As the federal government continues to shape the future of virtual healthcare, a major addiction treatment advocacy group is raising red flags about one proposed path forward. At the heart of the debate is telehealth prescribing of controlled substances—a crucial service that expanded rapidly during the COVID-19 pandemic and has since become a lifeline for many seeking addiction treatment.
The American Society of Addiction Medicine (ASAM), led by President Dr. Brian Hurley, recently voiced strong opposition to the DEA’s proposal to implement a special registration process for telehealth prescribing. While the idea may appear to offer a streamlined solution, ASAM warns it could end up restricting care, burdening providers, and entangling treatment further with law enforcement protocols.
The Special Registration Plan: A Flawed Path Forward?
The special registration process, authorized under 21 U.S.C. § 802(54)(E), would allow certain providers to prescribe controlled substances via telehealth without first conducting an in-person examination. This concept, on paper, aims to offer continuity for patients who benefited from pandemic-era telehealth flexibility. However, Dr. Hurley, writing in Health Affairs, described this plan as “misguided.”
He argued that the special registration model risks becoming another bureaucratic obstacle, much like the now-eliminated X waiver once required for prescribing buprenorphine. According to Hurley, such a system could discourage clinicians from offering virtual addiction treatment, thereby reducing access for patients in need.
Rather than leaning into a registration model exclusive to the DEA, Hurley advocates for an alternate approach allowed under 21 U.S.C. § 802(54)(G)—one that requires consensus between the DEA and the U.S. Department of Health and Human Services (HHS). This strategy would maintain telehealth prescribing of controlled substances while ensuring proper safety protocols are in place without adding unnecessary hurdles.
Lessons from the Pandemic: A Case for Flexibility
During the COVID-19 public health emergency, telehealth became a vital means of delivering behavioral health and addiction treatment services. The relaxed regulations allowed providers to begin telehealth prescribing of controlled substances, such as buprenorphine, without an initial in-person visit. Contrary to fears of increased diversion or misuse, federal research showed no corresponding spike in overdose deaths related to expanded buprenorphine access during this time.
In fact, the data tells a promising story: virtual care didn’t just work—it improved access and outcomes. “Historically, the DEA has seen a lack of an in-person medical evaluation as an indication of likely diversion,” Hurley wrote. “But after three years of successful virtual practice, it should no longer be considered a red flag.”
These findings support the idea that telehealth prescribing of controlled substances can be both safe and effective when regulated through thoughtful, collaborative policy—not rigid, law enforcement-centric frameworks.
Risks of a Special Registration System
Hurley’s key concern with the DEA’s proposal is that it adds complexity without improving safety. Under the special registration provision, the DEA would hold exclusive authority, with no required input from HHS. Providers would need to demonstrate a “legitimate need” to qualify, which opens the door for subjective decision-making and possible inconsistencies across regions and provider types.
Moreover, Hurley argues this could dissuade clinicians from utilizing telehealth at all, limiting care for patients who cannot easily travel to a clinic for an in-person assessment—especially those in rural or underserved areas. This is particularly dangerous when access to medications for opioid use disorder (MOUD), like buprenorphine, is already limited in many communities.
Instead of creating another restrictive framework, Hurley suggests a more flexible approach that allows for telehealth prescribing of controlled substances under a new rule jointly created by HHS and the DEA. This would enable the government to enforce “bona fide exam” standards and necessary safety checks—such as mandatory electronic prescribing and use of prescription drug monitoring programs—without reverting to outdated or ineffective models.
Avoiding the Mistakes of the X Waiver
The cautionary tale of the X waiver looms large in this discussion. Although originally intended to ensure safe prescribing of buprenorphine, the waiver system became a major deterrent for clinicians, adding layers of training and certification that many found cumbersome.
Ironically, Hurley notes that some of the worst cases of improper prescribing occurred even under the X waiver system, where in-person visits were still required. “Thus, history informs us that a telehealth-focused special registration process would not likely deter clinicians who knowingly or intentionally wish to prescribe buprenorphine in an unauthorized manner,” he wrote, “without also reducing access to legitimate medical care.”
This reality underscores why ASAM believes telehealth prescribing of controlled substances should not be tethered to another potentially ineffective regulatory scheme.
A Smarter Path Forward: The DEA-HHS Collaboration
Rather than defaulting to the special registration process, ASAM urges regulators to pursue the alternative clause in the Ryan Haight Act that fosters cooperation between HHS and the DEA. This path allows for rulemaking that reflects the realities of modern healthcare—particularly the success and safety of telehealth prescribing of controlled substances over the past few years.
By creating a rule that incorporates virtual bona fide exams, requires e-prescribing, and mandates real-time monitoring for diversion risks, regulators can strike a balance: protecting public safety while ensuring people with addiction have uninterrupted access to care.
“In short, the DEA and HHS got it partly right the first time,” Hurley said. “A special registration process should not be the next step for telemedicine prescribing of buprenorphine.”
Final Thoughts: Protect Access, Don’t Restrict It
The future of telehealth prescribing of controlled substances hinges on the decisions made now. ASAM’s firm stance reminds policymakers that increased regulation does not always mean increased safety. Sometimes, it simply means fewer patients getting the help they need.
Rather than repeating past mistakes or creating new barriers, the DEA and HHS have an opportunity to chart a smarter, more effective path—one rooted in data, patient needs, and common sense. For those relying on virtual addiction care, the stakes couldn’t be higher.
