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Controlled Substances - NAPLEX

  1. A 43-year-old female presents to pick up new prescriptions from an urgent care visit for acute dental pain after extraction. She is currently taking clonazepam (Schedule IV) 1 mg by mouth twice daily, sertraline 100 mg by mouth daily, and zolpidem (Schedule IV) 10 mg by mouth at bedtime as needed (uses most nights). Allergies: hydrocodone (itching). Medical history: generalized anxiety disorder, insomnia. Labs: serum creatinine 0.8 mg/dL (0.6–1.3), AST 22 U/L (10–40), ALT 19 U/L (7–56). New prescription: tramadol (Schedule IV) 50 mg by mouth every 6 hours as needed for pain, #20. What is the best recommendation for this patient's therapy?
    Answer: Recommend non-opioid analgesics first and contact the prescriber to avoid tramadol due to additive central nervous system depression with clonazepam and zolpidem This question evaluates the recognition of dangerous drug interactions with controlled substances in the setting of acute pain management. The critical patient-specific factor is the concurrent use of two CNS depressants (clonazepam and zolpidem) with a proposed third CNS depressant (tramadol), creating significant risk for respiratory depression and sedation. Option A is correct because it prioritizes non-opioid alternatives and recognizes the serious interaction potential between tramadol and the existing benzodiazepine/Z-drug combination. Option B is dangerously incorrect as it not only ignores the interaction but suggests doubling the zolpidem dose, which could be fatal. Option C is wrong because meperidine has even more concerning interactions and toxicity risks, especially with serotonergic medications like sertraline. Option D inappropriately suggests excessive monitoring without addressing the core safety issue. The clinical framework is that combining multiple CNS depressants significantly increases overdose risk, and alternative pain management strategies should be explored first, especially for acute dental pain which typically responds well to NSAIDs and acetaminophen.
  2. A 56-year-old female (weight 76 kg) is on long-term zolpidem (Schedule IV) 10 mg nightly for insomnia and reports needing 2 tablets nightly to sleep. Current medications: zolpidem 10 mg nightly, venlafaxine XR 150 mg daily, and melatonin 5 mg nightly. Allergies: none. Medical history: insomnia, major depressive disorder; no substance use disorder history. Labs: serum creatinine 0.9 mg/dL (0.6–1.3). Which controlled substance management action is most appropriate for this patient?
    Answer: Recommend a gradual taper/discontinuation plan and nonpharmacologic insomnia strategies; contact prescriber to reassess therapy rather than escalating zolpidem dose This question assesses the management of tolerance and dependence in long-term non-benzodiazepine hypnotic use for insomnia. The key patient-specific factor is the patient's self-escalation to double zolpidem doses, indicating potential dependence alongside venlafaxine, which may worsen insomnia if not addressed. Option A is the best choice as recommending a gradual taper with nonpharmacologic strategies and prescriber reassessment prevents withdrawal while avoiding escalation. Option B is incorrect because indefinite increases risk adverse effects, a misconception that tolerance justifies higher doses. Option C is suboptimal as adding alprazolam compounds sedation; option D dangerously enhances effects with alcohol. A pearl is that zolpidem is recommended for short-term use per AASM guidelines. Use a deprescribing framework incorporating cognitive behavioral therapy for insomnia in controlled substance management.
  3. A 23-year-old female (weight 55 kg) is picking up a new prescription for methylphenidate immediate-release (Schedule II) 20 mg orally three times daily for ADHD. She reports she sometimes takes "extra doses" during exams and then runs out early. Current medications: methylphenidate (new), ethinyl estradiol/levonorgestrel daily. Allergies: none. Medical history: ADHD; no substance use disorder history. Labs: not available. What is the best way to manage this patient's medication adherence?
    Answer: Counsel to take only as prescribed, discuss risks of misuse, and coordinate with prescriber for a structured plan (e.g., smaller quantities with more frequent fills and PDMP monitoring) This question assesses strategies for promoting adherence and preventing misuse in patients on stimulant therapy for ADHD. The key patient-specific factor is the patient's self-reported pattern of taking extra doses during high-stress periods, leading to early shortages, which raises concerns for potential misuse or diversion. Option A is the best choice as counseling on proper use, discussing misuse risks, and coordinating with the prescriber for structured plans like smaller quantities and PDMP monitoring fosters adherence and safety. Option B is incorrect because recommending dose doubling promotes nonadherence and misuse, a misconception that self-adjustment is harmless for stimulants. Option C is suboptimal as self-switching to modafinil bypasses medical oversight; option D risks diversion by suggesting unlocked storage. A clinical pearl is that stimulants have high abuse potential, requiring patient education on storage and disposal. Implement a decision framework using opioid-like risk mitigation tools, such as treatment agreements, for all controlled substances with misuse potential.
  4. A 24-year-old female (weight 60 kg) started lisdexamfetamine (Schedule II) 50 mg by mouth every morning 2 weeks ago for ADHD. Current medications: lisdexamfetamine 50 mg daily and ethinyl estradiol/levonorgestrel 1 tablet daily. Allergies: none. Medical history: ADHD; no substance use disorder. Labs: not available. She reports palpitations, insomnia, and decreased appetite; her blood pressure today at the pharmacy kiosk is 152/92 mmHg (previously ~118/72) and heart rate is 112 beats/min. Which controlled substance management action is most appropriate for this patient?
    Answer: Contact the prescriber promptly to assess stimulant-related adverse effects and consider dose reduction or discontinuation; counsel to avoid other stimulants (caffeine/decongestants) until evaluated This question addresses cardiovascular adverse effects of stimulant medications requiring urgent intervention. The key patient-specific factors are new-onset hypertension (152/92 mmHg), tachycardia (112 bpm), and cardiac symptoms (palpitations) after starting a moderate-high dose of lisdexamfetamine. Option B is correct because these cardiovascular effects require prompt medical evaluation and likely dose reduction or discontinuation of the stimulant, plus counseling to avoid other sympathomimetics that could worsen symptoms. Option A is dangerous as taking stimulants at bedtime would worsen insomnia without addressing cardiovascular risks. Option C is inappropriate and dangerous as adding another stimulant (pseudoephedrine) would exacerbate cardiovascular symptoms. Option D incorrectly minimizes serious cardiovascular effects that require immediate attention. The clinical framework emphasizes that stimulant-induced cardiovascular effects (hypertension, tachycardia, palpitations) require prompt evaluation and intervention, as they can progress to serious outcomes including myocardial infarction, stroke, or sudden death, particularly at higher doses.
  5. An emergency oral CII is dispensed. A written prescription arrives on day 6. Pharmacist should:
    Answer: Accept; within the 7-day limit An emergency oral CII prescription must be followed by a written prescription within 7 days. Day 6 falls within that window, so you may accept it. The tempting error is the 72-hour rule, but that applies to partial fills of CII, not to the emergency follow-up written prescription.
  6. A dentist writes for lisdexamfetamine for ADHD. The pharmacist should:
    Answer: Refuse; not dental scope Lisdexamfetamine treats ADHD, a medical or psychiatric condition, not a dental problem. A dentist's prescriptive authority is limited to dentistry, so this prescription is outside scope and must be refused. Don't assume a valid DEA number is enough; it only confirms registration, not that this prescriber may treat ADHD.
  7. A 41-year-old male (weight 85 kg) is on chronic therapy with mixed amphetamine salts extended-release (Schedule II) 30 mg each morning. He is newly prescribed linezolid 600 mg twice daily for 10 days for a skin infection. Current medications: mixed amphetamine salts ER 30 mg daily and albuterol inhaler as needed. Allergies: none. Medical history: ADHD, asthma; no substance use disorder. Labs: serum creatinine 0.9 mg/dL (0.6–1.3). Which action should the pharmacist take regarding this prescription?
    Answer: Contact the prescriber because linezolid has monoamine oxidase inhibitor activity and may increase risk of hypertensive reaction with stimulants; consider alternative antibiotic or hold stimulant with monitoring This question tests the pharmacist's knowledge of drug interactions involving controlled substances, specifically the interaction between stimulants and antibiotics with monoamine oxidase inhibitor (MAOI) activity. The key patient-specific factor is the concurrent use of mixed amphetamine salts, a Schedule II stimulant, and linezolid, which exhibits weak MAOI activity, potentially leading to hypertensive crisis or serotonin syndrome. Contacting the prescriber is the best choice because it allows for evaluation of the interaction risk, consideration of alternative antibiotics, or temporary holding of the stimulant with appropriate monitoring to ensure patient safety. Dispensing linezolid while advising to double the stimulant dose is incorrect as it could exacerbate the interaction and is not evidence-based, while simply dispensing both with post-course blood pressure monitoring fails to address the acute risk during concurrent use; switching to methylphenidate without prescriber involvement violates controlled substance regulations and does not eliminate the interaction risk. A common misconception is that all stimulants are interchangeable without oversight, but Schedule II medications require prescriber authorization for changes. A transferable clinical pearl is to always check for MAOI interactions with sympathomimetic agents like stimulants using resources like drug interaction databases. Guidelines for controlled substance management emphasize proactive pharmacist intervention in potential interactions to prevent adverse events.
  8. A 60-year-old male (weight 86 kg) is being tapered off long-term alprazolam (Schedule IV) 2 mg orally three times daily for 5 years. The prescriber proposes reducing directly to alprazolam 0.5 mg three times daily starting tomorrow. Current medications: alprazolam as above and buspirone 10 mg twice daily. Allergies: none. Medical history: generalized anxiety disorder; no seizure history; no substance use disorder. Labs: serum creatinine 0.9 mg/dL (0.6–1.3). What is the best recommendation for this patient's therapy?
    Answer: Recommend a slower taper plan (e.g., 10%–25% dose reduction every 1–2 weeks, with adjustments) and consider converting to a longer-acting benzodiazepine if appropriate This question tests safe tapering strategies for chronic high-dose benzodiazepines to minimize withdrawal. The key patient-specific factor is the long-term alprazolam use at high doses, where rapid reduction risks severe withdrawal like seizures, despite no seizure history. Option B is the best choice as recommending a slower taper (10%–25% every 1–2 weeks) with possible conversion to longer-acting agents allows safe discontinuation and symptom monitoring. Option A is incorrect because rapid reduction increases withdrawal risk, a misconception for short-acting benzodiazepines. Option C is suboptimal as abrupt stop with zolpidem substitution doesn't prevent withdrawal; option D delays taper unnecessarily. A pearl is that ASAM recommends individualized tapers for benzodiazepine dependence. Use a framework incorporating patient input and adjunct therapies for controlled substance discontinuation.
  9. A 29-year-old female (weight 62 kg) presents with a prescription for codeine/guaifenesin cough syrup (Schedule V) 10 mg/100 mg per 5 mL: take 10 mL every 4 hours as needed for cough. Current medications: fluconazole 200 mg daily (day 3 of 7) and sertraline 50 mg daily. Allergies: none. Medical history: pneumonia being treated outpatient; no substance use disorder. Labs: serum creatinine 0.7 mg/dL (0.6–1.3). Which controlled substance management action is most appropriate for this patient?
    Answer: Dispense and counsel to avoid other sedatives and alcohol, and to use the lowest effective dose for the shortest duration This question evaluates the dispensing and counseling for Schedule V cough syrups containing codeine in patients on interacting medications. The key patient-specific factor is the concurrent fluconazole and sertraline, which may increase codeine levels via CYP interactions, heightening sedation and respiratory risks. Option A is the best choice as dispensing with counseling on avoiding sedatives and alcohol, plus using the lowest dose briefly, minimizes adverse effects while treating the cough. Option B is incorrect because increasing the dose risks overdose, a misconception that Schedule V implies no sedation. Option C is suboptimal as adding diphenhydramine compounds CNS depression; option D promotes improper storage facilitating diversion. A pearl is that even low-codeine products require opioid-like precautions per DEA. Use a framework screening for interactions and educating on short-term use for over-the-counter controlled substances.
  10. Non-LTC, nonterminal patient CII partial fill due to low stock. Remaining supply must be:
    Answer: Within 72 hours; annotate it For a standard Schedule II partial fill due to low stock, you must dispense the remaining supply within 72 hours and annotate the prescription. The tempting 60-day rule applies only to LTC or terminally ill patients, so it doesn't apply to this non-LTC, nonterminal patient.
  11. A 61-year-old female (weight 70 kg) is receiving chronic therapy for neuropathic pain. Current medications include transdermal fentanyl (Schedule II) 50 mcg/hour patch every 72 hours, oxycodone (Schedule II) 5 mg by mouth every 6 hours as needed (uses 1–2 tablets/day), fluconazole 200 mg by mouth daily (started yesterday for esophageal candidiasis), and amlodipine 5 mg by mouth daily. Allergies: none. Medical history: cancer in remission, chronic pain; no substance use disorder. Labs: serum creatinine 0.7 mg/dL (0.6–1.3), AST 30 U/L (10–40), ALT 34 U/L (7–56). Which controlled substance management action is most appropriate for this patient?
    Answer: Identify the interaction (fluconazole inhibits CYP3A4), counsel on overdose risk, and contact the prescriber to consider fentanyl dose reduction and enhanced monitoring for sedation/respiratory depression This question tests recognition of significant drug interactions affecting controlled substances, specifically the CYP3A4 interaction between fluconazole and fentanyl. The critical patient-specific factor is the recent addition of fluconazole, a strong CYP3A4 inhibitor, to a patient on transdermal fentanyl, which is metabolized by CYP3A4. Option C is correct because it identifies the mechanism (CYP3A4 inhibition), recognizes the clinical consequence (increased fentanyl levels and overdose risk), and recommends appropriate actions including prescriber notification, potential dose adjustment, and enhanced monitoring. Option A is incorrect because transdermal delivery does not avoid hepatic metabolism and drug interactions. Option B is wrong and dangerous as the interaction would increase, not decrease, fentanyl levels. Option D is inadequate because while naloxone is important, it doesn't address the need for dose adjustment and monitoring. The clinical pearl is that CYP3A4 inhibitors can significantly increase fentanyl concentrations leading to potentially fatal respiratory depression, requiring proactive dose adjustments and careful monitoring when such combinations cannot be avoided.
  12. A 66-year-old female (weight 60 kg) presents with new confusion and falls 1 week after starting diazepam (Schedule IV) 5 mg orally three times daily for muscle spasms. Current medications: oxycodone immediate-release (Schedule II) 5 mg every 6 hours as needed (uses 2–3/day), diphenhydramine 25 mg at bedtime as needed, and hydrochlorothiazide 25 mg daily. Allergies: sulfonamides (hives). Medical history: chronic neck pain, osteoporosis, mild chronic kidney disease. Labs: serum creatinine 1.4 mg/dL (0.6–1.3), estimated creatinine clearance 35 mL/min, alanine aminotransferase 30 U/L (7–56). Which controlled substance management action is most appropriate for this patient?
    Answer: Recommend tapering off diazepam and avoiding concurrent sedatives; contact prescriber to switch to non-benzodiazepine options and reassess opioid use due to fall risk This question tests the recognition and management of benzodiazepine-related adverse effects in elderly patients on polypharmacy. The key patient-specific factors are the patient's age, new confusion and falls, concurrent opioid and diphenhydramine use, and reduced renal function, heightening risks of sedation and falls. Option B is the best choice as tapering diazepam and avoiding concurrent sedatives minimizes CNS depression, while contacting the prescriber for non-benzodiazepine alternatives and opioid reassessment addresses fall risk comprehensively. Option A is incorrect because increasing diazepam could worsen adverse effects, a misconception that higher doses improve efficacy in spasms. Option C is suboptimal as combining with diphenhydramine exacerbates anticholinergic burden; option D neglects immediate action, wrongly assuming symptoms resolve without intervention. A pearl is that benzodiazepines are listed in Beers Criteria as potentially inappropriate for older adults due to fall risk. Use a framework like deprescribing protocols, starting with slow tapers and nonpharmacologic options for controlled substance management in the elderly.
  13. A 36-year-old male (weight 82 kg) is on stable therapy with buprenorphine/naloxone (Schedule III) 8 mg/2 mg sublingual twice daily. He presents with a new prescription for oxycodone immediate-release (Schedule II) 10 mg every 4 hours as needed for "breakthrough pain" from a different prescriber. Current medications: buprenorphine/naloxone as above and ibuprofen 600 mg three times daily. Allergies: none. Medical history: opioid use disorder, chronic shoulder pain. Labs: serum creatinine 1.0 mg/dL (0.6–1.3). Which action should the pharmacist take regarding this prescription?
    Answer: Contact both prescribers to coordinate care due to high overdose risk and potential reduced oxycodone efficacy; verify indication and consider nonopioid or supervised pain plan This question assesses the management of concurrent full agonist opioids with buprenorphine in opioid use disorder treatment. The key patient-specific factor is the addition of oxycodone to stable buprenorphine/naloxone, which may reduce oxycodone efficacy due to receptor blockade and heighten overdose risk. Option B is the best choice as contacting prescribers to coordinate, verify indication, and consider alternatives prevents harm and ensures integrated care. Option A is incorrect because buprenorphine does affect other opioids, a pharmacological misconception. Option C risks precipitated withdrawal; option D promotes unsafe dose escalation. A pearl is that SAMHSA advises against combining buprenorphine with full agonists without supervision. Use a decision framework reviewing PDMP and communicating with providers for multi-prescriber controlled substance scenarios.
  14. A 57-year-old female (weight 69 kg) has been receiving morphine extended-release (Schedule II) 30 mg orally every 12 hours for chronic pain. The prescriber sends a new electronic prescription: "morphine ER 30 mg every 12 hours, dispense 60, refills: 3." Current medications: morphine ER as above, polyethylene glycol 17 g daily. Allergies: none. Medical history: chronic pain; no substance use disorder. Labs: serum creatinine 1.0 mg/dL (0.6–1.3). Which action should the pharmacist take regarding this prescription?
    Answer: Contact the prescriber to correct the prescription because Schedule II prescriptions cannot be refilled; dispense only the authorized quantity for this fill per applicable law This question assesses understanding of federal regulations for prescribing and dispensing Schedule II controlled substances, particularly restrictions on refills for opioids like morphine extended-release. The key patient-specific factor is the electronic prescription for morphine ER with 3 refills, which violates DEA rules as Schedule II medications cannot have refills, though multiple prescriptions can be issued for up to 90 days in certain cases. Contacting the prescriber to correct the prescription is the best action because it ensures compliance with law by dispensing only the authorized quantity without unauthorized refills, preventing potential diversion or misuse. Processing with 3 refills is incorrect as electronic prescribing does not override the no-refill rule for Schedule II drugs, and adding refills as partial fills or converting to immediate-release without prescriber input violates regulations and could lead to inappropriate dosing. A common misconception is that electronic prescriptions allow flexibility in refills for controlled substances, but DEA guidelines strictly prohibit this for Schedule II to minimize abuse risk. A clinical pearl is to verify all controlled substance prescriptions against state and federal laws, using tools like prescription drug monitoring programs (PDMPs). Frameworks for monitoring include assessing patient risk factors and ensuring prescriptions align with CDC opioid prescribing guidelines for chronic pain.
  15. A 46-year-old female (weight 73 kg) calls the pharmacy reporting a serious adverse reaction after starting a controlled medication. Current medications: phentermine (Schedule IV) 37.5 mg by mouth every morning (started 5 days ago from a weight-loss clinic), hydrochlorothiazide 25 mg by mouth daily, and albuterol inhaler as needed. Allergies: sulfonamides (hives). Medical history: obesity, hypertension; no substance use disorder. Labs: potassium 3.2 mEq/L (3.5–5.0), serum creatinine 0.9 mg/dL (0.6–1.3). She reports severe chest pain, shortness of breath, and a near-syncope episode that led to an emergency department visit; she was told she had an arrhythmia. Which controlled substance management action is most appropriate for this patient?
    Answer: Advise discontinuation and urgent medical follow-up, and submit an FDA MedWatch report for a serious adverse event associated with phentermine This question evaluates the appropriate response to serious adverse events from controlled substances requiring regulatory reporting. The key patient-specific factors are serious cardiovascular events (chest pain, arrhythmia, near-syncope) occurring shortly after starting phentermine, a sympathomimetic anorectic with known cardiovascular risks. Option D is correct because it addresses both immediate patient safety (discontinuation and urgent follow-up) and regulatory requirements (FDA MedWatch reporting for serious adverse events). Option A is dangerous as it ignores serious cardiovascular toxicity that could progress to fatal outcomes. Option B incorrectly suggests tapering, which is unnecessary for phentermine and delays addressing the urgent safety issue. Option C inappropriately suggests switching to another stimulant which would likely cause similar or worse cardiovascular effects. The clinical framework emphasizes that serious adverse events from controlled substances require immediate discontinuation, appropriate medical referral, and regulatory reporting to FDA MedWatch to contribute to post-market surveillance and protect public health.
  16. A 45-year-old male (weight 88 kg) is prescribed tramadol (Schedule IV) 50 mg orally every 6 hours as needed for dental pain for 5 days. Current medications include paroxetine 40 mg daily, bupropion XL 300 mg daily, and sumatriptan 50 mg as needed for migraines. Allergies: none. Medical history: depression, migraines, seizure history (last seizure 10 years ago). Labs: serum creatinine 1.0 mg/dL (0.6–1.3). Which action should the pharmacist take regarding this prescription?
    Answer: Contact the prescriber to recommend an alternative non-tramadol analgesic due to increased seizure and serotonin syndrome risk with current medications This question examines the identification of drug interactions and contraindications with tramadol in patients with seizure history and serotonergic medications. The key patient-specific factors are the concurrent use of paroxetine, bupropion, and sumatriptan, which increase seizure and serotonin syndrome risks with tramadol, compounded by the patient's prior seizures. Option B is the best choice as contacting the prescriber to recommend a non-tramadol analgesic prevents potentially life-threatening interactions while ensuring appropriate pain management. Option A is incorrect because dispensing without intervention ignores significant risks, a misconception that tramadol's Schedule IV status implies low danger. Option C is suboptimal as increasing tramadol could heighten adverse effects without addressing interactions; option D dangerously promotes alcohol use, which lowers seizure threshold further. A clinical pearl is that tramadol should be avoided in patients on multiple serotonergic agents per FDA warnings. Apply a decision framework screening for seizure risk and drug interactions using tools like Lexicomp before dispensing controlled substances.
  17. A 63-year-old female (weight 58 kg) is taking methadone (Schedule II) 10 mg orally three times daily for chronic pain prescribed by her primary care provider. She is newly prescribed clarithromycin 500 mg twice daily for 10 days by an urgent care clinic. Current medications: methadone as above, sertraline 100 mg daily, and furosemide 20 mg daily. Allergies: none. Medical history: chronic pain, heart failure. Labs: potassium 3.2 mEq/L (3.5–5.0), magnesium 1.6 mg/dL (1.7–2.2), serum creatinine 1.1 mg/dL (0.6–1.3). Which controlled substance management action is most appropriate for this patient?
    Answer: Contact prescribers to avoid or change clarithromycin due to increased methadone levels and QT prolongation risk; recommend correcting electrolytes and consider electrocardiogram monitoring This question tests the management of drug interactions between methadone and macrolides in patients with cardiac risk factors. The key patient-specific factors are clarithromycin's potential to increase methadone levels and prolong QT interval, exacerbated by hypokalemia, hypomagnesemia, and heart failure. Option B is the best choice as contacting prescribers to avoid clarithromycin, correct electrolytes, and consider ECG monitoring prevents torsades de pointes and overdose. Option A is incorrect because antibiotics like clarithromycin do interact via CYP3A4 inhibition, a common oversight. Option C is suboptimal as increasing methadone risks toxicity; option D underestimates acute risks with insufficient monitoring. A pearl is that methadone requires QT monitoring per FDA black box warnings when combined with QT-prolonging drugs. Use a framework assessing electrolyte status and ECG needs for high-risk opioid interactions.
  18. A 67-year-old male (weight 76 kg) is brought to the pharmacy by his daughter after starting a new medication for anxiety. Current medications include alprazolam (Schedule IV) 1 mg by mouth three times daily (started 10 days ago), diphenhydramine 25 mg by mouth at bedtime as needed, lisinopril 20 mg by mouth daily, and metformin 1000 mg by mouth twice daily. Allergies: penicillin (rash). Medical history: type 2 diabetes, hypertension, mild cognitive impairment; no known substance use disorder. Labs: serum creatinine 1.2 mg/dL (0.6–1.3). The daughter reports he fell twice this week and is "confused and very sleepy." What is the most important monitoring parameter for this medication?
    Answer: Monitor for falls, confusion, and excessive sedation, especially during initiation and dose increases This question addresses monitoring parameters for benzodiazepines in elderly patients with cognitive impairment. The key patient-specific factors are advanced age (67 years), mild cognitive impairment, and the recent initiation of a high-dose benzodiazepine regimen combined with another anticholinergic/sedating medication (diphenhydramine). Option A is correct because falls, confusion, and excessive sedation are the most critical safety concerns with benzodiazepines in elderly patients, particularly those with baseline cognitive impairment. Option B is incorrect as neutropenia is not a concern with alprazolam (this would be relevant for clozapine). Option C is wrong because alprazolam does not affect coagulation or INR. Option D is incorrect as alprazolam does not cause hyperkalemia. The clinical pearl is that benzodiazepines are potentially inappropriate medications in elderly patients (Beers Criteria) due to increased sensitivity and risk of falls, cognitive decline, and delirium, requiring close monitoring for these adverse effects rather than laboratory parameters.
  19. A 39-year-old male presents to the pharmacy with prescriptions from two different prescribers. Current medications include amphetamine/dextroamphetamine extended-release (Schedule II) 20 mg by mouth every morning, pregabalin (Schedule V) 150 mg by mouth twice daily, and hydrocodone/acetaminophen (Schedule II) 5 mg/325 mg by mouth every 6 hours as needed (#120 filled 12 days ago). Allergies: none. Medical history: ADHD, fibromyalgia, chronic shoulder pain; history of stimulant use disorder (in remission). Labs: serum creatinine 1.3 mg/dL (0.6–1.3), AST 20 U/L (10–40), ALT 18 U/L (7–56). Today he presents a new hydrocodone/acetaminophen prescription for 10 mg/325 mg, 1 tablet every 4 hours as needed, #180, stating his prior prescription was "lost," and he requests early fill. Which controlled substance management action is most appropriate for this patient?
    Answer: Verify the prescription and loss claim by reviewing the prescription drug monitoring program and contacting the prescriber; document findings and use professional judgment before dispensing This question tests appropriate response to potential prescription fraud or diversion involving multiple controlled substances. The critical red flags include early refill request for Schedule II opioids (filled only 12 days ago), claim of lost medication, significant dose escalation, and history of substance use disorder. Option C is correct because it follows proper protocols: verifying through PDMP review to check for multiple prescribers or pharmacies, contacting the prescriber to verify the prescription and discuss the lost medication claim, documenting all findings, and using professional judgment based on the complete picture before making a dispensing decision. Option A inappropriately dispenses without verification despite multiple red flags. Option B is overly punitive and doesn't follow proper procedures. Option D addresses an irrelevant storage issue while ignoring the core concerns about potential diversion. The clinical framework for handling suspicious controlled substance requests includes PDMP consultation, prescriber verification, documentation of decision-making, and balancing patient care needs with prevention of diversion.
  20. A 27-year-old male (weight 80 kg) started lisdexamfetamine (Schedule II) 50 mg orally each morning for attention-deficit/hyperactivity disorder 2 months ago. He reports palpitations and decreased appetite; he also takes pseudoephedrine 60 mg twice daily for congestion and drinks 3–4 energy drinks/day. Allergies: none. Medical history: ADHD, seasonal allergies; no substance use disorder history. Vitals today: blood pressure 152/94 mmHg, heart rate 112 bpm. Labs: serum creatinine 0.9 mg/dL (0.6–1.3). What is the best recommendation for this patient's therapy?
    Answer: Recommend stopping pseudoephedrine and limiting caffeine/energy drinks, and notify the prescriber to reassess stimulant dose and cardiovascular monitoring This question assesses the management of stimulant therapy complications, including cardiovascular risks and drug interactions. The key patient-specific factors are elevated blood pressure and heart rate, likely exacerbated by lisdexamfetamine combined with pseudoephedrine and high caffeine intake, increasing sympathetic stimulation. Option B is the best choice because stopping pseudoephedrine and limiting caffeine reduces additive stimulant effects, while notifying the prescriber for dose reassessment and cardiovascular monitoring prevents serious events like hypertension or arrhythmias. Option A is incorrect as continuing without intervention ignores acute vital sign changes, a misconception that annual monitoring suffices for stimulants. Option C is suboptimal because adding clonazepam introduces sedation and dependence risks without addressing the root cause; option D risks worsening symptoms by increasing the stimulant dose, contrary to guidelines for managing adverse effects. A clinical pearl is that stimulants like lisdexamfetamine require baseline and periodic cardiovascular assessment per FDA labeling. Employ a decision framework evaluating concurrent sympathomimetics and lifestyle factors when monitoring controlled substance safety.

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