Prescribing Controlled Substances via Telehealth: What Every Provider Should Know

By: Edoardo Guidi

Since the government passed House Bill 23 (Chapter 2019 – 137), the practice of telemedicine has increased significantly. Since the advent of the COVID-19 pandemic, telemedicine has been utilized more every year (154% more in 2024 than the previous year). The practice of telemedicine increases patient access to care, particularly in mental health, pain management, and chronic disease management. In these cases, doctors may opt to give “controlled substance” therapy.

This post explores the key considerations, rules, and evolving trends around prescribing controlled substances in the digital age.

What are controlled substances and how are they classified?

Controlled substances are drugs or chemicals whose manufacture, possession, or use is regulated by the government due to its potential for abuse, addiction, or harm. They have potential for abuse or dependence and are regulated under the Controlled Substances Act (CSA) in the United States. These substances are classified into five schedules based on their potential for abuse and their medical use.

Schedule I:

• High potential for abuse.
• No accepted medical use in the U.S.
• There is a lack of accepted safety for use of these drugs under medical supervision. Examples include: Heroin, LSD, ecstasy, marijuana (federally), and methaqualone.

Schedule II:

• High potential for abuse, with use potentially leading to severe psychological or physical dependence.
• There are accepted medical uses but with restrictions. Examples include: Cocaine, methamphetamine, fentanyl, oxycodone, and Adderall.

Schedule III:

• Moderate to low potential for physical and psychological dependence.
• Accepted for medical use. Examples include: Anabolic steroids, ketamine, testosterone, and products containing less than 90 milligrams of codeine per dosage unit (like Tylenol with codeine).

Schedule IV:

• Low potential for abuse and low risk of dependence.
• Accepted for medical use. Examples include: Xanax, Valium, Ambien, and Tramadol.

Schedule V:

• Lower potential for abuse than Schedule IV.
• Accepted for medical use.
• Often used for antidiarrheal, antitussive (cough-suppressing), and analgesic purposes. Examples include: Cough preparations with less than 200 milligrams of codeine per 100 milliliters (like Robitussin AC), Lomotil, and Lyrica.

Given the potential risks associated with these substances, the federal government enforces strict regulations on their prescription, sale, and distribution.

What the law provides:

According to the law, a telehealth provider may not use telehealth to prescribe a controlled substance listed in Schedule II of section 893.03, Florida Statutes, unless the controlled substance is prescribed for the following:

• the treatment of a psychiatric disorder;
• inpatient treatment at a hospital licensed under Ch. 395, Florida Statutes;
• the treatment of a patient receiving hospice services as defined in s. 400.601, Florida Statutes; or
• the treatment of a nursing home resident as defined in s. 400.021, Florida Statutes.

When it comes to prescribing controlled substances, telehealth encounters require extra care due to stringent federal and state regulations.

Things to Consider if you want to sell controlled substances:

In order to sell these substances via telemedicine, one must obtain a license. Both state and federal licenses are required. At the federal level, you must register with the Drug Enforcement Administration (DEA) to obtain a DEA Number following the regulations of the Controlled Substances Act (CSA). At the state level, a license must be obtained from the Florida Department of Health (DOH), which includes registration with the Prescription Drug Monitoring Program (PDMP), known as E-FORCSE. Additionally, it’s crucial to comply with the Ryan Haight Act, which mandates that controlled substances can only be prescribed via telemedicine after an in-person medical visit, unless specific exceptions apply.

According to the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, controlled substances can be prescribed only after an initial in-person meeting between the doctor and the patient. However, due to the complexities of covid-era restrictions, the DEA temporarily waived the requirement for an in-person medical examination before prescribing a controlled substance and waived state registration requirements for such prescriptions for the duration of the pandemic.

After the COVID period, it was thought that the DEA would reinstitute the requirement to have an in-person visit for prescribing controlled substances, but instead, thanks in part to SAMHSA (Substance Abuse and Mental Health Services Administration), a proposed rule was issued in March 2023 titled “Prescribing Controlled Substances via Telemedicine when the practitioner and patient have not had a previous in-person medical evaluation.” The proposed rule would allow practitioners to prescribe an initial 30-day supply of a non-narcotic Schedule III, IV and V drugs according to section 893.03, Florida Statutes.

A doctor licensed under chapter 458, chapter 459, chapter 461, or chapter 466; a medical assistant licensed under chapter 458 or chapter 459; or an advanced practice registered nurse licensed under part I of chapter 464 who prescribes any controlled substance listed in Schedule II, Schedule III, or Schedule IV as defined in section 893.03, for the treatment of chronic nonmalignant pain, shall:

1. Designate themselves as prescribers of controlled substances in their medical profile.
2. Comply with the requirements of this section and applicable board rules.