Clinicians

Screening for Stimulant Misuse Risk Before Referral

September 12, 2026 · 6 min read

Last updated September 12, 2026

Prescribers increasingly ask the referring counselor a direct question: is this a safe patient for a controlled substance? The question is fair. Stimulants are Schedule II, non-medical use among young adults is well documented, and the prescriber often has thirty minutes with a patient you have seen for several hours. A short, systematic misuse screen, done before referral and documented in your report, protects the client, the prescriber, and you. It also identifies the clients for whom a non-stimulant recommendation is the better first step.

The base rates

Most adults with ADHD who are prescribed stimulants take them as directed, and treatment is associated with lower, not higher, rates of substance use disorder over time (Chang et al., 2014). At the same time, non-medical stimulant use among college students runs between five and ten percent annually in most surveys, and the most common source is a peer with a prescription. So the risk is real but concentrated, and the goal of screening is to find the concentration, not to treat every client as a suspect.

The risk factors worth asking about

Current or past substance use disorder, especially stimulant or cocaine use. A first-degree relative with substance use disorder. Prior non-medical use of prescription stimulants, which many college-age clients will disclose if asked matter-of-factly. Requesting a specific stimulant by brand name and declining to discuss alternatives. A history of lost or early-refill prescriptions. Antisocial traits or a conduct disorder history. Living arrangements where diversion is easy and lucrative, such as a dorm or a fraternity house. None of these is disqualifying alone. Two or more should shape the recommendation.

How to ask

Normalize and be direct. ‘I ask everyone these questions because the medications used for ADHD are controlled substances and I want to give your prescriber a complete picture.’ Then: have you ever used a prescription stimulant that was not prescribed to you? Has anyone in your family had a problem with alcohol or drugs? Tell me about your own alcohol and drug use, currently and in the past. Have you ever sold or given away a prescription? Asked in that tone, most clients answer honestly. Add a brief standardized measure: the AUDIT-C for alcohol, the DAST-10 for drugs, and, if you want a stimulant-specific tool, the items from the Stimulant Misuse Questionnaire.

What the answers change

Low risk (no history, no red flags): refer with a note that you screened and found no contraindication. Moderate risk (one factor, such as a family history or remote non-medical use): refer and recommend that the prescriber consider a long-acting formulation, which has lower misuse potential, with pill counts or a controlled-substance agreement. High risk (active substance use disorder, prior diversion, multiple factors): recommend treating the substance use first or concurrently, and suggest the prescriber start with a non-stimulant such as atomoxetine or viloxazine, which are not controlled. You are not making the prescribing decision, but a clear recommendation with a rationale is what a good prescriber wants from you.

Documenting it

Include a short section in your report titled ‘Substance use and misuse risk screening.’ List the instruments and scores, the history obtained, and your risk formulation in one paragraph. State your recommendation. This section takes ten minutes to write and it is the part of your report a prescriber will read first. Keep the tone clinical; the client will likely read it too, and there is no reason for it to be accusatory.

Your ongoing role

If the client continues in counseling, you are the monitor the prescriber does not have. Ask at intervals how the medication is being taken, whether any has been shared or lost, and whether the client is using it for anything other than its intended purpose, such as staying awake or losing weight. Report concerns to the prescriber with the client’s knowledge and consent where possible. That partnership is what makes stimulant treatment safe, and it is a role counselors are well placed to fill. The clinician hub covers the other parts of the referral relationship.

The bottom line

Screen every adult ADHD client for misuse risk before referral, using direct questions and a brief standardized measure. Sort into low, moderate, and high risk, tie a specific medication recommendation to each, and document it in its own section. Ten minutes of work makes the referral more useful and the treatment safer.