Telehealth Adderall Prescription: Ryan Haight and State Licensure
A 22-year-old college student in Portland, Oregon, presents an electronic prescription for amphetamine/dextroamphetamine 20 mg, quantity 60, from a psychiatric nurse practitioner. The prescription notes that the visit was by telehealth. The nurse practitioner is licensed in Washington and has a Washington DEA registration, but she is not licensed in Oregon and has no Oregon DEA registration. The patient says the visit happened while he was in his Oregon dorm room, although he sometimes sees the prescriber when he is in Vancouver. The pharmacy calls the prescriber's office and is told, 'We do telehealth for Oregon patients all the time; the DEA number is active.' The patient is asking for the prescription to be filled today because he is out of medication and has exams.
1. May the Oregon pharmacy fill this Schedule II prescription? Identify the federal and state defects.
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No. There are at least two independent problems. First, Oregon requires the prescriber to be licensed in Oregon to prescribe for a patient located in Oregon, unless a specific exception applies. A Washington license does not authorize practice in Oregon. Second, the prescriber has only a Washington DEA registration. DEA registrations are state-specific, and a practitioner generally must be registered in the state where the controlled substance is prescribed or dispensed. Third, the federal Ryan Haight Act generally requires at least one in-person medical evaluation before a Schedule II controlled substance is prescribed by telemedicine, unless a recognized telemedicine exception applies. A routine telehealth visit from a dorm room does not satisfy the in-person requirement. The office's statement that it does telehealth for Oregon patients does not cure the licensure or registration defects. The pharmacist should not fill the prescription.
2. Would the answer change if the nurse practitioner had an Oregon license but still had only a Washington DEA registration?
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Not necessarily; the DEA registration problem would remain. A state license allows the practitioner to practice in Oregon, but controlled-substance prescribing also requires the appropriate DEA registration. The pharmacist should verify the prescriber's Oregon license and Oregon DEA registration before filling a Schedule II prescription. If the practitioner has an Oregon license but no Oregon DEA registration, the pharmacist should not fill unless the practitioner can show a valid legal basis for the registration used. The pharmacist should also confirm that the prescription was issued for a legitimate medical purpose and that the patient was physically located in Oregon at the time of the visit. The pharmacist should document the verification attempts and the reason for refusal. The patient should be referred to an Oregon-licensed prescriber with the appropriate DEA registration, and the pharmacist should not simply transfer the prescription to another pharmacy without resolving the defects.
3. What if the patient had an in-person visit with the same nurse practitioner in Vancouver, and the prescription was issued there? How should the pharmacist analyze that situation?
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The analysis changes but does not automatically become a fill. If the patient was physically in Washington and the prescriber was licensed and DEA-registered in Washington, the Ryan Haight in-person requirement may be satisfied and the prescription may be valid where issued. The pharmacist must then determine whether Oregon law permits the filling of an out-of-state Schedule II prescription and whether the prescriber meets Oregon's requirements for prescribing to an Oregon patient. The pharmacist should verify the prescriber's Washington license and DEA registration, confirm the in-person visit, and check the Oregon PDMP. The pharmacist should also consider whether the patient is establishing care in Oregon and whether the quantity and directions are appropriate. If any requirement is unclear, the pharmacist should not fill until it is resolved. The pharmacist should document the verification and the legal basis for the decision, because an out-of-state Schedule II prescription is a high-risk transaction that requires more than a quick call to the prescriber's office.