Is it safe to prescribe Adderall (amphetamine and dextroamphetamine) to a patient with a history of methamphetamine addiction?

Prescribing Adderall in a Patient with Methamphetamine Addiction History

Adderall should not be prescribed to patients with a history of methamphetamine addiction due to high risk of abuse, dependence, and potential for relapse. 1

Rationale for Contraindication

• Amphetamines (including Adderall) have been extensively abused, with documented tolerance development, extreme psychological dependence, and severe social disability 1
• Adderall (amphetamine and dextroamphetamine) is a Schedule II controlled substance with high abuse potential and pharmacological properties similar to methamphetamine 1
• The FDA drug label specifically warns that the "least amount feasible should be prescribed or dispensed at one time in order to minimize the possibility of overdosage" 1
• Abrupt cessation following prolonged high-dose amphetamine administration results in extreme fatigue and mental depression 1

Risk Assessment Considerations

• A history of substance use disorder, particularly methamphetamine addiction, significantly increases the risk of:

  • Medication misuse and diversion 2
  • Development of harmful drug-related behaviors 2
  • Relapse to methamphetamine use 3, 4

• Drug interactions are particularly concerning as amphetamines may:

  • Enhance the activity of tricyclic antidepressants and other sympathomimetic agents 1
  • Have dangerous interactions with MAO inhibitors, potentially causing hypertensive crisis 1
  • Counteract the effects of antihypertensives and other medications 1

Alternative Approaches

For patients with both ADHD and methamphetamine use disorder:

1. Non-stimulant ADHD medications should be considered first-line:

   • Atomoxetine (Strattera) 2
   • Extended-release guanfacine (Intuniv) 2
   • Extended-release clonidine (Kapvay) 2

2. Comprehensive addiction treatment should be prioritized:

   • Linkage to addiction treatment and recovery resources 2
   • Mental health services when applicable 2
   • Behavioral therapy and psychosocial support 2

Special Considerations

• While some early research has explored the use of methylphenidate (not Adderall) for methamphetamine use disorder treatment, results have been mixed and insufficient to recommend this approach 5, 6
• A small study of dextroamphetamine for methamphetamine addiction showed no reduction in methamphetamine use despite some reduction in withdrawal and craving 7
• Any consideration of controlled substances in patients with addiction history requires:
  • Careful evaluation and risk stratification 2
  • Close monitoring and reassessment 2
  • Signed release for information exchange between providers 2

Conclusion

The risks of prescribing Adderall to a patient with methamphetamine addiction history significantly outweigh any potential benefits. Non-stimulant medications for ADHD combined with comprehensive addiction treatment represent the safest and most appropriate approach for these patients.