Prescribing controlled drugs by telehealth: the rules are still temporary

Clinicians in the United States can still prescribe controlled medications — including ADHD stimulants and buprenorphine for opioid use disorder — to patients they have never examined in person, because a pandemic-era waiver of the in-person requirement has been extended a fourth time, now running through 31 December 2026 [s1]. The permanent framework meant to replace it, a Drug Enforcement Administration "special registration" system, remains only a proposal [s2].

That unsettled state is the story. The direct-to-consumer telehealth companies that prescribe stimulants, weight-loss drugs and other controlled or prescription medicines are operating under a temporary rule that has now been renewed rather than resolved, and the rules that would govern them permanently are still being written.

The in-person rule, and the waiver

The starting point is the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, which generally requires a practitioner to conduct an in-person medical evaluation before prescribing a controlled substance, with a limited exception for the defined "practice of telemedicine" [s2]. When COVID-19 was declared a public health emergency in 2020, the DEA and the Department of Health and Human Services waived that in-person requirement so controlled medications could be prescribed over telemedicine. That waiver is the legal basis on which much of the current direct-to-consumer prescribing rests.

Rather than let it expire, the agencies have repeatedly extended it. The most recent action, a joint DEA–HHS rule published on 31 December 2025, is the fourth temporary extension; it keeps the telemedicine flexibilities in place from 1 January 2026 through 31 December 2026 [s1]. The effect is that, for now, a first prescription of a controlled medication after a telemedicine-only encounter remains permissible [s1]. Controlled stimulants used for ADHD fall squarely within this, which is why online ADHD services have been able to operate — and why their legal footing moves with each extension. The dynamics of stimulant prescribing are examined separately in coverage of prescribing trends in Ontario.

The permanent framework is still a proposal

A fourth extension is, by definition, not a settled policy. The permanent replacement the DEA has floated is a "special registration" framework, set out in a proposed rule published on 17 January 2025 [s2]. That proposal would create a special registration and authorise three types of it, and would add what the DEA calls heightened prescription, recordkeeping and reporting requirements [s2]. The agency's stated aim is to expand patient access to controlled-substance medications via telemedicine while mitigating the risk of diversion that such expansion carries [s2].

As of this writing that rule is a proposal, not a final rule; its comment period ran to 18 March 2025 [s2]. Until it is finalised, the special-registration system does not exist in operative form, and the temporary extensions are the only thing keeping telemedicine prescribing of controlled drugs lawful. The repeated short-term renewals — rather than finalisation — are themselves a signal that the design questions are unresolved.

Where a permanent rule did land: buprenorphine

There is one area where the agencies moved past extension to a durable rule. A DEA–HHS final rule, also published on 17 January 2025 and effective 18 February 2025, expanded the circumstances under which DEA-registered practitioners may prescribe the schedule III–V controlled substances that the FDA has approved for treating opioid use disorder — chiefly buprenorphine — via a telemedicine encounter, including an audio-only encounter [s3]. Under the rule, the practitioner reviews the patient's state prescription drug monitoring programme data before prescribing [s3].

That carve-out reflects a specific policy judgement: for opioid use disorder, where buprenorphine reduces overdose risk and access is the binding constraint, regulators were willing to make a telemedicine pathway permanent under defined conditions. It is the clearest statement of the trade-off running through all of these rules — expanding access against guarding against diversion — and the one place the balance has been struck with a final rule rather than a countdown clock.

What it means, and what to watch

For a patient or a reader, the practical position is this: prescribing controlled medications after a telemedicine-only visit is currently allowed, but on the strength of a waiver that now expires at the end of 2026 unless extended or replaced [s1]. For the direct-to-consumer telehealth industry, the regulatory foundation is explicitly provisional, and the diversion concerns the DEA cites in its proposed framework are the reason the permanent rules carry heavier recordkeeping and reporting duties than the emergency waiver did [s2].

The thing to watch is whether the special-registration rule is finalised before the current extension lapses. If it is, the improvised pandemic arrangement becomes a standing system with its own controls; if it is not, the pattern of year-end extensions is likely to continue. Either way, the safety question regulators keep returning to is not whether telemedicine prescribing can work — the evidence on remote and audio-only care is mixed but real — but how to keep controlled drugs from leaking out of a system built for convenience.