Virtual prescribing expected to be delayed again, same uncertainty
In November, the Office of Management and Budget (OMB) said the DEA may soon extend telemedicine electronic prescribing flexibilities for a fourth time. Over the past 5 years since the start of Covid PHE, temporary extensions have been critical for patients prescribed controlled medicines via telemedicine, for whom face-to-face requirements pose significant barriers to continuity of care. While another extension beyond the last day of 2025 will certainly be welcomed by providers and patients amid a multi-year cycle of uncertainty regarding telemedicine e-prescribing for controlled substances, we remain hopeful that the DEA will finalize meaningful and permanent regulatory policy regarding telemedicine e-prescribing subsidies in 2026.
It’s important to take a moment here to review the current state of things. The core issue remains the impending expiration again of the DEA's exception allowing electronic prescribing of controlled substances via telemedicine without an initial in-person visit. While the purpose of the Ryan Haight Act of 2008 was for Congress and the DEA to clarify policy regarding telemedicine electronic prescribing subsidies, the bill was riddled with misunderstandings, confusion, and a lack of consistency in federal and state legislation and prescribing flexibilities.
Clinicians rely on federal and state telemedicine flexibility to prescribe essential treatments for ADHD, anxiety, depression and other serious behavioral health conditions — medications that help patients remain stable, functional and safe. For many patients, these medications are an important part of psychiatry, family medicine, and pediatric care, not a luxury item. Disruptions in access often lead to instability, safety risks, and worsening of symptoms.
The cycle continues, but remains unclear
While another extension would provide temporary relief, it does not address the fact that providers, patients and health systems still lack the permanent regulatory clarity they need to plan future care with confidence. From late November through Christmas, clinics and pharmacies were flooded with calls from patients and parents asking if they could still get their medications, and unfortunately, many patients and families were left in limbo with their prescriptions. This uncertainty is unfolding, and ongoing drug shortages are already negatively impacting patients and frustrating healthcare providers and pharmacists.
For families suffering from ADHD, anxiety and other behavioral health issues, these medications are life-changing. Clinicians consistently emphasize that these drugs address real physiological imbalances in brain chemicals, just as other drugs address physical imbalances throughout the body. When access is disrupted, the consequences are obvious. Children experience difficulties in school, escalate behavioral problems, increase family stress, and in some cases, increase their risk of involvement in the juvenile justice system.
Regulatory whiplash is a clinical issue
The disruption caused by regulatory uncertainty is not limited to prescription controlled substances. During the recent government shutdown, Dr. Helen Hughes, media director for the Office of Telemedicine at the Johns Hopkins University School of Medicine, Healthcare IT News: “It is deeply frustrating and devastating to see the government shutdown hinder our telehealth progress. When we see critical opportunities for care disappear, we hope Congress will act quickly to permanently restore these essential services for our patients.”
Her remarks reflected clinicians' experiences when telemedicine policies were subject to temporary solutions. Whether the issue is Medicare coverage or DEA prescribing authority, last-minute delays can directly disrupt patient care, in addition to the administrative burden of canceled visits, late refills, and panic. Clinicians are forced to focus on managing uncertainty rather than fully focusing on practicing medicine.
What does this look like in practice
The Ryan Hite Online Pharmacy Consumer Protection Act contains in-person visit requirements, which remain the biggest source of confusion about the legislation.
Providers typically ask about:
- Will all patients need to be seen in person starting in the near future?
- Can care continue if another psychiatrist or clinician has seen the patient in person within the past few months?
- Are prescriptions filled immediately after an extension protected?
There is no clear answer. As a result, clinics have had to redesign schedules, document defensively rather than clinically, debate whether patients are being brought in unnecessarily, and manage increasing call volumes from pharmacies, parents, and schools.
Providers should not be forced to guess
During this long murky period, clinicians heard little from the DEA. Many in the medical community believe that silence is unacceptable given the stakes for patients.
Lack of communication from the DEA is often attributed to concerns about diversion. Diversion prevention is designed to reduce the abuse and illegal distribution of controlled substances. While this remains an important goal, providers stress that effective regulation should distinguish so-called pharmaceutical companies from legitimate prescribers. It should not make clinicians afraid of treating patients appropriately.
Medical professionals should not be expected to be able to decipher legislation that even legal scholars have trouble interpreting. In the absence of clear rules, many rely on good faith clinical judgment informed by legal counsel, documentation, and patient needs. When regulations are vague, good-faith interpretations are considered valid for clinicians acting in the best interests of their patients.
Extensions are not the solution
In a MedCity News article last year about how to respond to virtual prescribing policy changes, I provided several practical strategies to help providers operate amid ongoing regulatory uncertainty.
The guide emphasizes at a high level:
- Tighten compliance processes
- Enhance coordination with pharmacy and nursing teams
- Maintain clear patient communication
- Carefully document clinical decisions
I also call on policymakers to provide permanent, actionable guidance. These suggestions are still relevant today.
Extensions may delay disruption but do not solve the underlying problem. Until clear, lasting guidance from the DEA emerges, this cycle will continue. Every November and December, clinicians wait as care delivery remains vulnerable to policy delays.
Photo Credit: Big Stock Photos
Dr. Tom Milam serves as Chief Medical Officer of Iris Telehealth and President of Iris Medical Group, guiding their team of clinicians on telemedicine and industry best practices. He earned a bachelor's degree in Anthropology from West Virginia University, graduating magna cum laude and Phi Beta Kappa. He went on to earn a master's degree in divinity from Yale University, where he served as associate scholar, and later earned his doctorate in medicine (MD) from the University of Virginia. He received his psychiatry residency training at Duke University and the University of Virginia. Dr. Milam, who has practiced in North Carolina and New Zealand, is an associate professor of psychiatry and behavioral medicine at Virginia Tech's Carillion School of Medicine and Research Institute, where he has taught for the past 15 years.
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