California Opioid Prescribing Guidelines and Requirements

California opioid prescribing guidelines require clinicians to query the CURES database before and during controlled-substance therapy, limit new acute-pain opioid prescriptions to a seven-day supply, obtain a specific informed-consent discussion before prescribing to minors, offer naloxone to high-risk patients, taper rather than abruptly stop long-term therapy, and transmit prescriptions electronically. The rules sit across the Health and Safety Code, the Business and Professions Code, and Medical Board of California (MBC) guidance, and they are enforced through license discipline and, at the federal level, exclusion from Medicare and Medicaid.

Checking 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’s 12-month Patient Activity Report. The check has to happen no earlier than 24 hours, or the previous business day, before the prescription is issued.¹

If the controlled substance continues as part of the patient’s treatment, the prescriber must consult CURES at least once every six months thereafter.²

When the CURES Check Is Waived

Several situations exempt the prescriber from the lookup:²

Patients admitted to or transferring between a licensed clinic, outpatient setting, health facility, or county medical facility.
Prescriptions issued in a hospital emergency department, provided the supply does not exceed seven days with no refills.
Buprenorphine prescribed in a hospital emergency department 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; the prescriber may issue a five-day, non-refillable supply and must document the reason in the patient’s record.

One structural limit is worth knowing. California shares CURES data only with the Veterans Health Administration, not with the multi-state PMP InterConnect system.³ Prescriptions a patient filled in Nevada or Oregon will not appear on a California report.

The Seven-Day Cap on New Acute-Pain Prescriptions

When a patient needs opioids for short-term pain and hasn’t had an opioid prescription in the prior 12 months, the initial supply is capped at seven days.⁴ The prescriber should choose the lowest effective dose of an immediate-release formulation. Extended-release and long-acting opioids are not appropriate for acute pain.

The cap does not apply to patients in active cancer treatment, hospice or palliative care, or those with traumatic injuries other than surgical procedures. If a prescriber decides a situation warrants exceeding seven days, the rationale must appear in the patient’s medical record.⁴

Ongoing Duties for Long-Term Opioid Therapy

Once therapy is expected to continue beyond three months, the MBC strongly recommends a written treatment agreement covering treatment goals, the conditions under which the prescriber will stop or adjust the medication, and the patient’s commitment to use a single prescriber and a single pharmacy for controlled substances.⁵

Reassessment should occur at least every three to six months, evaluating whether the opioid is actually improving pain and function. Urine drug testing should be performed before starting long-term therapy and at least annually afterward, both to confirm the patient is taking the prescribed medication and to screen for other substances.

Offering Naloxone

California law requires prescribers to offer naloxone to patients at elevated overdose risk, including patients prescribed 90 or more morphine milligram equivalents (MME) per day and those taking opioids alongside benzodiazepines.⁶ This is not optional once a patient hits either threshold.

Tapering and Ending Opioid Therapy

Abrupt discontinuation after long-term use is dangerous. MBC guidelines warn against rapid tapers or sudden stoppage, citing risks of acute withdrawal, pain flares, severe psychological distress, suicidal thoughts, overdose, and a turn to illicit opioids.⁵ Cutting a patient off cold is not cautious prescribing.

The recommended approach is a gradual taper of roughly 10% per month or slower, especially for patients who have been on opioids for a year or more. Some patients will need the taper paused and restarted. Adjuvant medications like clonidine, hydroxyzine, and loperamide can help manage withdrawal symptoms.⁵

If a prescriber decides to end opioid therapy or terminate the patient relationship, the patient must receive written notice at least 30 days in advance. The notice should include tapering instructions, a bridging prescription when appropriate, and options for finding another provider. A patient cannot be dismissed from the practice solely because of an opioid use disorder diagnosis; doing so can constitute patient abandonment.⁵

Diversion is the one exception. If a patient is confirmed to be selling or giving away medication, the prescriber owes no additional prescriptions, tapering instructions, or 30-day notice. The obligation shrinks to a minimum of 15 days of emergency treatment before ending care.⁵

Prescribing to Patients Under 18

Before prescribing an opioid to a minor for the first time, the prescriber must have a specific 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 like alcohol or benzodiazepines.⁷

Document the discussion in the patient’s record. Emergency care is exempt.

Sending the Prescription Electronically

Since January 1, 2022, all prescriptions issued by a licensed healthcare practitioner to a California pharmacy must be submitted electronically. The requirement applies to controlled substances as well, which must also comply with federal DEA electronic prescribing regulations. 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.⁸

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.⁸ Separately, controlled-substance prescription pads must carry a 12-character serial number and a corresponding barcode.⁹

Prescribing Controlled Substances by Telemedicine

Federal rules normally require an in-person medical evaluation before a controlled substance can be prescribed. The DEA has extended COVID-era telemedicine flexibilities through December 31, 2026, so prescribers can continue issuing Schedule II through V prescriptions through audio-video telemedicine encounters without first seeing the patient in person. For opioid use disorder treatment, audio-only encounters remain available for Schedule III through V medications such as buprenorphine.¹⁰

Every California requirement still applies in a telemedicine encounter, including the CURES check and any supply limits.¹⁰ The flexibilities are temporary, and the rules for telemedicine controlled-substance prescribing have shifted repeatedly since 2020.

What Happens When Prescribers Don’t Follow the Rules

A prescriber who fails to consult CURES as required is referred to their licensing board for investigation.¹¹ The Medical Board retains authority to 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.¹²

Federal consequences escalate further. The HHS Office of Inspector General is required by law to exclude from Medicare and Medicaid any individual with a felony conviction related to the unlawful manufacture, distribution, or dispensing of controlled substances.¹³ For a physician whose practice depends on patients covered by federal health programs, exclusion ends the career.

1
Medical Board of California. Controlled Substance Utilization Review and Evaluation System CURES Mandatory Consultation Frequently Asked Questions
2
Medical Board of California. Mandatory Use – CURES
3
National Association of Boards of Pharmacy. PMP InterConnect – Prescription Drug Monitoring Program
4
California Legislative Information. California Health and Safety Code HSC 11159.2
5
Medical Board of California. Guidelines for Prescribing Controlled Substances for Pain
6
California Legislative Information. California Health and Safety Code HSC 11159.3
7
California Legislative Information. California Health and Safety Code HSC 124961
8
California State Board of Pharmacy. Electronic Data Transmission Prescriptions – Frequently Asked Questions
9
Medical Board of California. Prescribing Rules – CURES
10
Drug Enforcement Administration. DEA Extends Telemedicine Flexibilities to Ensure Continued Access to Care
11
California Legislative Information. California Health and Safety Code HSC 11165.4
12
California Legislative Information. California Business and Professions Code BPC 2241.5
13
Office of Inspector General. Background Information