Texas Telemedicine Prescribing for Chronic Pain

Texas does not ban telemedicine for chronic pain. It bans the lazy version of it. The Texas Medical Board's rule at 22 Tex. Admin. Code § 175.3(b), in its current form since January 9, 2025, says a physician treating chronic pain via telemedicine "must use audio and video two-way communication," unless three conditions are all met. The Texas Board of Nursing has a parallel rule for APRNs. For a pain or primary care practice with Texas patients, those few lines decide which visits can be done by phone.

What does the rule say?

Section 175.3(a) restates the basic Texas test for a valid prescription: a physician-patient relationship under Tex. Occ. Code § 111.006, and compliance with every other applicable law, including the Medical Practice Act and the Texas Controlled Substances and Dangerous Drug Acts (Health and Safety Code chapters 481 and 483).

Section 175.3(b) adds the chronic pain requirement. A physician prescribing for chronic pain via telemedicine must use two-way audio and video unless the patient:

1. is an established pain patient of the prescribing physician;
2. receives a prescription identical to the one issued at the previous visit; and
3. was seen by the prescribing physician, or their delegate, in the last 90 days, either in person or by two-way audio and video.

So an audio-only refill call is allowed for a stable patient on an unchanged prescription who had a video or in-person visit within 90 days. A new pain patient, a dose change, a new drug, or a gap longer than 90 days all require video or an in-person visit.

Does the rule apply to nurse practitioners?

Yes, through the nursing board's own rule. 22 Tex. Admin. Code § 217.24(e) says telemedicine used to treat chronic pain "with scheduled drugs by any means other than via audio and video two-way communication is prohibited," unless the patient is an established patient of the APRN being treated for chronic pain, is receiving an identical prescription, and has been seen in the last 90 days, in person or by audio-video, by the prescribing APRN, a physician or another health professional as defined in Tex. Occ. Code § 111.001. The board explains its reasoning in the rule: chronic pain is a legitimate condition, but the Legislature has already regulated pain treatment and pain management clinics, so the board found clear intent to limit chronic pain treatment by telemedicine.

How does Texas define chronic pain?

The Medical Board's pain management clinic rules at 22 Tex. Admin. Code § 172.1 give the working definitions. Chronic pain is pain "not relieved with acute, post-surgical, post-procedure, or persistent non-chronic pain treatment," associated with a chronic pathological process causing continuous or intermittent pain "for no less than 91 days from the date of the initial prescription for opioids." Acute pain is limited to 30 days from the first opioid prescription, and post-surgical or persistent non-chronic pain runs more than 30 and up to 90 days. Cancer, hospice, end-of-life and palliative care pain are carved out of the acute definition.

Practically, a patient on opioids for more than 90 days is a chronic pain patient for Texas purposes, and the audio-video rule applies from that point.

Can a Texas NP or PA prescribe Schedule II pain medication by telemedicine?

Usually not, and telemedicine is not the reason. Under Tex. Occ. Code § 157.0511, a physician may delegate controlled substance prescribing to an APRN or PA for Schedules III through V, in supplies of no more than 90 days including refills. Schedule II may be delegated only in a hospital facility-based practice for patients admitted for at least 24 hours or in the emergency department, or for hospice patients. A virtual pain practice built on NP prescribers is therefore limited to Schedule III to V drugs in Texas.

When does a pain practice need a clinic certificate?

Tex. Occ. Code chapter 168 defines a pain management clinic as a facility where a majority of patients are issued, on a monthly basis, a prescription for opioids, benzodiazepines, barbiturates or carisoprodol, excluding Suboxone (§ 168.001). Such a clinic may not operate in Texas unless certified by the Medical Board (§ 168.101), and owners, operators, employees and contractors cannot have had a controlled substance license denied or restricted, or been disciplined for inappropriate prescribing (§ 168.201). Whether a telehealth-only practice serving Texas patients is a "facility" under the chapter is a question for Texas counsel; a practice whose majority of Texas patients get those drugs monthly should ask it before launch.

What else applies to a Texas pain prescription?

• PDMP. The prescriber must check the Texas PMP before prescribing opioids, benzodiazepines, barbiturates or carisoprodol (Tex. Health & Safety Code § 481.0764). See PDMP checks for telehealth prescribers.
• A full Texas license. Texas has no telehealth registration; physicians need a full license, apart from out-of-state telemedicine licenses held as of September 1, 2022 (22 Tex. Admin. Code § 175.1).
• DEA rules. Through December 31, 2026, DEA's temporary rule (90 FR 61301) covers prescribing without a prior in-person evaluation. From January 1, 2027, absent a final special registration rule or another extension, the Ryan Haight Act's in-person requirement returns. Texas's audio-only refill exception does not change the federal answer. See what changes on January 1, 2027.

How should a practice build this into scheduling?

• Flag Texas chronic pain patients on scheduled drugs in the EHR.
• Default every visit for them to video; allow audio-only only when the system confirms an identical prescription and a video or in-person visit within 90 days.
• Block NP and PA Schedule II orders for Texas outpatients.
• Track the share of Texas patients on opioids, benzodiazepines, barbiturates or carisoprodol each month against the chapter 168 threshold.

The Texas page in our telehealth law index has the related citations. A State Expansion Pack ($595 per state) covers Texas for one service line, and DEA Telemedicine Readiness ($1,450) handles the federal side. All of it is research for your counsel to review, not legal advice.