Prescribing controlled substances has always required judgment. In 2026, it also requires anticipating how your prescribing patterns will look to pharmacists, insurers, and regulators. Pharmacists are expected to question outlier doses, insurers flag claims outside FDA recommendations, and prescription monitoring programs (PMPs) compare your prescribing with that of your peers.

Most psychiatrists will never face criminal charges, but many will face scrutiny. The goal is not to practice fearfully, but to prescribe in a way that is clinically safe, sound, and defensible.

Here are the prescribing patterns most likely to trigger problems, and how to manage them safely.

Landmine #1: Doses that exceed usual practice
Controlled substances should generally be prescribed at the lowest effective dose, but sometimes higher amounts are necessary. Every controlled substance has an FDA-recommended maximum dose. You can exceed that maximum, but the further you move beyond norms, the stronger your rationale and documentation must be.

For ADHD, the FDA maximum dose for mixed amphetamine salts is typically 40 mg/day, with allowance up to 60 mg/day in select cases. Prescriptions for 80–120 mg/day will stand out. Patients may claim they are rapid metabolizers, but stimulant dosing is not guided by CYP testing, and evidence does not support escalation on that basis. Higher doses increase risks of psychosis, cardiovascular events, diversion, and misuse. Deaths involving prescribed stimulants have increased in recent years (Practice Guideline, J Addict Med 2024;18:38752709).

If you exceed typical dosing:

• Document symptom severity and functional impairment.
• Record prior treatment trials and your rationale for the increase.
• Specify measurable functional benefit at the higher dose.
• Reassess regularly and adjust if benefit is unclear.

Benzodiazepine dosing follows a typical pattern. Tolerance develops, doses creep upward, and patients report that the medication “doesn’t work like it used to.” For panic disorder, the FDA allows higher doses of clonazepam (up to 4 mg/day rather than the typical maximum of 2 mg/day) and alprazolam (up to 10 mg/day rather than the typical maximum of 4 mg/day) when there is clear functional benefit. Dose escalation increases risk of cognitive impairment, falls, respiratory suppression, and withdrawal syndromes; however, this risk may be outweighed by benefits in panic disorder.

Before increasing the dose, clarify the specific functional improvement that you expect, review non-benzodiazepine options, and document the risk–benefit discussion. Prescribing above usual doses is not illegal, but these prescriptions are visible to insurers and regulators.

Additionally, when you prescribe outside typical dosing ranges, consider contacting the pharmacist proactively to explain your rationale. Communication can prevent delays, denials, and unnecessary suspicion.

Schedule II stimulants cannot be refilled and post-dated prescriptions are not permitted. However, you may issue up to a 90-day supply by writing separate prescriptions with future fill dates. For stable patients, this approach reduces early refill requests and pharmacy friction.

Landmine #2: High-risk combinations
Certain drug combinations predictably attract scrutiny because they raise the risk of morbidity and mortality.

Co-prescribing opioids and benzodiazepines increases the risk of overdose deaths by 2–4 times, particularly at opioid doses of 50 morphine milligram equivalents or more per day. If you prescribe both:

• Document why alternatives were insufficient.
• Confirm no active substance use disorder.
• Check the PMP.
• Use the lowest-risk agent and monitor closely.
• Plan to deprescribe when possible.

Among benzodiazepines, oxazepam carries the lowest overdose risk, followed by lorazepam. Oxazepam’s slow onset reduces its rewarding qualities, while its short duration reduces its overdose risk. Toxicity is more common with long-acting or high-potency benzos like clonazepam, diazepam, and alprazolam.

The DEA has flagged the combination of an opioid, a benzodiazepine, and the muscle relaxant carisoprodol (Soma). Dubbed the “holy trinity,” it carries a high risk of misuse and overdose (Wang Y et al, Drug Alcohol Depend 2019;205:107693). Those risks are compounded by the fact that carisoprodol is metabolized into a barbiturate-like drug, meprobamate. Other muscle relaxants, like baclofen and cyclobenzaprine, are also risky. Even if you are prescribing only one of these medications, you may face scrutiny if the full combination exists.

Ketamine prescribing has also expanded, and at-home oral formulations are particularly risky. Reports of misuse, poisoning, and self-harm have increased alongside this trend (Palamar JJ et al, Drug Alcohol Depend 2025;268:112549). Oral ketamine has limited evidence for major depression due to low bioavailability. Adding other controlled substances in this setting increases both clinical risk and regulatory visibility.

When high-risk combinations are unavoidable, make your rationale explicit in the chart.

Landmine #3: Inadequate monitoring
Clinical judgment is not enough without consistent monitoring.

Check the PMP every time you prescribe a controlled substance—not annually, not “when concerned,” but every time. Document that you checked. Unexpected findings—multiple prescribers, early fills, dose escalation—are common.

Consider obtaining a urine drug screen before initiating long-term controlled substances and at least annually thereafter, with more frequent or random testing in higher-risk cases. If you choose not to test, document your reasoning.

Be cautious with early refills or refills after missed appointments. If you provide them, limit the quantity, explain your reasoning, and set a clear follow-up plan. Patterns of casual refilling are difficult to defend later.

Telehealth prescribing of controlled substances deserves extra caution. Even when remote prescribing is permitted, verify identity, check the PMP before initiating treatment, and document your plan for follow-up, including whether an in-person visit or urine drug screen will occur. Remote care does not lower documentation and monitoring standards.

Landmine #4: Weak documentation
If your prescribing is reviewed, the record should clearly demonstrate four elements:

1. A legitimate diagnosis
2. Evidence of functional impairment
3. A clear rationale for the medication and dose
4. Ongoing reassessment

When prescribing buprenorphine for opioid use disorder, record the diagnosis and use only FDA-approved formulations. Approved products are critical because prescribing opioids to treat addiction has been illegal since the Harrison Narcotics Tax Act of 1914. Later laws carved out exceptions, such as methadone through specialized clinics and buprenorphine by DEA licensed prescribers after expanding the X-waiver system (which is no longer in effect). However, these exceptions apply only when the diagnosis matches with FDA-approved formulations.

When prescribing stimulants, document ADHD criteria and impairment—not simply a patient’s desire for better focus.

Reviewers will rely on what is in the chart, not what you recall doing.

Landmine #5: Casual PRN benzodiazepine prescribing
PRN benzodiazepines often drift into daily use. Setting expectations early is easier than reversing long-term dependence.

Safer prescribing includes:

• Assessing for substance use history, concurrent opioid therapy, fall risk, and cognitive impairment.
• Writing “PRN severe anxiety” rather than “PRN anxiety.”
• Specifying a defined 30-day supply.
• Counseling patients to avoid alcohol and opioids.
• Teaching coping strategies for acute anxiety.
• Clarifying that the medication should improve functioning, not simply sedate the patient.

These guardrails are easier to maintain when you build them into your workflow from the start.

Even with good intentions, some patients can become overly dependent on benzodiazepines to cope with various emotions, including feelings that are normal parts of life. Instead of benefiting from these medications, some may withdraw from activities or fall deeper into anxiety-driven thoughts, such as believing, “If I don’t take my benzodiazepine, something really bad will happen!” These situations may signal that it’s time to consider reducing or stopping the medication.

Here are steps for addressing this:

1. Elicit the patient’s perspectives and motivations.
2. Provide education and review treatment objectives, referencing the initial rationale for prescribing.
3. Observe the current clinical context and emphasize a collaborative approach focused on the patient’s well-being and safety.
4. Anticipate and normalize apprehension about change.

Engaging patients in discussions about their perspectives on benzos can strengthen the therapeutic alliance and set the stage for change. Ideally, they will be empowered to express their own concerns about the medication. The topic will feel challenging for some patients, so it’s essential to acknowledge their emotions without reinforcing them. Pay attention to whether their anxiety shifts more toward concern about losing access to their medication. If so, offer alternative ways to interpret and address this difficulty.

CARLAT VERDICT
Prescribe controlled substances as if someone will review your chart. Stay within usual dosing limits when possible, avoid high-risk combinations, monitor consistently, and document clearly whenever you depart from the norm.