What are the laws and regulations for prescribing Schedule II (controlled substances) medications to patients out of state?

Schedule II Controlled Substance Prescribing Across State Lines

Federal law technically requires at least one in-person evaluation before prescribing Schedule II controlled substances via telemedicine, though the DEA has stated it does not intend to interfere with legitimate telemedicine prescribing and has promised (but not delivered since 2008) further clarification on this issue. 1

Federal Requirements

Ryan Haight Act Restrictions

• The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 places restrictions on "prescribing by means of the internet" for controlled substances 1
• The Act technically requires prescribers to conduct at least one in-person evaluation before prescribing a controlled substance during telemedicine practice 1
• While telemedicine is listed as an exception, the DEA has left provisions incomplete since 2008 regarding special telemedicine registration 1
• The DEA has indicated it does not intend to interfere with legitimate controlled substance prescribing during telemedicine practice 1

Licensure Requirements

• Full medical licensure is required in the state where the patient is physically located during the telemedicine encounter, not where the patient resides 1
• If the patient site and prescriber site are in different states, full licensure in both states is usually required 1
• The Interstate Medical Licensure Compact streamlines licensure across participating states (18 states have adopted it as of 2017, with 8 additional states and DC introducing legislation) 1

State-Level Variations

Limited Licensure Options

• Several states allow limited licensure specifically for providing telemedicine services, though these have different restrictions on scope and practice 1
• A few states allow telepsychiatry services from physicians licensed in neighboring states 1
• Some states allow emergency telemedicine services without a license, but with regulations on extent and frequency 1

Additional State Requirements

• Some states mandate specific conditions for clinical encounters or require the telepsychiatrist to maintain a physical practice location in that state 1
• Some states require patients be evaluated only in state or federally operated clinics/hospitals, or require a licensed healthcare professional to accompany the patient 1
• Several states have enacted specific legislation to allow prescribing of controlled substances during telemedicine practice, particularly for telepsychiatry 1

Prescription Drug Monitoring Programs (PDMPs)

• Forty-one states have operational PDMPs that track Schedule II through IV (or II through V) controlled substances 1, 2
• Most states allow healthcare providers and pharmacists to access PDMPs for patients under their care 2
• The CDC recommends checking the state PDMP before prescribing any Schedule II medication to identify potential diversion or doctor shopping 2
• Interstate communication between PDMPs remains limited despite the National All Schedules Prescription Electronic Reporting Act (NASPER) passed in 2005 1

Critical Caveats for Out-of-State Prescribing

Regulatory Compliance

• Prospective prescribers must assess legislation in both the state where they are licensed and where the patient is physically located 1
• Even if licensed in a distant state, regulations could prohibit participation in civil commitment processes 1
• Regulatory guidelines regarding mental health treatment of youth vary by jurisdiction, including reporting of child endangerment and treatment of children in foster care 1

Documentation Requirements

• Careful record-keeping of prescribing information (quantity, frequency, renewal requests) is required by state and federal law 3
• Some states have specific documentation requirements for Schedule II prescriptions including total quantity, number of days, strength, dose, and frequency 2

Buprenorphine-Specific Restrictions

• One state prohibits all advanced practice clinicians from prescribing buprenorphine for opioid use disorder despite general scope of practice laws permitting it 4
• Five states require physician assistant supervision by a federally waivered physician for buprenorphine prescribing 4
• Three states require nurse practitioner supervision by a federally waivered physician for buprenorphine prescribing 4

Practical Recommendations

• Verify full licensure in the state where the patient is physically located during the telemedicine encounter before prescribing any Schedule II controlled substance 1
• Review both federal Ryan Haight Act requirements and specific state legislation regarding telemedicine prescribing of controlled substances 1
• Access the state PDMP in the patient's location before prescribing to identify potential diversion or concurrent prescriptions 1, 2
• Consider whether the Interstate Medical Licensure Compact applies to streamline multi-state licensure 1
• For buprenorphine prescribing specifically, verify state-specific supervision requirements beyond general scope of practice laws 4