With a little over nine weeks left before the federal telemedicine prescribing exception expires, its proposed long-term replacement is still in review. I checked the saved record from the Office of Information and Regulatory Affairs: OIRA received DEA’s special-registration rule on August 25, and it remained pending as of October 24. A clinician starting a patient on a controlled medication this week has a year-end deadline to plan around and a replacement whose final terms remain unpublished.
DEA has already extended the exception four times. I would plan for a fifth extension as the likelier near-term outcome: the agencies have repeatedly chosen continuity of care while they finish the rules, and the latest extension explicitly gives that rationale. A final rule would also leave practices with implementation work between publication and use. Another extension buys time for both. Betting a patient’s next refill on that judgment, though, is a poor compliance plan.
Three federal prescribing rules matter here. The broad temporary exception covers qualifying remote prescriptions through December 31. A separate final buprenorphine rule offers an ongoing basis for treating opioid use disorder, with a six-calendar-month prescribing period for each patient. The pending special-registration rule would create a more durable system for eligible clinicians and certain telemedicine platforms. Each comes with different conditions.
The January 1 prescription list
The current extension, signed by DEA Administrator Terrance C. Cole and published last December, permits qualifying Schedule II–V prescribing before a clinician’s first in-person evaluation of the patient. Prescriptions must still serve a legitimate medical purpose, fall within the clinician’s authority and comply with applicable federal and state law. The exception generally covers audio-video visits, with audio-only treatment available for qualifying opioid-use-disorder medications.
For a practice sorting its patients, the federal picture looks like this:
| Medication or treatment situation | Available federal basis today | What changes if the temporary exception expires |
|---|---|---|
| Schedule II stimulants, including Adderall, prescribed before a clinician’s first in-person evaluation | The broad temporary exception, when its conditions are met | Arrange a qualifying in-person visit with the prescriber, or establish a different legal basis for continued prescribing. |
| Buprenorphine for opioid use disorder, before a clinician’s first in-person evaluation | The temporary exception or the separate final buprenorphine rule, under the conditions of the rule used | The separate rule stays available. Track six calendar months from the first prescription issued under it. Before that period ends, arrange a qualifying in-person visit with the prescriber or establish another legal basis. |
| Other qualifying Schedule III–V controlled medications prescribed before a clinician’s first in-person evaluation | The temporary exception, subject to its conditions; other statutory exceptions may apply in particular cases | Arrange a qualifying in-person visit with the prescriber, or establish a different legal basis for continued prescribing. |
| Controlled medications prescribed after the prescribing clinician has conducted a qualifying in-person evaluation | The usual prescribing framework, subject to clinical, registration and other legal requirements | Continue under the usual prescribing requirements; the expiration leaves this basis intact. |
The separate buprenorphine rule has practical requirements of its own: review of the patient’s state prescription-monitoring data, documentation and pharmacy identity verification. During the extension, clinicians can choose the temporary exception instead. Switching to the separate rule means adopting its conditions and tracking its patient-specific clock.
For a telehealth platform, the useful year-end exercise is to identify any services that depend on this exception, then map affected patients by medication, state, prior in-person evaluation and next refill date. A patient who needs an in-person appointment in January needs somewhere to go. That takes scheduling, a receiving clinician and a transfer of records.
Who carries the safeguards?
DEA’s January 2025 special-registration proposal would put certain telemedicine platforms under registration requirements alongside clinicians. It also proposes prescription-monitoring checks and tighter conditions for Schedule II medications.
Some of the objections are concrete. In the American Psychiatric Association’s March 18 comment letter, CEO and medical director Marketa Wills warned that added state registrations and fees could shrink access to an already limited workforce. The association supported prescription-monitoring checks while pointing to gaps in interstate data sharing. It also challenged the proposed requirement that Schedule II prescriptions issued under special registration constitute less than half of a clinician’s monthly Schedule II prescribing.
A psychiatrist running a largely remote practice could face a difficult choice under that proposal: arrange more in-person care or limit the patients served through special registration. I find the cap a blunt safeguard: a clinician’s proportion of remote prescriptions tells us little about the quality of any patient’s care. DEA should explain why that ratio would catch unsafe prescribing.
Two million pills and a Medicaid study
Lindsey Hammerslag, a researcher at the University of Kentucky, and colleagues offer one reason to protect remote access. Their 2023 JAMA Network Open study examined Kentucky and Ohio Medicaid claims from 2020. In Kentucky, 48.0% of patients who started buprenorphine through telemedicine remained in treatment at 90 days, compared with 44.4% of patients starting through other care. In Ohio, the figures were 31.6% and 27.9%. The association held after adjustment for measured patient characteristics.
The researchers found no statistically significant association between telemedicine initiation and medically treated nonfatal overdose. Overdose events were rare, limiting the study’s power to detect a difference. The claims analysis also leaves room for patient-selection effects and other unmeasured differences.
Adderall has a different record. On October 2, the Justice Department announced that a federal jury in western Michigan had convicted Jonathan Decker, a doctor from Rockford, of conspiracy and six counts of distributing controlled substances. Prosecutors said he distributed more than two million stimulant pills through Done, the ADHD platform, and was paid more than $1 million for his prescriptions. He was the eleventh defendant convicted in the case. The company’s CEO, Ruthia He, had been sentenced to six years in prison; clinical president David Brody had received two.
The details are worse than the pill count. Prosecutors described a patient whose mother told Decker and Done that her daughter had schizophrenia and that Adderall worsened her psychotic symptoms. Decker continued prescribing. When pharmacies began refusing to fill his stimulant prescriptions, according to the release, he speculated that “running a meth lab seems like a pretty good idea.” I find that line chilling beside the mother’s warning: she was asking the doctor and company to recognize harm, while he was treating pharmacy refusals as an obstacle.
One criminal case cannot measure the safety of virtual psychiatry as a whole. But the records give a platform two specific jobs: preserve access to treatment that helps patients stay in care, and make sure a warning like that mother’s reaches someone with the authority to stop a prescription. Another extension could keep the first job possible. The second already belongs to the people running the service.
Reporting note: This is an analysis of public regulatory records, a published study, a clinician association’s comments and a Justice Department prosecution account. No interviews were conducted. Status as of Oct. 24.