California’s opioid prescribing guidelines require clinicians to check the state’s CURES prescription monitoring database before writing a controlled substance prescription, cap initial opioid supplies for acute pain at seven days, and impose specific duties for long-term therapy, tapering, prescribing to minors, and offering naloxone to high-risk patients. The rules come from a mix of Health and Safety Code sections, Business and Professions Code provisions, and Medical Board of California (MBC) guidance. Falling short of them can trigger licensing board discipline and, in serious cases, exclusion from Medicare and Medicaid.
Check CURES Before You Prescribe
Before writing a prescription for any Schedule II through V controlled substance, a California prescriber must query the Controlled Substance Utilization Review and Evaluation System (CURES) and review the Patient Activity Report showing every controlled substance dispensed to that patient statewide over the previous 12 months. The report must be pulled no earlier than 24 hours, or the previous business day, before the prescription is issued.1Medical Board of California. Controlled Substance Utilization Review and Evaluation System CURES Mandatory Consultation Frequently Asked Questions
If the patient continues on the controlled substance, CURES must be consulted again at least once every six months for the duration of treatment.2Medical Board of California. Mandatory Use – CURES
When the CURES Check Is Waived
A handful of situations do not require a CURES lookup:2Medical Board of California. Mandatory Use – CURES
- Patients admitted to or transferring between a licensed clinic, outpatient setting, health facility, or county medical facility.
- Emergency department prescriptions of no more than a seven-day, non-refillable supply.
- Buprenorphine prescribed in the ED for opioid use disorder.
- Controlled substances prescribed as part of a surgical procedure at a licensed facility, limited to a five-day, non-refillable supply.
- Patients receiving hospice care.
- Situations where no one with CURES access is reasonably available or the system is down. In that case, the prescriber may issue a five-day, non-refillable supply and must document the reason in the patient’s record.
The Seven-Day Cap on Initial Opioid Prescriptions
When a patient needs opioids for acute pain and has not had an opioid prescription in the prior 12 months, the initial supply cannot exceed seven days.3California Legislative Information. California Health and Safety Code HSC 11159.2 The prescription should be for the lowest effective dose of an immediate-release formulation. Extended-release and long-acting opioids are not appropriate for acute pain.
The seven-day cap does not apply to patients in active cancer treatment, hospice or palliative care, or patients with traumatic injuries other than surgical procedures. When a prescriber decides a longer supply is warranted, the reasoning has to appear in the medical record.3California Legislative Information. California Health and Safety Code HSC 11159.2
Rules for Long-Term Opioid Therapy
When opioid treatment extends past the acute phase, a different set of obligations takes over. The MBC strongly recommends a written treatment agreement whenever therapy is expected to run longer than three months. These agreements set out treatment goals, the circumstances under which the prescriber will adjust or stop the medication, and the patient’s commitment to use a single prescriber and a single pharmacy for controlled substances.4Medical Board of California. Guidelines for Prescribing Controlled Substances for Pain
Reassessment should happen at least every three to six months, focused on whether the opioid is actually improving pain and function rather than simply whether the patient wants to continue it. Urine drug testing should be performed before starting long-term therapy and at least annually thereafter, both to confirm the patient is taking the prescribed medication and to screen for other substances.
Offer Naloxone at Elevated Risk
California law requires prescribers to offer naloxone to patients at elevated overdose risk. That includes patients prescribed 90 or more morphine milligram equivalents (MME) per day and patients taking opioids alongside benzodiazepines.5California Legislative Information. California Health and Safety Code HSC 11159.3 It is not optional once a patient hits those thresholds.
Tapering and Ending Opioid Therapy
Stopping opioids abruptly after long-term use is dangerous. The MBC warns against rapid tapers or sudden discontinuation, citing risks of acute withdrawal, pain flares, severe psychological distress, suicidal thoughts, overdose, and a shift to illicit opioids.4Medical Board of California. Guidelines for Prescribing Controlled Substances for Pain Cutting a patient off is not cautious prescribing; it creates a different set of serious harms.
The recommended approach is a gradual taper of roughly 10% per month or slower, especially for patients on opioids for a year or more. Some patients will need the taper paused and restarted after an adjustment period. Adjuvants such as clonidine, hydroxyzine, and loperamide can help manage withdrawal symptoms.4Medical Board of California. Guidelines for Prescribing Controlled Substances for Pain
A prescriber who decides to end opioid therapy or terminate the patient relationship must give the patient written notice at least 30 days in advance. The notice should include tapering instructions, a bridging prescription when appropriate, and information about finding another provider. A patient cannot be dismissed from a practice solely because of an opioid use disorder diagnosis; doing so can constitute patient abandonment.4Medical Board of California. Guidelines for Prescribing Controlled Substances for Pain
Confirmed diversion is the one exception. If a patient is selling or giving away medication, the prescriber has no obligation to provide additional prescriptions, tapering instructions, or the 30-day notice. A minimum of 15 days of emergency treatment must be offered before ending care.4Medical Board of California. Guidelines for Prescribing Controlled Substances for Pain
Extra Steps When the Patient Is a Minor
Before writing a first opioid prescription for a patient under 18, the prescriber must have an informed-consent discussion with both the patient and a parent or guardian. The conversation has to cover the risk of addiction and overdose, the heightened addiction risk for people with co-occurring mental health and substance use conditions, and the danger of combining opioids with central nervous system depressants such as alcohol or benzodiazepines.6California Legislative Information. California Health and Safety Code HSC 124961
The discussion must be documented in the patient’s record. Emergency care is exempt.
Electronic Prescribing Is Mandatory
Since January 1, 2022, all prescriptions issued to a California pharmacy must be submitted electronically, and all California pharmacies must be able to receive them. Controlled substance prescriptions must comply with federal DEA electronic prescribing rules as well. Exemptions cover hospice and long-term care settings, prescriptions issued within the Department of Corrections and Rehabilitation, and situations where the prescriber and dispenser are the same entity.7California State Board of Pharmacy. Electronic Data Transmission Prescriptions – Frequently Asked Questions
Pharmacists who receive a written, oral, or faxed prescription are not required to verify whether an exception applies and can still dispense from legally valid non-electronic prescriptions.7California State Board of Pharmacy. Electronic Data Transmission Prescriptions – Frequently Asked Questions
Telemedicine Prescribing Through 2026
Federal rules normally require an in-person medical evaluation before a controlled substance prescription. The DEA has extended COVID-era telemedicine flexibilities through December 31, 2026, allowing prescribers to issue Schedule II through V controlled substance prescriptions via audio-video telemedicine without a prior in-person visit.8Drug Enforcement Administration. DEA Extends Telemedicine Flexibilities to Ensure Continued Access to Care
For opioid use disorder treatment, prescribers can use audio-only encounters to prescribe Schedule III through V medications such as buprenorphine. Every other California requirement, including the CURES check and any applicable supply limits, still applies whether the encounter happens in person or by video.8Drug Enforcement Administration. DEA Extends Telemedicine Flexibilities to Ensure Continued Access to Care The flexibilities are temporary, and the regulatory landscape has shifted repeatedly since 2020.
What Happens When Prescribers Don’t Comply
A prescriber who fails to consult the CURES database as required is referred to their licensing board for investigation.9California Legislative Information. California Health and Safety Code HSC 11165.4 The Medical Board can discipline physicians for gross negligence, repeated negligent acts, incompetence, prescribing without an appropriate prior examination, and failing to keep accurate records of controlled substance purchases and disposals.10California Legislative Information. California Business and Professions Code BPC 2241.5
Federal consequences escalate from there. The HHS Office of Inspector General must exclude from Medicare and Medicaid any individual with a felony conviction related to the unlawful manufacture, distribution, or dispensing of controlled substances.11Office of Inspector General. Background Information For a physician whose practice depends on federally covered patients, exclusion is effectively a career-ending sanction.