MD & DO Doctors creating addicts?

[BestoFriedo-Todo]

Is anyone else concerned about the way SOME doctors are pumping out addictive substances? I've done a few rotations through a lot of clinics now, and MOST doctors are cutting back on prescribing controlled substances. And if they're not trying to cutback on prescribing these medications, then they are monitoring the pt they prescribe the meds to very strictly, with mandatory 3 month follow ups for refills, per our state's guidelines, and 2-4 drug screening yearly.

I have recently come across a PCP office in particular that seems to flat out disregard these guidelines, and hand out these addictive medications to patients like its candy. I'm not in a position to question a doctor. I'm just a lowly med school applicant, but it makes me feel uncomfortable. All the other offices I have been to, including pain management are actively working to fight addiction or managing it very closely, except this office.

For example, these are the refill request that were approved yesterday within a 3 hour time frame.
- 34 year old male - Adderall 30mg and Xanax .5mg. Pt last seen 10 months ago.
- 63 year old female - Ativan. Last seen in January of 2015.
- 32 year old female - Adderall 20mg 3 times a day. Last seen 6 months ago.
- 31 year old female - Adderall 20mg XR and Adderall 10mg last seen 4 months ago.
- 32 year old Male - Oxycodone 15mg for knee pain. Last seen January 2018, but that was his first visit. No pain management or Ortho physician monitoring or treating the issue.
-45 year old female - Adderall 30mg XR
- 89 year old female - Xanax .5mg three times daily.
- 57 year old male - Oxycontin 40mg xr and Oxycodone 15mg. Last seen 12/11/2017. No problem right? He is within the 3 months,right? Problem with him is drove 90 miles past 4 major cities and who knows how many Primary Care offices just to get his meds from this office. That brings up red flags for me. And he is not the only one, there are quite a few who travel grotesque distances to come to this specific office.
-48 year old female - Percocet 5-325, Valium 5mg and Adderall 20mg 3 times daily? At 48 years old?

That was within 3 hours. This PCP office literally provides more controlled substances than routine stuff such as Lisinopril, statins or Metformin. With the way these meds are being pushed out, the opioid crisis comes as no surprise. Then we have this adult ADHD surge. Are these Doctors, really helping? They aren't creating functioning adults or improving their quality of life. They're turning them into addicts, who can't manage without medications that only they prescribe. You wouldn't believe how nasty these patients turn if their doctor is out for 2 -3 days and they can't get their medications.

I'm rotating in primary care cause I have an interest in it, but I have no intention of being apart of pushing drugs like this. They aren't pain management, nor are they psych. Yet they push these meds out as if they specialized in both. I saw a 33 year old women come in and say, "I think I have ADHD". She filled out a 1 page screening form and walked out that office 15 mins later with an Adderall script that she will surely be using for the next 10 plus years of her life. We are located and an area that is dense with overdoses and illegal drug usage, but the legal drug usage through prescriptions should also be an area of concern. The ones prescribing these medications are doctors. So I can't believe they are so obtuse to not see the harm they are doing to their community. Their reviews are great, and I can see why the patients get what they want with little to no medical reasoning backing them.

Am I right to be a bit repelled by this or am I just being judgmental?

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[VA Hopeful Dr]

You are right to be bothered by it, but I would caution against being too judgemental. Wait until you're the primary care doctor seeing all these patients before you rush to Too Much judgment

 

[Atom612]

Currently taking an addiction medicine elective, and the addictionologist gave us the following scenario:

25 y/o female referred to his clinic by a surgeon who was concerned about her post-op analgesic use,

within a 4mo. period in 2001, was prescribed:

• Lortab #40 x 15 refills
• Xanax #20 x 8 refills
• Demerol #15 x 0 refills
• Soma #30 x 4 refills

shortly after, she was prescribed:

• Vicodin #30 x 14 refills
• Darvocet #20 x 3 refills
• Xanax #12 x 4 refills
• Soma #20 x 3 refills

He posed the question to us, is this addiction? Some of the class meekly were nodding their heads yes. He then gave us the following information:

• Lortab and Demerol last used (at the time of her visit) >6mos. ago
• Xanax and Vicodin last used >2 weeks ago
• Darvocet last used 2 days ago

Past surgical history:

• Total abdominal hysterectomy and bilateral salpingoophorectomy (2001)
• Partial small bowel resection (2001)

Past medical history:

• Partial small bowel obstruction
• pelvic endometriosis + adhesions
• pelvic inflammatory disease
• polycystic kidney disease

Allergies:

• NSAIDS d/t renal disease

The patient had two surgical procedures just 4 months apart from each other and opioid analgesics were prescribed before and after both, as they are notoriously very painful procedures. Her current use didn't meet the DSM-V criteria for opioid dependency syndrome.

It is easy to look at a list of medications and automatically saying, "that doesn't look right." But without knowing all of the facts, it's hard to know for certain whether someone is truly abusing their medications or not. It is better to reserve judgement unless you intimately know the reasoning that went into prescribing the drugs in the first place.

 

[Snoopy2006]

While I don't discount opioid addiction as an issue and I'm sure there are a minority of unscrupulous physicians out there, I think it's hard to have a full understanding of various clinical scenarios early on in your medical student career. The vast majority of physicians are taking care to address addiction issues and treat their patients, but responsibly.

 

[WingedOx]

While I don't discount opioid addiction as an issue and I'm sure there are a minority of unscrupulous physicians out there, I think it's hard to have a full understanding of various clinical scenarios early on in your medical student career. The vast majority of physicians are taking care to address addiction issues and treat their patients, but responsibly.

Still, it is a problem, and a serious one. My overly rigid opinion at this point is that PCPs shouldn't even be touching xanax, even in cases where mental health prescribers aren't readily available. It's not even a "you don't know what you're doing" type of thing, it's more of a harm reduction thing, and you're far more likely to create a problem by prescribing it than by simply taking that drug out of your arsenal. We've swung hard away from xanax in psychiatry simply because the benefits don't outweigh the risks of worsening the problem.

 

[VA Hopeful Dr]

Still, it is a problem, and a serious one. My overly rigid opinion at this point is that PCPs shouldn't even be touching xanax, even in cases where mental health prescribers aren't readily available. It's not even a "you don't know what you're doing" type of thing, it's more of a harm reduction thing, and you're far more likely to create a problem by prescribing it than by simply taking that drug out of your arsenal. We've swung hard away from xanax in psychiatry simply because the benefits don't outweigh the risks of worsening the problem.

Yep, hate it passionately. At this point I'll only continue it in legacy patients because the taper for those is a HUGE pain in the ass. No one new gets it, period.

 

[evilbooyaa]

Still, it is a problem, and a serious one. My overly rigid opinion at this point is that PCPs shouldn't even be touching xanax, even in cases where mental health prescribers aren't readily available. It's not even a "you don't know what you're doing" type of thing, it's more of a harm reduction thing, and you're far more likely to create a problem by prescribing it than by simply taking that drug out of your arsenal. We've swung hard away from xanax in psychiatry simply because the benefits don't outweigh the risks of worsening the problem.

Can I ask what the big issue with 0.25 or 0.5mg of Xanax q8 PRN for anxiety is? Outside of the super elderly. Truly curious. How about that amount of Xanax for those with a documented cancer diagnosis undergoing active treatment?

 

[WingedOx]

Yep, hate it passionately. At this point I'll only continue it in legacy patients because the taper for those is a HUGE pain in the ass. No one new gets it, period.

Now adderall, on the other hand, if PCPs want to put up with the hassle that's involved in writing that, they can be my guest.

 

[BestoFriedo-Todo]

Currently taking an addiction medicine elective, and the addictionologist gave us the following scenario:

25 y/o female referred to his clinic by a surgeon who was concerned about her post-op analgesic use,

within a 4mo. period in 2001, was prescribed:

• Lortab #40 x 15 refills
• Xanax #20 x 8 refills
• Demerol #15 x 0 refills
• Soma #30 x 4 refills

shortly after, she was prescribed:

• Vicodin #30 x 14 refills
• Darvocet #20 x 3 refills
• Xanax #12 x 4 refills
• Soma #20 x 3 refills

He posed the question to us, is this addiction? Some of the class meekly were nodding their heads yes. He then gave us the following information:

• Lortab and Demerol last used (at the time of her visit) >6mos. ago
• Xanax and Vicodin last used >2 weeks ago
• Darvocet last used 2 days ago

Past surgical history:

• Total abdominal hysterectomy and bilateral salpingoophorectomy (2001)
• Partial small bowel resection (2001)

Past medical history:

• Partial small bowel obstruction
• pelvic endometriosis + adhesions
• pelvic inflammatory disease
• polycystic kidney disease

Allergies:

• NSAIDS d/t renal disease

The patient had two surgical procedures just 4 months apart from each other and opioid analgesics were prescribed before and after both, as they are notoriously very painful procedures. Her current use didn't meet the DSM-V criteria for opioid dependency syndrome.

It is easy to look at a list of medications and automatically saying, "that doesn't look right." But without knowing all of the facts, it's hard to know for certain whether someone is truly abusing their medications or not. It is better to reserve judgement unless you intimately know the reasoning that went into prescribing the drugs in the first place.

With a pt on this much medication, I would expect her to have routine follow ups on a 1-3 month bases and being monitored very closely. Not come in once, and then continue receiving refills on Xanax for the next three years without ever seeing a provider.

 

[WingedOx]

Can I ask what the big issue with 0.25 or 0.5mg of Xanax q8 PRN for anxiety is? Outside of the super elderly. Truly curious. How about that amount of Xanax for those with a documented cancer diagnosis undergoing active treatment?

the rebound anxiety.

Xanax is awful for chronic anxiety because it's so short acting. Patients start associating the med with the short term rush of relief that they feel upon taking it rather than the absence of the anxiety itself. As a result they're basically riding waves of anxiety and relief multiple times throughout the day. It's a bad situation and it tends to make their anxiety even worse in the long run since riding those waves makes coming up with cognitive strategies to cope with that anxiety more difficult and they feel that the med is the only thing that "works" despite a baseline that's every bit as bad as before they started the med. It's a problem even at the smallest doses, though the 2 mg TID patients I've inherited are in an especially bad place, and tend to compare me to the devil himself when I say I'm not going to continue it .

FWIW, because I've seen the problem as having more to do with the frequency than the dose size, when I taper off, I tend not to switch to longer acting benzos like valium or klonopin. Occasionally I'll switch to lorazepam, though it's not always necessary. The best results that get the best adherence from the patient and the least distress on their part I get are from making gradual dose reductions to the current schedule of meds (usually TID when they show up at my door), and once I get them down to 0.25 mg doses, then going down to BID then daily. My addictions attending back in residency insisted he read a paper that stated this strategy had the best results, but then when I looked for the paper with him, neither of us could find it. Either way, anecdotally, it seems to work best for my clinic.

 

[VA Hopeful Dr]

Now adderall, on the other hand, if PCPs want to put up with the hassle that's involved in writing that, they can be my guest.

Yeah I used to care about that. Now as long as they get a decent eval from somewhere, I just don't care. The DEA doesn't bother us about stimulants and its not the same addiction issues as benzos or opioids so whatever.

 

[BestoFriedo-Todo]

Yeah I used to care about that. Now as long as they get a decent eval from somewhere, I just don't care. The DEA doesn't bother us about stimulants and its not the same addiction issues as benzos or opioids so whatever.

I think its only a matter of time before the ADHD stimulants becomes an issue. Dx the child with ADHD, then the mom, dad and uncle come in thinking they have it too. I know of pts who started the medication together, take the same dose as their 8 year old children and share scripts. Sometimes they literally come in as families to get their routine Adderall scripts. I can't wrap my mind around how these people go into their 30s, 40s, and sometimes 60s and get dx with Adult ADHD/ADD. A few people here and there, no problem. However, with how common it has become, we all know somethings up.

The adult ADHD dx is rising like it's a part of college tuition. In the near future, we will have a decent part of our work force dependent on amphetamines. Where I live, its common for pharmacies to literally run out of the medication because its prescribed so often. Pt's can't tell you the name of their BP or cholesterol medication, but they can say,spell and are over night experts on Adderall related products.

 

[operaman]

I think this problem runs far deeper and is far more complex than any of us can cover with a post here. Perhaps a quick summary is that any doc who doesn't think he or she is part of the problem is not really paying attention. The data are overwhelming in showing how all of us are contributing to the problem, not just PCPs writing chronic controlled substances.

In doing some research with the hope of making the case for some drastic reductions in the number of pills prescribed from those of us on the surgical side, I found a lot of papers discussing post-operative analgesia in other countries. The differences are pretty astounding - procedures where we typically write 30-60 strong opiates, other countries were doing tylenol/motrin and TWO - yes TWO! - doses of Tramadol! Forget getting "the one that begins with a D," these folks were lucky to get the one that begins with a T.

My personal opinion is that other developed nations may err too far on the other side, but I think we're already seeing a culture shift in medicine as we start re-evaluating our habits. On the surgical side, I'm hopeful for further papers looking at what people actually take after different operations. Some of what's out there suggests patients are taking 10-15% of the pills we give them after surgery. I have many patients who tell me they don't need any narcotics post op because they have so many from whatever their last surgery was. I'm hopeful that we will all start cutting back dramatically

OP - apologies for a brief hijack, I know this isn't addressing your question exactly. You certainly raise some potential red flags although they may all represent legit scripts. We live in a highly medicated society and it's very difficult to get people to stop taking these things.

 

[Tenk]

Xanax and OxyContin should be illegal.

The stupidist thing is stuff like this where clinics are prescribing this stuff in the thousands and I’m here in the ED writing for 6 Percocet and somehow I’m the one creating addicts. Ummm no.

 

[deleted763299]

I'm just a lowly med school applicant

Unfortunately, none of the examples you gave even registered in my mind as being that egregious. As you continue to gain clinical exposure, you'll see patients that are so stoned they're basically under general anesthesia from the cornucopia of controlled substances that they take at home. If you want to be truly horrified, ask them how they got to the clinic and I'd bet my bottom dollar they'll tell you "oh... I drove".

You're right to be worried. These patients are not going away any time soon.

 

[WingedOx]

Unfortunately, none of the examples you gave even registered in my mind as being that egregious. As you continue to gain clinical exposure, you'll see patients that are so stoned they're basically under general anesthesia from the cornucopia of controlled substances that they take at home. If you want to be truly horrified, ask them how they got to the clinic and I'd bet my bottom dollar they'll tell you "oh... I drove".

You're right to be worried. These patients are not going away any time soon.

Eh, the 89 year old on 1.5 of alprazolam/day really stands out as bad. I'd bet 100 bucks here on the spot that patient has had a fall.

As for the driving, PapaOx was an ophto in FL. That state had a system where he was able to void someone's driver's license with a few clicks of a mouse. Not sure who all has access to such a system, but damn if it isn't useful.

 

[BestoFriedo-Todo]

Tons of old ladies and men in their 60-80s with long term use of Xanax. We had on provider in the area, who the DEA finally shut down like a year ago for giving out too many controlled substances. He was past retirement age, and I think he was let go peacefully and without conflict, but his patients spilled all over the place. Coming to new providers saying " Dr. (insert out of network doctor name), gave me this for years ", and expecting the same thing. I don't know the exact details of trying to get someone off that medication, but from what the providers have told me, its pretty damn "hard" or impossible. A few of them have given up and just continued to give it to them.

One doctor in the area, gave it out and when that doctor leaves, everyone else is expected to continue his/hers plan of "care".

 

[VA Hopeful Dr]

Tons of old ladies and men in their 60-80s with long term use of Xanax. We had on provider in the area, who the DEA finally shut down like a year ago for giving out too many controlled substances. He was past retirement age, and I think he was let go peacefully and without conflict, but his patients spilled all over the place. Coming to new providers saying " Dr. (insert out of network doctor name), gave me this for years ", and expecting the same thing. I don't know the exact details of trying to get someone off that medication, but from what the providers have told me, its pretty damn "hard" or impossible. A few of them have given up and just continued to give it to them.

One doctor in the area, gave it out and when that doctor leaves, everyone else is expected to continue his/hers plan of "care".

And that is part of the problem, if they've been on this medicine for over 20 years getting them off and functioning is exceptionally difficult and very few of us have time to do it

 

[WingedOx]

Tons of old ladies and men in their 60-80s with long term use of Xanax. We had on provider in the area, who the DEA finally shut down like a year ago for giving out too many controlled substances. He was past retirement age, and I think he was let go peacefully and without conflict, but his patients spilled all over the place. Coming to new providers saying " Dr. (insert out of network doctor name), gave me this for years ", and expecting the same thing. I don't know the exact details of trying to get someone off that medication, but from what the providers have told me, its pretty damn "hard" or impossible. A few of them have given up and just continued to give it to them.

One doctor in the area, gave it out and when that doctor leaves, everyone else is expected to continue his/hers plan of "care".

We had a guy here a while before I showed up who we'll call Dr. Q, who has since been exiled out to the cornfields who was such a problem that I make sure to document "Former patient of Dr. Q" in the first few sentences of the note of any of his former patients. Absolutely no boundaries. Let his patients walk into his clinic absolutely whenever. Extremely liberal use of benzos AND opioids as a psychiatrist. I'm not sure that I can think of any patients of his who haven't had some sort of dependence issues. Every one of his patients when you ask about him will swear that "Dr. Q was a genius." They use the term "genius" every time. It blows my mind. He knew exactly what to give patients so they instantly felt better, and I think he kind of got off on that feeling of gratitude from his patients, damn the consequences.

I've gotten to the point where when I see one of these patients the first thing I do is tell them that if they want to continue with me as a patient, I'm going to start to lower them off of the stuff. It's easier at the time to ignore it and just continue the script, but in my own experience I've seen it just create more problems if I don't address it head on. They'll either just go doctor shopping somewhere else or they'll comply, but when I ignore it, I end up with situations where I'm suddenly dealing with a panicked patient who has unilaterally gone up on his meds and run out with a week before the next refill is due, had falls, had a situation requiring the patient to suddenly require a rapid taper due to other contraindications, etc. Right now I've only got one or two patients who I'm saying "screw it" and continuing the meds, and it wasn't for lack of trying. Temazepam in elderly patients is another bane of my existence.

 

[BestoFriedo-Todo]

We had a guy here a while before I showed up who we'll call Dr. Q, who has since been exiled out to the cornfields who was such a problem that I make sure to document "Former patient of Dr. Q" in the first few sentences of the note of any of his former patients. Absolutely no boundaries. Let his patients walk into his clinic absolutely whenever. Extremely liberal use of benzos AND opioids as a psychiatrist. I'm not sure that I can think of any patients of his who haven't had some sort of dependence issues. Every one of his patients when you ask about him will swear that "Dr. Q was a genius." They use the term "genius" every time. It blows my mind. He knew exactly what to give patients so they instantly felt better, and I think he kind of got off on that feeling of gratitude from his patients, damn the consequences.

I've gotten to the point where when I see one of these patients the first thing I do is tell them that if they want to continue with me as a patient, I'm going to start to lower them off of the stuff. It's easier at the time to ignore it and just continue the script, but in my own experience I've seen it just create more problems if I don't address it head on. They'll either just go doctor shopping somewhere else or they'll comply, but when I ignore it, I end up with situations where I'm suddenly dealing with a panicked patient who has unilaterally gone up on his meds and run out with a week before the next refill is due, had falls, had a situation requiring the patient to suddenly require a rapid taper due to other contraindications, etc. Right now I've only got one or two patients who I'm saying "screw it" and continuing the meds, and it wasn't for lack of trying. Temazepam in elderly patients is another bane of my existence.

The sense of entitlement these patients must have to come up to a doctor they've never seen before and demand you prescribe them controlled substance A through Z.

 

[libertyyne]

The sense of entitlement these patients must have to come up to a doctor they've never seen before and demand you prescribe them controlled substance A through Z.

I dont know if I would call this entitlement if they were prescribed meds by the previous doctor, they have no idea what is appropriate vs not. Its like you getting a prescription for diabetes, and your doctor retires , you would go to the new doctor expecting prescriptions to be renewed.

 

[BestoFriedo-Todo]

I dont know if I would call this entitlement if they were prescribed meds by the previous doctor, they have no idea what is appropriate vs not. Its like you getting a prescription for diabetes, and your doctor retires , you would go to the new doctor expecting prescriptions to be renewed.

I'm a bit more cynical. They may not know the details and rules the way a healthcare worker would, but I feel like they definitely know what they're asking for. It doesn't take a doctor or a nurse to know Percocet, Oxycotin, Xanax and whatever else they're wanting are controlled substance and that you live in an area that is infested with heroin labs, and overdoses. Despite this, they don't come in wanting to discuss treatment or plans for pain. They come in to a provider they don't know, with no records, no proof of dx and are basically demanding you give them something to keep them baked/high all day. That in my eyes is a entitlement. For DM, HTN, lipids and stuff like that, they can have their meds, cause theres not any risk of them ODing,abusing and selling lisinopril or metformin. And I can do labs and get the results in a day providing me with medical backing to give them those medications, but pain is touchy for me. I can get a carefully calculated numerical value to tell me how much and why I'm giving them a statin drug. I can't do that for pain. And due to the amount of drug seekers in my area, I wouldn't just give someone a pain script on face value without proper evaluation.

Had a 58 year old lady walk in not even 3 hours ago. OOS, New Pt, NO RECORDS whatsoever and she gives us her med list. And according to her handwritten piece of paper that she keeps in her purse, she takes norco 10-325 prn every 8 hours for back pain. She left very disgruntled with a referral to pain management and tramadol. Further research revealed this is her third time establishing care with a new provider this month.

 

[BestoFriedo-Todo]

Then again, I'm not even a first year. I'm just rotating through clinics watching how doctors do things. I did grow up in this area, and I've seen the drug abuse first hand. So I am very skeptical of all these pt's requesting controlled substances.

I'm sure everyone goes into medicine thinking they're going to better the community and cut back on narcotics. Actually doing it when you're in charge of and liable for a pt's care is another thing.

 

[SouthernGent]

What has boggled my mind that the studies done on Xanax for the FDA indicated (And recommended) it be only used short term, and yet people are on this stuff for years. Is it cause physicians didn't want to deal with tapering them or getting rid of something that "Worked"?

 

[Stagg737]

I can't wrap my mind around how these people go into their 30s, 40s, and sometimes 60s and get dx with Adult ADHD/ADD

You'd be surprised how many people go most of their lives with a mental health issue, function at an "okay" level, then find out later that they've had some disorder for years and just never knew it. Saw a 40-something year old lady break down out of happiness in my attending's clinic on her first follow-up after starting stimulants for ADHD because she had no idea what it actually meant to be able to focus on a single task and that her life had drastically improved since starting. I saw multiple older individuals have the same experience since then, almost all of whom had been having symptoms since they were children but just never sought treatment because they were always able to get by.

Also, I've got limited experience, but I'm not a fan of the term "adult ADD", as it implies their symptoms started later in life. The reality is that for these individuals they already had symptoms as children, but "grew out" of most of them as they were older but are still affected by some of them. I don't think it's unreasonable at all to start treating an adult who displays those residual symptoms so long as you're taking the steps to make a proper diagnosis.

Then again, I'm not even a first year. I'm just rotating through clinics watching how doctors do things. I did grow up in this area, and I've seen the drug abuse first hand. So I am very skeptical of all these pt's requesting controlled substances.

Agree with FactorV, in the sense that most of the cases you listed honestly don't seem that egregious (without more context to know why they're on those specific meds). I've seen some very highly regarded physicians prescribing treatments that I thought were outrageous at the time, but after the explanation about the individual case as well as what had been tried in the past, it became clear why those meds were being prescribed in the doses they were. Imo, the real red flags of what you're describing are that it's a PCP office where the majority of the patients seem to be on these regimens along with the fact that some of them are coming from so far away. That aspect really does sound like the office is doing some sketchy business.

 

[RM38]

As a pain physician some of the OP's cases are very concerning to me, especially as it seems they are refilling controlled meds without seeing patients. These medications have a lot of issues and need close monitoring including UDS and referrals to multimodal therapy when indicated. This is especially true with narcotics, but benzos and stimulants are certainly abused as well. To prescribe these substances to people and to not be seeing them for >6 months or even years is a serious concern. I have seen several docs get into trouble with situations like this and it destroyed their careers. If one of these patients ODs and you continued meds without proper monitoring, which I could easily argue was happening in some of the above cases, you will be up a creek with no paddle for sure when the family wants to sue you later or the DEA decides to investigate you. Big instance was another pain group that continued high dose narcs in a patient for something like 10 months without seeing her. No UDS or anything. Patient had a history of substance abuse and when they finally made her come in she tested positive for Heroin on UDS. By the time the result returned the patient had already OD'd on her meds and heroin before she could be weaned. The whole group all had their DEAs suspended for 6 months and many insurances dropped them. It totally destroyed their practice and careers. I understand people are busy, but if you do not have the time to manage these meds right, then don't do it at all. Addicts/abusers/diverters will take the path of least resistance when it comes to getting what they want. A lot of them talk to each other on various forms of social media and if you get a reputation for not testing, not enforcing abnormal results or doing other stuff like prescribing for many months with no follow up, you will be flooded with these patients real quick. That may explain why people are driving so far to see this guy unless it is a pure insurance issue like certain medicaid plans that have a very limited number of people whom accept it. Still to prescribe to young people with something like knee pain without proper work up is putting you at major risk and is an example of why pcps should not prescribe narcs most of the time. That is something I see all of the time. Young person with back pain on norco for 4 months without so much as PT or an X ray expecting me to just continue meds with no work up. The other thing I will never get is the benzo, adderall, opiate combos that I see all of the time. This is really not appropriate the vast majority of the time and I see this weekly. It is really a sign of someone whom would be referred to as a "chemical coper" and I know when those folks come in it is going to involve a long convo about medication appropriateness. PCPs are certainly not the only ones guilty of this as I see many people even in the pain world doing this stuff too, but many of the most egregious combos that I see do come from either pcps or other non fellowship trained pill mill/"pain physicians". I am also shocked to see how many people come to me from other pain docs after being discharged due to to cocaine/heroin/non prescribed narcs/etc that are also on benzo/adderall/ambien/soma from their pcp and they are NEVER stopped. Especially since many ODs in patients prescribed this stuff have multiple substances both prescribed and non-prescribed on board, you would think they would be more careful. They must know something is up because they send me the referral and even state in their note that the patient needs a new pain doc, but never address the fact that they should be stopping the benzos or what have you as well. Bottom line is be careful because these meds can burn you.