Telehealth and Pain Management: What Physicians Can and Cannot Do Remotely

The question a pain practice needs answered is narrower than whether telehealth is allowed. Remote evaluation, follow-up and non-controlled management have been ordinary medicine for years; the exposure sits on one act: prescribing a controlled substance to a patient no one in your practice has examined in person. That act is governed by a 2008 federal statute, a temporary rule with an expiration date on it, a proposed rule that was never finalized, and your own state’s law.

Two errors dominate published summaries here, and they point in opposite directions. One says the pandemic-era flexibilities were made permanent. The other says they have expired. As of September 17, 2026, both are wrong. What follows states the federal position as of that date, with the Federal Register citation behind each claim, then separates the remote work that is uncontroversial from the work that is not. Read it as a dated snapshot: this position has been re-set four times since 2023 and is scheduled to change again at the end of 2026.

The rule underneath everything: the in-person evaluation requirement

Under the Ryan Haight Online Pharmacy Consumer Protection Act of 2008, a prescribing practitioner may remotely prescribe controlled substances only after conducting at least one in-person medical evaluation of that patient, subject to seven statutory exceptions. The requirement is at 21 U.S.C. § 829(e); the excepted categories that count as “telemedicine” for this purpose are at 21 U.S.C. § 802(54)(A)–(G).

One detail matters more to an established practice than anything else here. DEA states that once one in-person evaluation has occurred, the Ryan Haight remote-prescribing rules no longer apply to that practitioner–patient relationship — “regardless of how much time has passed since the initial in-person medical evaluation or whether that evaluation was for a separate medical concern.” For the patient you injected last spring, the federal question is settled. The hard cases are new patients who arrived entirely online.

Where the flexibilities stand as of September 17, 2026

The flexibilities originate in two DEA “Dear Registrant” letters, dated March 25 and March 31, 2020, authorizing Schedule II–V controlled medications via audio-video telemedicine without a prior in-person evaluation, and Schedule III–V narcotics FDA-approved for maintenance and withdrawal management treatment of opioid use disorder via audio-only encounters. Four temporary rules have carried them forward:

• First Temporary Rule, 88 FR 30037, published May 10, 2023 — through November 11, 2023, with a one-year grace period to November 11, 2024 for relationships established on or before that date.
• Second Temporary Rule, 88 FR 69879, published October 10, 2023 — through December 31, 2024, superseding the grace period and applying to all relationships.
• Third Temporary Rule, 89 FR 91253, published November 19, 2024 — through December 31, 2025.
• Fourth Temporary Rule, 90 FR 61301, published December 31, 2025 — effective January 1, 2026 through December 31, 2026.

The accurate sentence, and the one worth pinning inside your own policy document, is this: as of September 17, 2026, the COVID-era DEA telemedicine flexibilities remain in effect under a temporary rule and are currently scheduled to expire at the end of December 31, 2026 (90 FR 61301); DEA has not finalized permanent rules. A search of DEA-authored rules and proposed rules published in the Federal Register between January 1 and September 17, 2026 returned none on telemedicine prescribing.

DEA extended rather than finalized to “provide time… to promulgate a final set of regulations… and allow sufficient time for providers to come into compliance with any new DEA registration, recordkeeping, or security requirements eventually adopted” — notice of implementation work, not a promise of continuity. Whether a fifth extension or a final rule has been signed but not yet published, and whether DEA will extend again, could not be established on September 17, 2026. Treat December 31, 2026 as live until a published document moves it.

Check the Federal Register, not DEA’s own site. DEA’s Diversion Control Division telemedicine page, checked September 17, 2026, still read that DEA “is in the process of drafting updated regulations for telemedicine,” its newest linked document dating from 2023. Any page, this one included, that says the rule “currently” allows something without saying when that was true will be wrong within months.

Special registration is a proposal, not an application window

On January 17, 2025, DEA published a notice of proposed rulemaking, “Special Registrations for Telemedicine and Limited State Telemedicine Registrations,” 90 FR 6541, proposing a Special Registration framework under 21 U.S.C. § 802(54)(E) that would authorize three types of special registration plus registration of certain direct-to-consumer telemedicine platforms. DEA received over 6,475 comments. As of September 17, 2026 it is still a proposed rule; no final Special Registration rule has been published. There is no application, no form and no queue, so if a vendor offers to prepare yours, end the conversation. Read the proposal only to see which remote workflows a final rule might touch.

DEA also published two final rules that day — “Expansion of Buprenorphine Treatment via Telemedicine Encounter” (90 FR 6504) and “Continuity of Care via Telemedicine for Veterans Affairs Patients” (90 FR 6523) — whose effective dates were delayed twice, to March 21, 2025 (90 FR 9841) and then December 31, 2025 (90 FR 13410). Whether they took effect, or were delayed again, withdrawn or superseded, is unresolved; no 2026 Federal Register document addressing them could be located. Do not build a workflow on either without confirming its status.

State law is the second gate, and it is not optional

Federal flexibility is permission from one regulator. It is time-limited and federal only, and it does not displace state law or the rules of the board that licenses you. Your state may restrict the modality, require its own controlled-substance authority or telehealth registration, impose prescription drug monitoring checks, or condition remote prescribing on an examination the federal rule would have excused. You also need licensure reaching the patient’s location on the day of the visit — a state question, not a DEA one.

We are not going to hand you a state-by-state map, because we could not verify one, and an unverified map is worse than none. Confirm with the board that licenses you and with the board in the state where the patient is sitting. Related obligations move on their own timetables: state pain and opioid CME mandates are set by state law and licensing boards, differ state to state and change frequently, as covered in our review of pain management CME requirements by state, while the federal one-time DEA training condition is a separate obligation on your registration that a state course does not satisfy, as our guide to MATE Act compliance for pain physicians explains. If PAs or nurse practitioners will carry part of the remote schedule, scope of practice is state- and facility-specific: the practice act, the supervision or collaborative agreement and facility privileges control, not this article, a structure set out in our discussion of whether PAs can perform pain management injections.

What is uncontroversially workable remotely

Strip out controlled-substance initiation and much of a pain practice runs well on video. None of the following depends on the temporary flexibilities, which is why it belongs in the remote schedule:

• Initial history and functional assessment — pain pattern, prior treatment and response, red-flag screening, sleep, mood and activity limits.
• Record and imaging review — reading outside films with the patient on screen, and explaining what they do not explain.
• Management without controlled substances — non-opioid oral agents, topicals, neuropathic classes, de-prescribing.
• Conservative-care direction and adherence follow-up — therapy referral, home program troubleshooting and pacing, including the options in our overview of physical therapy options for lower back pain.
• Candidacy and consent before an image-guided procedure — indication, realistic expectation, alternatives and risk, with time for questions a patient would not ask on procedure day.
• Post-procedure follow-up — response, duration of relief, and whether a diagnostic block answered the question you asked it, logic set out in our reference on interventional pain management procedures.
• Results review and care coordination — electrodiagnostic and imaging results, surgical and behavioral health referral, and case management that otherwise leaks into unbilled phone time.

Where remote care carries real risk

• The examination. Provocative maneuvers, joint stability testing, focal tenderness mapping and gait assessment are not available on camera; a diagnosis resting on them is not remote.
• The procedure. Image-guided injection is in-person by definition, as is anything needing a specimen or a device check.
• New controlled-substance starts. Prescribing to a patient no one in the practice has examined puts you entirely inside a rule scheduled to lapse.
• Audio-only encounters. The 2020 audio-only authorization reached Schedule III–V narcotics FDA-approved for maintenance and withdrawal management treatment of opioid use disorder. It was never a general audio-only allowance for pain prescribing.
• Assuming indefinite remote Schedule II prescribing. The flexibility is time-limited, federal only, and does not displace state rules.
• Thin documentation. Record modality, patient location, who else was present and the consent obtained, so a chart resting on the temporary rule is identifiable later.

Structuring remote visits so a rule change does not break your schedule

Decide by visit type, not case by case. Designate the categories that are remote by design — new-patient history, conservative-care follow-up, pre-procedure consent, results review — and put a first in-person evaluation into the pathway for any patient who may plausibly need a controlled substance. That sequencing moves most prescribing out of the temporary rule and under the established-relationship reading DEA stated. Then build two habits: flag every chart whose only basis for remote prescribing is the flexibility, so that if the December 31, 2026 date holds you work a list, not a crisis; and give one named person the Federal Register check, calendared for November 2026 rather than January.

The durable half of a pain practice is the half telehealth cannot absorb. Procedural capability, electrodiagnostic testing and image-guided injection happen in the room, unaffected by whichever way DEA rules — an argument developed in our analysis of interventional and conservative pain management training. Remote visits fill and triage around that core; they do not replace it.

Frequently asked questions

Can I prescribe controlled substances via telehealth?

As of September 17, 2026, yes, under a temporary rule: the flexibilities remain in effect and are scheduled to expire at the end of December 31, 2026 (90 FR 61301), and DEA has not finalized permanent rules. The flexibility is federal only, does not displace state law or board rules, and being time-limited is no foundation for a long-term prescribing model. Verify status in the Federal Register before relying on this answer.

What exactly is the in-person requirement?

The Ryan Haight Act of 2008 permits remote prescribing of controlled substances only after at least one in-person medical evaluation of that patient, subject to seven statutory exceptions (21 U.S.C. § 829(e); 21 U.S.C. § 802(54)(A)–(G)). DEA has stated that once one in-person evaluation has occurred, those rules no longer apply to that practitioner–patient relationship, regardless of how much time has passed or whether the evaluation was for a separate concern.

Is DEA’s special registration for telemedicine available yet?

No. It was published as a notice of proposed rulemaking on January 17, 2025 (90 FR 6541) and, as of September 17, 2026, had not been finalized. There is nothing to apply for, and no one can prepare an application for a registration that does not exist.

Do state rules differ from the federal rule?

Yes, and the federal rule does not override them. States set their own telehealth and prescribing conditions, and licensure must reach the patient’s location at the time of the visit. We did not verify any individual state’s telehealth prescribing rule for this article and will not generalize one; confirm with the board that licenses you and the board where the patient is located.

Where do I check the current rule before I rely on it?

The Federal Register, by docket and citation. Do not rely on DEA’s Diversion Control Division telemedicine page: checked September 17, 2026, it still said regulations were being drafted and its newest linked document was from 2023. Date-stamp what you record internally and re-check before each policy update or staff briefing.

Build the part of the practice a rule change cannot touch

If the remote schedule is full and the in-person half is the constraint, the gap is procedural. Empire’s Pain Management Training program, known as THE Pain Show, is accredited for 25.25 AMA PRA Category 1 Credits™, jointly provided by AKH, Inc, and Empire Medical Training; the agenda and registration details are on the course page. For a narrower need, Joint, Extremity and Non-Spinal Injection Training carries 6.75 credits for the complete in-person hybrid program; the rest of the curriculum sits on the pain management academy hub.

To be exact about it: that training is CME-accredited procedural education, not an ACGME-accredited fellowship, and it does not confer subspecialty board eligibility in pain medicine. Authorization to perform any procedure comes from state scope of practice plus the privileges your facility grants, never from a certificate — the same division of authority that decides what you may do remotely.

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