Abuse and diversion of controlled prescription medications is a large and growing problem in the U.S. In fact, individuals abusing controlled medications outnumber the abusers of cocaine, heroin, hallucinogens, and inhalants combined. The first of this two-part paper focuses on the pragmatic, ethical, and legal issues that challenge physicians and other providers who must care for someone suspected or confirmed to be using deception to obtain controlled medications for resale, personal recreational use, or other reasons not sanctioned by the medical profession. The second part will focus on a general approach that attempts to minimize potential harms while still addressing legitimate medical needs of these challenging patients. It is hoped that this paper will be a catalyst for deeper and wider discussions and research on this difficult healthcare-related issue.