Nine weeks out, DEA's telehealth prescribing cliff has no final rule in sight

For the fourth year in a row, telepsychiatry practices are heading into the holidays without knowing how they will prescribe controlled substances on January 2. The pandemic-era rules that suspended the Ryan Haight Act's in-person exam requirement expire at the end of December 31, 2026. The permanent framework meant to replace them is still under review, and nobody outside government has seen the text.

What is in force today

On December 31, 2025, DEA and HHS published a fourth temporary rule carrying the full set of COVID-19 flexibilities through 2026. Under it, a DEA-registered practitioner can prescribe Schedule II through V medications to a patient they have only seen by telemedicine, as long as the prescription serves a legitimate medical purpose and meets the other usual requirements. The agencies said they needed the extra year to write final regulations.

Two rules finalized in January 2025 also took effect on December 31, 2025, after a regulatory freeze delayed them twice:

• Buprenorphine for opioid use disorder. Practitioners may prescribe Schedule III–V medications approved for OUD, which in practice means buprenorphine, by audio-video or audio-only telemedicine. Without an in-person exam the initial supply is capped at six months, and the rule sets safeguards such as a prescription drug monitoring program (PDMP) check.
• VA continuity of care. A VA practitioner may prescribe by telemedicine to a VA patient who has already had an in-person evaluation by another VA practitioner.

These permanent rules stay in place whatever happens on December 31.

The rule that would replace the flexibilities

In January 2025 DEA proposed a "Special Registrations for Telemedicine" framework that drew more than 6,400 public comments. As proposed, prescribers would need an additional DEA registration to prescribe controlled substances by telemedicine without an in-person visit. A higher tier, the advanced telemedicine prescribing registration, would cover Schedule II drugs, and only certain specialists could qualify. Psychiatrists, hospice and palliative care physicians, long-term care physicians, pediatricians and neurologists were named, along with some board-certified mid-level practitioners. The proposal also called for a registration in each state where patients are located, PDMP checks that would expand to all states over time, and, as one option, a cap keeping telemedicine prescriptions under half of a clinician's monthly Schedule II prescriptions. The American Psychiatric Association and other groups criticized it as unworkable.

That proposal is the only version anyone can read. A final rule went to OIRA on August 25, 2026, and the Justice Department's regulatory agenda targets November 2026 for publication, according to health-law analysts. OIRA's listing does not include the text, so it is not yet known how much changed from the 2025 proposal. The final rule could also take effect after the flexibilities lapse. Each earlier extension was announced only shortly before the deadline.

What happens if nothing is published

If December 31 passes without a fifth extension or an effective final rule, the Ryan Haight Act's default applies again. With limited statutory exceptions, a practitioner must have done at least one in-person medical evaluation before prescribing a controlled substance by telemedicine. The buprenorphine and VA rules would still apply. For a new patient seen only by video, prescriptions for a stimulant, a benzodiazepine, a sleep medication such as zolpidem, pregabalin or a Schedule II opioid would generally need an in-person visit first.

What to do before December 31

1. List your exposure. Run a report of active patients on Schedule II–V medications who have never had an in-person evaluation with you, or with a colleague in a way that the rules recognize.
2. Prioritize in-person visits for patients on Schedule II stimulants and for those whose care would be hard to move. Document the evaluation clearly.
3. Separate out your OUD patients. Buprenorphine prescribing for OUD falls under the permanent rule. Check that your workflow meets its six-month and PDMP requirements.
4. Check state law. Some states have their own in-person or telehealth prescribing rules that apply regardless of federal policy.
5. Watch the Federal Register in November and December for the final special registration rule or a fifth extension, and plan for the possibility that neither arrives in time.

We will update this story when the final rule or an extension is published.