder is one thing but social anxiety? Give me a break...

If Adderall is making the patient psychotic how about we simply adjust the dose..?

I still see no justification for this combo unless maybe the benzo is at bedtime for sleep but it's always TID/QID and I still wouldn't go to Xanax as a first option for sleep.

 

[ldiot]

I agree with this 100%, one office asked me what gives me to right to ask for a diagnosis when their almighty Doctor ordained this sacred prescription. I responded that since prescribers were not able to police themselves, the DEA has charged us pharmacists to do it for you, thanks for that.

I get the same response and all I'm trying to do is bill part B for God's sake. Some of these idiots are clueless. And to be fair billing Medicare is also a joke; their idea of preventing waste/fraud/abuse is burying you in bogus paperwork so they can chargeback legitimate claims over technicalities.

 

[Wickett]

My pharmacist manager also said the same thing, and he claims that he will fill these scripts. I get the feeling that the DEA doesn't really care when it comes to ADHD meds, as long as the quantity and dosages are reasonable?

Unless there is a legitimate reason staring at you saying not to fill, you fill. If the dosing is in normal parameters, the patient shows no history of early fills/"losing meds"/"vacations" needing early fills, there are no crazy combos/duplications/other controlled meds inappropriately prescribed together, a DPS search shows no doc shopping or filling multiple scripts of the same med, controls aren't scattered amongst several doctors, etc., don't sweat it. I am a new grad and I get the anxiety, especially considering how school puts the fear of god in us about the DEA bringing the hammer down on us if we fill a script that gets used for illegitimate purposes. You will have much more trouble if you deny controls just because someone looks "shady" than if you fill if there are no red flags seen. You should have an innocent until proven guilty mentality on controls, not prove to me you are innocent.

Do not fill a CII that has an obvious red flag and don't display a pattern of crazy control filling and you will be ok. My current manager is pretty lax on his control filling, and he has 0 marks on his record after 45 years (when I started, I saw he only checked the DPS database 3x this year). The key is not filling controls in general too early/keeping track of when people get refills. I honestly dread my tramadol and benzo patients more than I do my C2 regulars, along with tracking appropriate refill times on controls. Everyone on tramadol goes on vacation 3 weeks after they pick up their med.

I have friendly debates/pick the brain of my current PIC about refilling controls early all the time (he does 3 days early on controls, even if they fill early for every single fill which adds up....I like limiting a 5 refill Rx to a week max total early filling, but he thinks I am being too hardassed about it. Just figure out what works for you. Better to lose your job than to lose your license because you listened to your manager.

 

[zelman]

"Innocent until proven guilty" only works when you have the power to get proof. You do not. You cannot suopena medical records. You cannot compel a urine screen. You can't interview a prescriber face to face. You can't even prove that the name on the prescription is a real person.

It should be more like, "Innocent until one red flag. Probably trouble at two red flags. Too much trouble at three."

 

[Dr Wario]

"innocent until proven guilty" only works when you have not had a four hour long interview with company lawyers and your regional LP manager where they dug through your records and found zero red flags yet still tell you that you are filling too many controls.

 

[RxPreceptor]

But the real point of a "scheduled" dose BZD + amphetamine combo is just wheel spinning & overprescribing. I genuinely feel some doctors don't give a **** say about doing something reasonable like titrating the dose of the stimulant or anxiolytics/sedative hypnotic before trying to antagonize (to some degree) the effects of the initial agent. Alprazolam being BZD of choice because alphabetically it's the first BZD (sarcasm), rather than say a less hepatic/accumulative BZD like lorazepam or temazepam

 

[Digsbe]

If dose seems appropriate and there are no issues on any PMP you can access, just use the DEA's list of red flags as a guide. It gets tricky when they're on vyvanse 140mg or adderall 150mg, but at normal doses, don't question the diagnosis. That's outside your area of expertise.


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In my state we are supposed to. It's specifically against the law to prescribe and dispense stimulants for weight loss or to be abused (like for academic performance). A pharmacist that negligently fills them can be in deep trouble. One whole staple regarding pharmacotherapy is making sure the drug is indicated and being prescribed ethically and properly.

 

[knight on horse]

Whether or not amphetamines are involved should Xanax really be used long term for mild/moderate social anxiety to begin with? Panic disorder is one thing but social anxiety? Give me a break...

Didn't say it was FDA approved

If Adderall is making the patient psychotic how about we simply adjust the dose..?

I thought it was funny

But you don't have to be psychotic to have an unpleasant experience with high dopamine.

That being said, the proper way to look at it is more dopamine = always good until psychosis. They may well have legitimate reasons to be upset at life that their high dopamine state now empowers them to act upon

Btw properly arrogance is the province of testosterone. In my amused enthusiasm to list traits i glommed it over. Yes dopamine will increases overall combativeness, but it is from testosterone that comes pure spiritual arrogance

I still see no justification for this combo unless maybe the benzo is at bedtime for sleep but it's always TID/QID and I still wouldn't go to Xanax as a first option for sleep.

You don't see any justification, they seem to enjoy it just fine. The FDA has an opinion as well

 

[knight on horse]

What irks me, is when a prescriber writes for both a dopaminergic and an anti dopaminergic medication at the same time. Particularly when they are a PA or NP.

But who knows, with the varied receptor subtypes and different effects and the individual organization of each brain, maybe they're onto something that works for the unfortunate patient. But a red flag

 

[radio frequency]

What irks me, is when a prescriber writes for both a dopaminergic and an anti dopaminergic medication at the same time. Particularly when they are a PA or NP.

But who knows, with the varied receptor subtypes and different effects and the individual organization of each brain, maybe they're onto something that works for the unfortunate patient. But a red flag

Like the patients on antipsychotics who also get their daily Adderall? That is always super questionable. We seem to have tons of psych NPs where I live and I see these combos from time to time from the private offices.

 

[PikminOC]

If dose seems appropriate and there are no issues on any PMP you can access, just use the DEA's list of red flags as a guide. It gets tricky when they're on vyvanse 140mg or adderall 150mg, but at normal doses, don't question the diagnosis. That's outside your area of expertise.


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What references do pharmacists use for dosing of stimulants within normal range?
Thanks

 

[PikminOC]

Do you feel it is ever appropriate to prescribe a benzodiazepine and stimulant together? When?

 

[swatchgirl]

lot of shady prescribers in my area of florida, but the Florida board passed a law last year making pharmacists jump through hoops before we can refuse to fill rx

I came across an article about that. "Pharmacy Crawl" is the new term for it, now? That's what I was confused about as well. If one of the red flags is "pharmacy hopping", or "pharmacy shopping" where the patient has many different pharmacies on their filling history, it might not necessarily be a red flag then, but is actually an artifact created by pharmacies erroneously turning the patient away, thereby forcing the patient to pharmacy-hop.

And if doctors are feeling the same pressure from the DEA, they might refuse to prescribe and force patients into doctor shopping, where several doctors are responsible for writing a patient's scripts for the same pain medication... a "red flag" that is also just another artifact created by doctors who turn the patient away erroneously due to fear of losing their license. What a mess the current states of pharmacy and medicine are in, thanks to the few bad apples that are out there (pill mill doctors, drug addicts, corrupt pharmacists, etc)... and the DEA's over-simplified ideology that pharmacists should serve as undercover gate keepers for drug abuse.

http://www.abcactionnews.com/money/...s-turning-away-thousands-of-patients-in-error

http://www.wsj.com/articles/SB10000872396390443720204578004873138298306

 

[catalyzt]

What references do pharmacists use for dosing of stimulants within normal range?
Thanks

For ADHD meds? Package insert.

 

[PikminOC]

Do you think psychiatrists may get the more complex cases that pcps can't handle and may get to higher doses like adderall 30 bid for adhd adult?

 

[catalyzt]

Do you think psychiatrists may get the more complex cases that pcps can't handle and may get to higher doses like adderall 30 bid for adhd adult?

Yes. It's not that common in my area to see it, but I do see it occasionally and my go-to in this scenario is PubMed and the latest treatment guidelines. Usually these resolve my questions if I have any about filling the prescription. I also take into account if the patient has been coming to my pharmacy on a monthly basis so I can see his/her dosing/frequency/medication history.

 

[zelman]

In my state we are supposed to. It's specifically against the law to prescribe and dispense stimulants for weight loss or to be abused (like for academic performance). A pharmacist that negligently fills them can be in deep trouble. One whole staple regarding pharmacotherapy is making sure the drug is indicated and being prescribed ethically and properly.

What I mean is a pharmacist shouldn't waste time going "hmmm this person doesn't seem to have adhd. Let me administer a battery of tests and scales to verify the accuracy of the diagnosis."

 

[PikminOC]

Do any of you guys have any success when suggesting therapy changes to the doctors? Blows my mind that this is our job now because boards of medicine won't police their own

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How would you like the medical board to police it?

 

[PikminOC]

Yes. It's not that common in my area to see it, but I do see it occasionally and my go-to in this scenario is PubMed and the latest treatment guidelines. Usually these resolve my questions if I have any about filling the prescription. I also take into account if the patient has been coming to my pharmacy on a monthly basis so I can see his/her dosing/frequency/medication history.

Have you seen pub medical articles to back this? I looked today and couldn't find them. Please post.

And btw, thanks you all for answers to my questions. I know you guys have a hard job and I like to be able to bridge the gap between us.

 

[zelman]

Do you think psychiatrists may get the more complex cases that pcps can't handle and may get to higher doses like adderall 30 bid for adhd adult?

That's a far cry from the 150 mg daily I gave as an example.

 

[catalyzt]

Have you seen pub medical articles to back this? I looked today and couldn't find them. Please post.

And btw, thanks you all for answers to my questions. I know you guys have a hard job and I like to be able to bridge the gap between us.

I usually look at the pre-phase IV clinical studies of the drug in question as well as published case studies involving a similar scenario and/or that particular drug. As far as a published review article on off-label dosing of stimulant medications goes, I haven't seen one but I only tend to search when I get one of those prescriptions.

Thanks for having an interest in being an active reader of this board. I personally really like it when I read comments from physicians. I really appreciate getting their insight on some of the topics that are discussed here.

 

[PikminOC]

I don't know how to get those articles that you are talking about. Those must be secretive pharmacist files? How do I get those?

 

[catalyzt]

I usually look at the pre-phase IV clinical studies of the drug in question as well as published case studies involving a similar scenario and/or that particular drug. As far as a published review article on off-label dosing of stimulant medications goes, I haven't seen one but I only tend to search when I get one of those prescriptions.

Thanks for having an interest in being an active reader of this board. I personally really like it when I read comments from physicians. I really appreciate getting their insight on some of the topics that are discussed here.

I did a quick search and found the following small study involving mixed amphetamine salts dosing titrated up to 30 mg b.i.d. at week 3 showing efficacy with few adverse effects:

Spencer T, Biederman J, et al. Efficacy of a mixed amphetamine salts compound in adults with attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 2001;58(8):775-782. doi:10.1001/archpsyc.58.8.775.

I didn't search more after finding this one, but maybe it helps.

 

[catalyzt]

I don't know how to get those articles that you are talking about. Those must be secretive pharmacist files? How do I get those?

Google Scholar (scholar.google.com) is your friend. Also, doing pub med searches like this all day long for GSK for 3 months probably helps me, too.

 

[PikminOC]

Thanks!

 

[PikminOC]

Any evidence regarding using benzodiazepine and stimulant together?

 

[radio frequency]

Do you think psychiatrists may get the more complex cases that pcps can't handle and may get to higher doses like adderall 30 bid for adhd adult?

Yes -- but 30 mg BID wouldn't make me bat an eye. I do have a middle-aged patient on 120 mg of generic Adderall per day for ADHD. It's not my favorite choice due to the risks of psychosis at high doses, but after talking with the patient, they've been on this high dose for many years now successfully and don't have any mental health history. I frankly wonder if they might handle a lower dose just as well with fewer side effects, but I assume that has been tried. They work a high stress job and don't outwardly show any signs of abuse, and their fill history is very clean. In their case I assume all else has been tried and fill as written. If they had any red flags (multiple prescribers, multiple controls, especially "uppers" and "downers", etc) I'd be more cautious and possibly not fill, depending on circumstance.

 

[PikminOC]

Uppers and downers like adderall and benzos?

 

[RxPreceptor]

I really wish doctors would look at MAX doses & MAX effective doses for ADHD Tx...max efficacious is lower than 1 would see often Rx'ed in practice. Lexicomp

 

[PikminOC]

I really wish doctors would look at MAX doses & MAX effective doses for ADHD Tx...max efficacious is lower than 1 would see often Rx'ed in practice. Lexicomp

We do look at that. As Psychiatrists, we get more complex cases.

And giga, thank you for your post. I have people on SSRIs at max dose too but with breakthrough anxiety who benefit from low dose benzos.

 

[radio frequency]

Uppers and downers like adderall and benzos?

Possibly, depending on dosing -- but I also look at opioids, etc. Basically, does this patient look like they are possibly diverting/selling/not actually using this for medical purposes? Those are always difficult questions and there sometimes aren't clear answers, but talking with the patient and sometimes the prescriber can sometimes explain situations. Of course I'm concerned about appropriateness of treatment too, but that can be hard to assess in outpatient pharmacy when patients have a complex mental health history. I concur with giga's post as well.

 

[Drugsarefun2350]

How would you like the medical board to police it?

Possibly mandating that before any controlled substance is rx'd the doctor has to check PDMP (I believe state of new york does this, someone correct me if I'm wrong). Just caught a guy yesterday who's filled 14 months of xanax 2mg this year alone. Was using different pharmacies but all from the same doctor. I called the doctor and the nurse says "this is why i like xyz pharmacy because you guys are so good at catching this". I wanted to be like, uh you can check this database too you know. Few months ago had an rx faxed to me for valium. in the special comments it says "please make sure patient is not getting from multiple doctors". Check PDMP, what do you know, pt is getting from multiple doctors.

As far as improper prescribing goes, I think harsher punishments and more frequent monitoring of physicians prescribing would maybe curb overprescribing. I've read a lot of the disciplinary records for physicians here in Florida and a lot of the time they just get a fine and a mandate to take some CE hours regarding ethics and proper prescribing. It also takes on average I believe around a year and a half for the board to actually do something from when they receive a complaint. You can put a lot of drugs in the community in a year and a half.

 

[radio frequency]

I've read a lot of the disciplinary records for physicians here in Florida and a lot of the time they just get a fine and a mandate to take some CE hours regarding ethics and proper prescribing. It also takes on average I believe around a year and a half for the board to actually do something from when they receive a complaint. You can put a lot of drugs in the community in a year and a half.

...I feel like every time I get a patient transfer from Florida, their controlled substances are an absolute train wreck. Seems to be a lot more inappropriate prescribing down there.

 

[Drugsarefun2350]

...I feel like every time I get a patient transfer from Florida, their controlled substances are an absolute train wreck. Seems to be a lot more inappropriate prescribing down there.

I've only been a pharmacist for 2 years, the sad part is I heard it used to be a lot worse

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[owlegrad]

...I feel like every time I get a patient transfer from Florida, their controlled substances are an absolute train wreck. Seems to be a lot more inappropriate prescribing down there.

I can't even tell you how many patients I have seen on multiple benzos, multiple opioids, benzo+stimulant, and least we forget the holy trinity. It's crazy.

 

[radio frequency]

I can't even tell you how many patients I have seen on multiple benzos, multiple opioids, benzo+stimulant, and least we forget the holy trinity. It's crazy.

Not in Florida, but I've also seen some messed up prescribing locally. I feel like it's often from doctors or NPs who just don't have the backbone to tell pushy patients "no" or "that's not a good idea." Weirdly, I hardly ever see "bad" prescribing of controls from PAs.

With prodding over many months, I finally got an NP to change a patient's prescriptions from including scheduled tramadol and hydrocodone/APAP and "PRN" oxycodone (in quotations because the patient clearly took it four times daily, not four times daily as needed) to just tramadol and hydrocodone/APAP (possibly still questionable but maybe less so now?). The NP also prescribed this patient guaifenesin/codeine. As though the oxycodone and the hydrocodone had no antitussive effects....