The expansion of telehealth has permanently altered how controlled substances are prescribed in the United States. What began as a temporary public health response during COVID has evolved into a long-term structural change, bringing new access for patients while introducing regulatory ambiguity and operational strain for pharmacies. As telehealth prescribing becomes normalized, pharmacies find themselves navigating a complex intersection of federal law, state regulation, patient expectations, and compliance risk.

Understanding this shift requires revisiting the legal framework that governs controlled substances, how emergency-era flexibilities changed prescribing behavior, and what those changes now mean for pharmacy operations on the ground.

From the Ryan Haight Act to Pandemic-Era Flexibility

The Ryan Haight Act was enacted in 2008 with a specific goal: to stop illegitimate online prescribing of controlled substances by requiring an in-person medical evaluation before such medications could be prescribed. At the time, the concern was largely about rogue internet pharmacies and prescribers operating without meaningful patient relationships or oversight.

That framework held steady until the COVID-19 public health emergency, when federal regulators temporarily waived the in-person requirement to preserve access to care. Under these emergency rules, DEA-registered providers were permitted to prescribe controlled substances via telehealth without having first seen the patient in person, provided certain safeguards were met.

This change dramatically expanded telehealth prescribing, particularly for ADHD medications, anxiety treatments, and pain management therapies. While it solved real access problems during a crisis, it also shifted significant responsibility downstream to pharmacies, which became the final checkpoint in a much more fragmented care model.

Where the Rules Stand Now

As the public health emergency ended, regulators faced pressure to unwind temporary policies without cutting off access for patients who had come to rely on telehealth. The DEA has since issued temporary extensions while proposing longer-term rules that would partially reinstate in-person evaluation requirements, potentially with narrow telehealth exceptions.

The regulatory posture remains in flux. While enforcement agencies have signaled a renewed focus on oversight, particularly around high-volume telehealth prescribing models, definitive rules are still evolving. Pharmacies are left operating in an environment where legal expectations exist, but clarity does not always.

Complicating matters further is the interplay between federal and state law. Even when federal rules allow a certain prescribing practice, state boards of pharmacy or medicine may impose stricter requirements. Pharmacies must comply with whichever rule is more restrictive, even when prescribers are operating under different interpretations or assumptions.

How Telehealth Prescribing Has Changed Pharmacy Operations

Telehealth has altered not just the volume of controlled substance prescriptions, but the nature of the work required to dispense them safely. Pharmacies increasingly see prescriptions originating from out-of-state prescribers, virtual-only clinics, or high-throughput telehealth practices. These prescriptions often require additional scrutiny, documentation, and verification.

Pharmacists are now routinely expected to assess legitimacy with limited clinical context. Medical records are rarely shared proactively. Diagnosis details may be minimal. Prescribers may be difficult to reach. Yet the expectation of corresponding responsibility remains unchanged.

As a result, prescription processing takes longer. Clarification calls increase. Patients experience delays. Phone volume rises. What once might have been a straightforward dispensing decision becomes a compliance review layered on top of routine workflow.

The Gatekeeper Role and Its Limitations

Pharmacists are legally obligated to ensure that controlled substance prescriptions are issued for a legitimate medical purpose. In the telehealth era, that obligation often means identifying and resolving red flags without access to the full picture. Common concerns include prescribing patterns that appear standardized across patients, cash-only telehealth models, early refill requests, or inconsistent patient histories.

The challenge is not that pharmacists are unwilling to perform this role. It is that the role has expanded without the tools or information needed to perform it efficiently. Pharmacies are expected to act as gatekeepers, yet they frequently lack timely access to prescribers or sufficient documentation to resolve concerns quickly.

This gap contributes to frustration on all sides. Patients may feel unfairly blocked. Prescribers may feel questioned. Pharmacists bear the risk of getting it wrong.

Access Versus Safety

Telehealth has unquestionably improved access to care, particularly for patients with ADHD, anxiety disorders, chronic pain, or limited access to local providers. For many, virtual care reduced wait times and geographic barriers that previously made treatment difficult.

At the same time, regulators and pharmacies have legitimate concerns about diversion, overprescribing, and fragmented care. When patients receive controlled substances from multiple providers or switch telehealth platforms frequently, continuity suffers. Monitoring becomes harder. Risk increases.

Pharmacies operate at the center of this tension. They are expected to support access while preventing harm, often in real time and under pressure. When supply shortages intersect with telehealth-driven demand, that tension becomes even sharper, particularly for stimulant medications and other high-demand controlled therapies.

Drug Categories Under Heightened Scrutiny

ADHD stimulants remain the most visible pressure point, especially given ongoing national shortages. Telehealth prescribing has increased demand at the same time supply has remained constrained, placing pharmacies in the position of managing patient frustration while navigating heightened regulatory scrutiny.

Benzodiazepines and opioids present different but equally complex challenges. Long-term use, co-prescribing risks, and overdose concerns make these categories a focal point for regulators. Testosterone and other controlled hormone therapies prescribed through telehealth have also drawn attention due to questions around diagnostic rigor and ongoing monitoring.

In each case, pharmacies must apply consistent standards while adapting to widely varying prescribing models.

Legal and Liability Exposure for Pharmacies

The concept of corresponding responsibility means that pharmacies can face enforcement action even when prescribers are the source of problematic prescribing. Audits increasingly focus on whether pharmacies identified and addressed red flags appropriately, rather than simply whether prescriptions were valid on their face.

State boards may impose expectations that exceed federal guidance, and those expectations are often enforced retrospectively. Documentation quality matters. Consistency matters. The absence of a clear violation does not always protect against scrutiny.

This reality has made compliance decision-making a significant source of stress and operational burden for pharmacy teams.

The Changing Role of the Pharmacist

The modern pharmacist’s role now extends well beyond dispensing. Pharmacists are compliance reviewers, communicators, and risk managers, often without additional staffing or reimbursement to support these functions. Communicating with remote prescribers can be slow and inefficient, particularly when telehealth providers operate at scale.

The cumulative effect is increased mental load and workflow strain. Compliance decisions carry legal consequences, and making them repeatedly under time pressure contributes to burnout across the profession.

What Comes Next

While final regulatory outcomes remain uncertain, several trends appear likely. Greater accountability for telehealth prescribers is expected, along with narrower exceptions for prescribing controlled substances without in-person evaluations. Telehealth models may evolve toward hybrid approaches that incorporate physical exams and better documentation sharing.

For pharmacies, preparation will be key. Standardized review protocols, clear escalation pathways, staff training, and improved documentation practices will become increasingly important. Operational tools that reduce manual burden and improve visibility into prescription legitimacy may also play a larger role.

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