On February 24, 2023, the Drug Enforcement Administration (DEA) proposed permanent rules that would extend certain telehealth flexibilities introduced during the COVID-19 Public Health Emergency, which is set to end May 11, 2023.

The proposed rules would allow the prescribing of certain controlled medications via telemedicine without needing an in-person evaluation, expanding patient access to critical therapies beyond the scheduled end of the Public Health Emergency.

Which Telemedicine Flexibilities Could Be Impacted?

Not all the pandemic-era flexibilities will be protected under the proposed rules. Instead, the DEA is focusing on protecting access to mental health and substance use disorder services through expanded telemedicine flexibilities.

The proposed rules would provide safeguards for telemedicine consultations that meet these limited criteria:

• Those in which a medical practitioner has never conducted an in-person evaluation of a patient; AND
• which result in the prescribing of a controlled medication.

The proposed rules DO NOT affect:

• Telemedicine consultations that do not involve the prescribing of controlled medications.
• Telemedicine consultations by a medical practitioner that has previously conducted at least one in-person medical examination of a patient.

The proposed rules also will not affect telemedicine consultations with a patient who was referred by another medical practitioner who previously had conducted an in-person evaluation of that patient. Prescriptions written by medical practitioners via telemedicine based on a referral will require additional recordkeeping obligations however.

DEA’s Proposed Telemedicine Rules

The proposed rules would allow DEA-registered practitioners to prescribe Schedule III-V non-narcotic controlled medication via telemedicine consultation to a patient:

• Not previously evaluated in person; and
• Not referred by a medical practitioner who evaluated the patient in person.

For these types of consultations, medical practitioners will be able to prescribe up to a 30-day supply of Schedule III-V non-narcotic controlled medications or a 30-day supply of buprenorphine for the treatment of opioid use disorder.

An in-person visit would be required for refills of these prescriptions.

The full text of the proposals may be found here and here. The rules will be open for public comment for 30 days, which the DEA will then consider before drafting final regulations.

Prescribing Controlled Substances Via Telemedicine – Before, During & After COVID-19

Under the U.S. Controlled Substances Act of 2008 (21 U.S.C. 829(e)), a practitioner can only prescribe controlled substances after conducting an in-person examination of the patient. The Act was passed to curb online pharmacies offering controlled substances – including opioids – without a valid doctor-patient relationship.

The U.S. Controlled Substances Act does include some exceptions to the in-person medical evaluation requirement, including treatment during a Public Health Emergency, such as the one declared by the Secretary of Health and Human Services on January 31, 2020.

While the Public Health Emergency (PHE) remains in effect, DEA-registered practitioners may issue prescriptions for all schedule II-V controlled substances to patients for whom they have not conducted an in-person medical evaluation via telemedicine consultation.

Requirements for a PHE exception to controlled substance prescriptions include:

• Acting in the usual course of their professional duties, the physician or prescribing practitioner issues the prescription to treat a valid medical purpose.
• In issuing the prescription, a two-way, interactive telemedicine appointment is conducted via a real-time, audio-visual system.
• The physician or prescribing practitioner complies with all relevant State and Federal laws.

With the Public Health Emergency set to expire May 11, 2023, the DEA proposed its rules to ensure that patients do not experience lapses in care.

Although the new rules would expand the use of telemedicine for prescribing controlled substances beyond what was allowed before the Public Health Emergency, they would re-establish some limitations by requiring at least one in-person visit.

Which Medications Can be Prescribed Through Telemedicine?

DEA’s proposed rules impact controlled medicines. Because controlled medicines have the potential to cause physical or psychological dependence, they are subject to strict DEA regulation and are classified into different schedules based on their potential for abuse with Schedule I substances being considered the most dangerous and Schedule V substances being considered the least dangerous.

The DEA rules would impact Schedule III, IV, and V medications. Examples of these include anabolic steroids, buprenorphine, Ambien, Tramadol, Valium, Xanax, Lomotil, and Lyrica. The DEA published guidance to patients to help determine if their prescription will be impacted by the proposed telehealth rules. A complete list of controlled substances (I-V) can be found here.

Texas Laws on Prescribing Controlled Substances

Texas providers must follow all federal telemedicine and prescribing regulations. In addition, telehealth prescribers in Texas are required to adhere to the same standard of care as an in-person setting. This means that the validity of a prescription issued as a result of a telemedicine service is determined by the standards that would apply to the issuance of the prescription in an in-person setting. As always, the prescription must be issued for a legitimate medical purpose.

Are Your Practice’s Telemedicine Services Compliant?

The proposed changes to federal regulations surrounding the prescribing of controlled substances via telemedicine are important for healthcare providers to consider, as they can have a significant impact on their telemedicine prescribing flexibilities.

Consult with a healthcare attorney to ensure that your practice, clinic, or facility is compliant with all legal requirements and that any new rules are adhered to as the nation and state and federal governments transition out of the COVID-19 Public Health Emergency.