In modern medicine, few areas are as highly scrutinized as stimulant prescribing for ADHD. As a psychiatrist who supervises mid-level clinicians across multiple states, I get more prescriber questions and general angst about this topic daily than all other topics in psychiatry combined.
Health care professionals have good reason to be concerned and somewhat confused. Physicians navigating the 2025 stimulant landscape find themselves in a precarious position — balancing increasing and ever-changing regulatory oversight by the DEA and increasing dispense resistance from pharmacies, with overwhelming patient interest and demand for stimulants. It’s a medical minefield that lacks a roadmap.
Despite being one of the most common chief complaints in both primary care and psychiatry, ADHD still lacks clear, unified, codified specialty-backed diagnosing and prescribing guidelines that most other psychiatric conditions enjoy. The American Psychiatric Association (APA) has published codified Clinical Practice Guidelines for a multitude of conditions, including depression, schizophrenia, alcohol use disorder, eating disorders, antipsychotic use in dementia, and (most recently) the prevention and treatment of delirium. These published algorithms provide clear, codified diagnostic and prescribing guidelines for many of the most common and complex psychiatric conditions. Despite its frequent presentation and regulatory complexity, however, ADHD remains conspicuously absent from the APA’s Clinical Practice Guidelines.
On the bright side, The American Professional Society for ADHD and Related Disorders (APSARD) is currently developing the first set of ADHD guidelines for adults. This is a great start. But given the complexity of ADHD diagnosing and the highly controlled nature of the first line medications, physicians still need definitive direction and concrete guidelines from a neutral, well-known subject matter expert body like the APA. There is some concern, whether justified or not, that APSARD’s special interest and advocacy in ADHD will ultimately result in diagnosing and prescribing guidelines that are too lenient. The APA encompasses clinicians with a very wide range of perspectives on the diagnosis. Would these diverse viewpoints lead to more comprehensive guidelines? It’s a fair point to consider.
ADHD is one of the most diagnosed and treated disorders in modern American medicine. And yet, it lacks a unified, authoritative framework for diagnosis and medication management. This void creates major inconsistencies in clinical practice, leaving physicians vulnerable to scrutiny without an agreed upon medical roadmap. The result? A system where doctors are left guessing, pharmacists are left second-guessing, and regulators are left trying to rein in a disorder with undefined policy level guidelines.
The question is: Why?
Why does the APA, which offers robust prescribing guidance for conditions ranging from major depression to eating disorders, remain conspicuously silent on ADHD? Is it because ADHD is an “orphan” diagnosis — one that no single specialty wants to claim as its own? Psychiatry, neurology, pediatrics, and primary care all address ADHD, yet none fully own it because the diagnostic process lacks consensus, and the medications are so highly regulated. Who wants to sign their name on a schedule II controlled medication when nobody can agree on what is required to prescribe it? This ambiguity trickles down to regulators and pharmacies, who in turn struggle to balance the need for access with the need for (undefined) clinical oversight.
In an era when stimulant prescribing is under more scrutiny than ever, the lack of clear guidelines does not just orphan the diagnosis itself — it orphans those of us responsible for treating it. Can an ADHD diagnosis be made in a virtual setting or is an in-person visit truly medically necessary? Can an ADHD diagnosis be made on clinical history alone, or is additional standardized testing required? Should stimulants be the first line option for all patients? Even in those with a history of a substance use disorder? How much of a stimulant prescription should be given at each prescription? When and how often should urine drug screens be utilized? With all these questions hotly contested and an increasingly scrutinized schedule II medication on the other end, it’s no wonder clinicians run for the hills.
To complicate matters more, recent research has found that “adults between the ages of 26 and 34 who started their ADHD stimulant medications through telehealth have a higher risk of SUD even after accounting for mental health conditions.” Do these additional telehealth prescribing concerns contribute to ADHD’s orphan status? It certainly doesn’t help.
Here’s the thing about orphans: they need the MOST care and attention — not the least. Without decisive leadership and clear consensus on these key treatment questions, clinicians remain in a regulatory gray zone, left to navigate one of the most high-risk prescribing areas in medicine without a reliable compass. Until that changes, patients, too, will continue to bear the unintended consequences of an orphan diagnosis: lack of care, inconsistent care, non-evidence-based care, and increased clinician burnout.
How do you approach ADHD prescribing? Share in the comments.
Dr. Lauren Grawert is a double board-certified addiction psychiatrist. She received her medical degree from Medical University of South Carolina College of Medicine and has been in practice 15 years. She speaks multiple languages, including Spanish. She was chief of psychiatry at Kaiser Permanente of the Mid-Atlantic from 2018-2022. She is currently the CMO at Aware Recovery Care. She enjoys working with the media in her spare time to reduce stigma around mental illness and addiction. She has been interviewed by SAMHSA on co-occurring disorders and most recently published articles in Capital Psychiatry and Northern Virginia Magazine.
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