Should I prescribe Adderall (amphetamine) and opioids to a patient who has no documented indication or prescription?

Do Not Prescribe Adderall or Opioids to This Patient

You should not prescribe Adderall (amphetamine) or opioids to a patient who has no documented medical indication, as doing so violates federal controlled substances law and exposes you to significant legal and regulatory sanctions. 1, 2

Legal and Regulatory Framework

• Prescribing controlled substances without a legitimate medical purpose is illegal under federal law and constitutes misprescribing that can result in criminal prosecution, loss of DEA registration, and medical board sanctions 2, 3
• The CDC explicitly recommends that clinicians should not prescribe opioids without establishing a documented pain condition that warrants such therapy, and the same principle applies to stimulants like Adderall 1
• Prescribing controlled substances based solely on patient demand, without clinical indication, represents diversion and is not protected as legitimate medical practice 2, 3

Required Clinical Documentation Before Any Controlled Substance Prescribing

Before prescribing opioids, you must document:

• A specific pain diagnosis with objective findings 1
• Functional impairment caused by the pain condition 1
• Previous trials of nonopioid therapies (physical therapy, NSAIDs, other nonpharmacologic approaches) 1
• Assessment of overdose risk factors including substance use history 1
• Discussion of serious risks including respiratory depression, opioid use disorder, and death 1

Before prescribing amphetamines, you must document:

• A diagnosis of ADHD or narcolepsy with appropriate diagnostic evaluation 4
• Assessment for contraindications and substance use disorder risk 4

This patient has none of these documented indications 4

The Specific Danger of This Clinical Scenario

• Patients requesting both opioids and stimulants without documented indications represent a high-risk pattern for substance use disorder and diversion 5
• Research shows that 38% of ED patients with untreated opioid use disorder test positive for amphetamine-type stimulants, and concurrent use significantly increases overdose risk and social harms 5
• The CDC warns that prescribing opioids to patients with active substance use dramatically increases the risk of fatal overdose 1

Your Appropriate Clinical Response

Inform the patient clearly that you cannot prescribe these medications without documented medical indications 4:

• Explain that controlled substances require specific diagnoses and prior treatment attempts 1, 4
• Offer to evaluate any legitimate pain or ADHD concerns through proper diagnostic workup 4
• Provide referrals to pain management specialists or psychiatrists if clinically appropriate after proper evaluation 4
• Document this conversation thoroughly in the medical record 1, 2

Screen for Substance Use Disorder

Given this request pattern, you should:

• Assess for opioid use disorder using DSM-5 criteria 1
• If criteria are met, offer or arrange evidence-based treatment with buprenorphine or methadone maintenance therapy combined with behavioral therapies 1
• Provide naloxone for overdose prevention 1
• Never dismiss the patient from care, as this constitutes patient abandonment—instead, offer appropriate substance use disorder treatment 1

Critical Pitfall to Avoid

Do not prescribe these medications "just this once" to maintain the therapeutic relationship or because the patient is insistent 2, 3. This exposes you to:

• Criminal prosecution for unlawful distribution of controlled substances 2, 3
• Civil liability and medical board sanctions 2, 3
• Enabling potential substance use disorder or diversion 1

The appropriate response is compassionate refusal with offer of legitimate evaluation and treatment for any underlying conditions, including substance use disorder if present 1, 4.