Is DEA Hurtling Us Toward the Telehealth Cliff?

As its December 31, 2025 deadline looms, the DEA has given no signal on the future of telemedicine prescribing for controlled substances. What was supposed to be a temporary fix during the COVID-19 crisis, controlled substance telemedicine prescribing has evolved into a critical access point for millions of patients—especially those in rural and underserved communities. Yet despite years of warnings, legislative mandates, and public outcry, the agency has failed to provide a permanent solution. If the DEA doesn’t act soon, we’re not just approaching a telehealth cliff—we’re hurtling toward it with no guardrails. The consequences of this could be devastating, cutting off care for thousands and unraveling a system that has proven both effective and essential. As outlined below, DEA has very few options for how it may proceed over the coming months.

The historical relationship between telemedicine and controlled substance prescribing is complicated and multifaceted. In the 1990s, the rise of rogue online pharmacies selling controlled substances without patients seeing their prescribing doctors prompted Congress take action, which led to the passage of the Ryan Haight Online Pharmacy Consumer Protection Act in 2008 (the "Ryan Haight Act"). The Ryan Haight Act required an in-person medical evaluation before prescribing controlled substances online and included seven exceptions, such as during a public health emergency or under a special registration process. However, the special registration pathway was never implemented.

Over a decade later, Congress reinforced this mandate through the SUPPORT for Patients and Communities Act of 2018 (the "SUPPORT Act"). Section 3232 of the SUPPORT ACT reaffirmed DEA’s obligation to publish regulations for the special registration. Congress went so far as to set a statutory deadline of October 24, 2019 for DEA to launch the special registration, which DEA has still failed to do.

The, in 2020, the COVID-19 pandemic forced a rapid shift in healthcare delivery. In response to the public health emergency, the DEA temporarily waived the in-person exam requirement under the Ryan Haight Act, allowing providers to prescribe controlled substances via telemedicine. This emergency flexibility became a lifeline for patients needing treatment for conditions such as ADHD, opioid use disorder, and anxiety.

In March 2023, the DEA issued a Notice of Proposed Rulemaking titled Telemedicine Prescribing of Controlled Substances When the Practitioner and the Patient Have Not Had a Prior In-Person Medical Evaluation. However, the proposed rule did not include the long-promised special registration pathway. Instead, introduced a prescriber referral requirement that many stakeholders found unworkable and was criticized for being drafted by political appointees unfamiliar with telemedicine and how it operated. In response to widespread criticism, the DEA issued three temporary extensions to preserve telemedicine access—on May 10, 2023; October 10, 2023; and November 19, 2024. The third extension is set to expire on December 31, 2025, leaving the future of telemedicine prescribing in limbo.

In January 2025, just days before a change in administration, the DEA released its long-awaited Special Registration Notice of Proposed Rulemaking. Unfortunately, rather than offering a workable framework to preserve telemedicine access, the proposal was riddled with restrictive and impractical provisions that drew immediate criticism from stakeholders and even internal DEA staff. Among the most burdensome requirements was a mandate for clinicians to conduct Prescription Drug Monitoring Program (PDMP) checks in all 50 states—regardless of whether the state already had robust monitoring systems or whether the patient was located there. The rule also imposed a cap that would allow only 50% of a provider’s Schedule II prescriptions to be issued via telemedicine, effectively penalizing clinicians who specialize in remote care.

Further, the proposal restricted telemedicine prescribing of Schedule II drugs to the practitioner’s state of licensure, undermining the very cross-state flexibility that makes telehealth viable for rural and underserved populations. Only select specialties—such as psychiatry, hospice, palliative care, pediatrics, and neurology—would be permitted to prescribe Schedule II substances remotely, excluding many qualified providers who have been safely and effectively treating patients via telemedicine for years. The rule also required audiovisual communication for all telemedicine encounters, disallowing audio-only visits even in cases where video access is limited or impractical.

Perhaps most concerning, the rule introduced a vague and arbitrary limitation on telemedicine platforms, requiring them to obtain a separate registration and comply with additional reporting and oversight mechanisms that many view as duplicative and unworkable. These restrictions, taken together, reflect a fundamental misunderstanding of how telemedicine operates in practice and threaten to dismantle a system that has become essential for millions of patients. Instead of expanding access, the DEA’s proposal risks creating a regulatory bottleneck that could drive providers out of telehealth entirely and leave vulnerable populations without care.

Now, the DEA faces three options. First, it could proceed with finalizing the special registration rule before the December 31, 2025 deadline. While this would technically fulfill the agency’s long-standing obligation under the Ryan Haight Act and the SUPPORT Act, doing so would present a host of implementation challenges and legal risks. One of the most pressing concerns is that the final rule may differ significantly from the proposed version published in January 2025. Under administrative law, such discrepancies can trigger “logical outgrowth” issues—meaning stakeholders could argue they were not given a fair opportunity to comment on the final provisions, potentially rendering the rule vulnerable to legal challenge.

Moreover, the current proposal includes a number of controversial restrictions that have drawn criticism from both industry leaders and internal DEA staff. These include mandatory PDMP checks in all 50 states, arbitrary caps on the percentage of patients who can be treated via telemedicine for Schedule II drugs, and limitations on which specialties are allowed to prescribe these medications remotely. If finalized in its current form, the rule could impose operational burdens so severe that many telemedicine companies—particularly those focused on behavioral health, addiction treatment, and ADHD care—may be forced to shut down or drastically scale back services. The ripple effects would be felt most acutely by patients who rely on telemedicine for consistent, stigma-free access to care. In rural and underserved areas, where in-person providers are scarce, the loss of telehealth options could mean the difference between receiving treatment and going without. Finalizing the rule without significant revisions could therefore not only destabilize the telehealth industry but also create a public health crisis by cutting off access to essential medications for thousands of patients.

Second, the DEA could issue another extension, maintaining the current flexibilities for another year. While this would preserve access in the short term, it would also prolong uncertainty for providers and patients who are waiting for a long-term solution.

Third, the DEA could opt to take no action at all, allowing the current emergency telemedicine flexibilities to expire on December 31, 2025. This would automatically reinstate the original provisions of the Ryan Haight Act, including the requirement for an in-person medical evaluation before any controlled substance can be prescribed via telemedicine. Critically, there would be no grandfathering clause—meaning that even patients who have been receiving care remotely for months or years would suddenly be required to schedule and attend in-person visits to continue their treatment.

This abrupt shift would have far-reaching consequences. Patients who rely on telemedicine for access to medications like buprenorphine (used in opioid use disorder treatment), stimulants for ADHD, and anti-anxiety medications would face immediate disruptions. Many of these individuals live in areas with limited access to in-person providers, and some may struggle with transportation, mobility, or stigma that makes in-person care impractical or even impossible. For them, telemedicine isn’t just a convenience—it’s a lifeline.

If the DEA allows the flexibilities to lapse without a replacement framework, the result could be a public health crisis. Providers would be forced to discontinue care for patients who cannot meet the in-person requirement, potentially leading to untreated mental health conditions, relapse in addiction recovery, and increased strain on emergency services. The sudden loss of access could also exacerbate health disparities, particularly in rural and underserved communities where telehealth has helped bridge longstanding gaps in care.

In short, after more than 15 years of delay, the DEA has yet to deliver on a mandate that Congress made crystal clear back in 2008—and reaffirmed in 2018. Despite repeated deadlines, mounting public pressure, and a global health crisis that exposed the urgent need for telemedicine access, the agency has dragged its feet at every turn. Now, with the expiration of emergency flexibilities just months away, the DEA’s indecision is no longer just bureaucratic inertia—it’s a direct threat to patient care. The agency’s failure to act decisively has created a regulatory vacuum that jeopardizes access to essential medications for millions. Whether telemedicine remains a viable option for vulnerable patients or collapses under the weight of outdated rules will depend entirely on whether the DEA finally chooses to do its job—or lets the system fall off the telehealth cliff it’s spent years ignoring.