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The rate of Americans using pain medications like codeine, morphine, oxycodone and hydrocodone long term has remained stable in the last five years, but the amount of medication they take has increased, according to a new report.

The report, called A Nation in Pain, comes from pharmacy benefit manager Express Scripts and shows that almost half of chronic painkiller users are taking short-acting combinations that increase the risk for addiction, and often these cocktails are very dangerous.

Sixty percent of Americans on pain treatments for longterm conditions were prescribed potentially dangerous mixtures. One in three patients were taking a combination of an opiate and an anti-anxiety benzodiazepine, which is the most common combo in multiple drug overdose deaths. Eight percent were taking what’s called a “Houston Cocktail”: an opioid, muscle relaxant and a benzodiazepine. And nearly 30% were taking multiple painkillers together.

Use was most rampant in small Southeastern cities, and two-thirds of patients were prescribed the drugs by two or more physicians. About 40% filled their prescriptions at multiple pharmacies.

“There could be instances when prescribing these combinations of drugs is appropriate, but not at this scale,” said Jo-Ellen Abou Nader, the senior director of Fraud, Waste and Abuse at Express Scripts in a statement.

You can read the full report here.

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