Telehealth in Substance Use Counseling: What Changed, What Stayed, and What You Need to Document

Telehealth in substance use counseling used to feel like a side quest. Then COVID hit and the whole industry sprinted into video calls with shaky wifi and headphones held together with hope.

You already lived that.

Now you sit in 2026 with a new problem. Your clients still want remote care. Your agency still wants productivity. Auditors still want clean documentation. And the rules keep shifting in chunks.

So let’s talk about telehealth in substance use counseling in plain language. What changed. What stayed. What you need to write down so your note holds up.

I learned this the hard way.

Back in my homeless years, I missed appointments for reasons that sound made up to people with stable housing. A dead phone. A shelter kick out. A bus transfer that never came. That mess taught me a simple truth. Access beats intention. Telehealth can remove barriers fast. It can also create new ones fast.

Your documentation decides which one you deliver.

What changed

Telehealth in substance use counseling changed in three big areas: privacy enforcement, prescribing rules, and payment rules.

First, the free for all tech era ended. During the public health emergency, the federal government gave providers breathing room on HIPAA telehealth tools. That enforcement discretion ended, and OCR published guidance for audio only care under the HIPAA rules. HHS+1

Second, controlled substance prescribing by telemedicine kept evolving. A federal rule published for public inspection says DEA and HHS extended certain telemedicine flexibilities through December 31, 2026. This extension aims to prevent a sudden snap back to pre pandemic restrictions and gives time for permanent regulations. Public Inspection Federal Register

Third, Medicare drew a clearer line between behavioral health telehealth and everything else. For behavioral or mental telehealth, Medicare allows services with the patient at home and without geographic restrictions. The CMS MLN booklet lists substance abuse disorder services under the behavioral or mental telehealth bucket and allows two way interactive audio only technology for that bucket, with the patient at home. Centers for Medicare & Medicaid Services

Here is the question you probably ask in supervision: Do these changes mean telehealth got harder?

Yes, in one way. Sloppy systems create risk now. Tight systems create safety.

What stayed the same

Telehealth in substance use counseling did not change the fundamentals of counseling.

You still need rapport. You still need accurate assessment. You still need a plan that fits the client’s actual life.

Privacy rules also stayed strict. 42 CFR Part 2 still limits use and disclosure of substance use disorder patient records and keeps protections tied to records that identify a person as having or having had a substance use disorder. eCFR+1

And Part 2 still expects that redisclosure warning to travel with the record in the ways the regulations allow. SAMHSA describes this notice requirement in its confidentiality FAQ, tied to 42 CFR 2.32. SAMHSA+1

You still face the same clinical reality too.

A client can nod on video and still drink at night. A client can cry on the phone and still miss housing court the next morning. Telehealth does not change ambivalence. It changes access. Then your skill carries the rest.

That is where addiction counselor continuing education matters. Real addiction counseling training turns telehealth from “I hope this counts” into “I know what I am doing.” That supports addiction counseling certification and drug counselor certification in every state that touches your work.

What you need to document every time

Telehealth in substance use counseling wins or loses in the note. Your note needs to show what happened, where it happened, and why it met the standard of care.

Keep it simple. Document these items.

• Patient location at start of session

• Modality used, video or audio only

• Identity confirmation method

• Consent for telehealth

• Privacy check, who was present on each end

• Risk screen and safety plan steps used

• Clinical content, interventions, response, plan

• Any coordination of care or record sharing with consent details

That list looks basic. It protects you.

1) Location and emergency planning

Remote work changes crisis response. In an office, you can walk to a supervisor. You can call security. You can keep eyes on the client.

On telehealth, you need location. Every time.

HHS telebehavioral health guidance pushes providers to prepare an emergency plan, including an emergency contact or support person who can help in a crisis. telehealth.hhs.gov+1

So write this in your note in one line. Client location. Emergency contact on file. Your steps taken.

2) Modality and tech limits

Audio only sessions happen for real reasons. Phones break. Data runs out. Some clients live in shelters with no privacy for video.

Medicare rules matter here. CMS states that for behavioral or mental telehealth, you may use two way interactive audio only technology, and the patient must be in their home. Centers for Medicare & Medicaid Services

So document the modality and the reason it was used. Keep it factual. No drama.

3) Consent

Consent is not optional in telehealth culture. States vary. Many states include telehealth specific informed consent requirements in laws or policies. CCHP+1

Write your consent line the same way every time. Consent obtained. Method used. Client questions answered.

Here is the question I hear from counselors: Is verbal consent enough?

Often yes. Many telebehavioral health models accept verbal consent documented at the start of the session. telehealth.hhs.gov
Your agency policy and state rules decide the exact process, so your note needs the proof of consent each visit.

4) Privacy and Part 2 thinking

Telehealth changes privacy in a brutal way. You do not control the room the client sits in. You do not control who walks behind the camera. You do not control smart speakers.

So you ask one direct question. Are you in a private space right now?

Then you document the answer.

Part 2 stays central. The federal rules restrict disclosure of records that identify a person as having or having had a substance use disorder. eCFR+1

You already know the vibe. Clients get harmed when privacy gets sloppy. I lived that stigma. You do not need more reasons for clients to hide.

5) Risk and safety planning in remote care

Telehealth sessions can feel calm right up until they do not.

Build one repeatable safety line in your notes. Suicidality screen completed. Risk level. Safety plan reviewed. Emergency contact confirmed.

The American Psychological Association informed consent checklist highlights a safety plan need that includes an emergency contact and the closest emergency room to the patient’s location for crisis situations. American Psychological Association

No extra words. No long speech. Just clear documentation.

What changed for opioid treatment programs and MOUD screening

Telehealth in substance use counseling intersects with MOUD care more than ever.

SAMHSA’s table of changes for 42 CFR Part 8 states that the final rule allows screening patients for buprenorphine initiation via audio only or audio visual telehealth under certain conditions. It also allows screening for methadone initiation via audio visual telehealth under certain conditions. SAMHSA+1

CMS adds its own piece. The CMS MLN booklet states that OTPs may provide periodic assessments via audio only telecommunications and describes an intake add on code via two way audio video technology tied to methadone initiation, subject to SAMHSA and DEA requirements at the time. Centers for Medicare & Medicaid Services

Your takeaway is simple.

Document the clinical basis for the session. Document the modality. Document compliance with program rules.

That protects clients. That protects you.

How this ties to your credential and CEUs

Telehealth in substance use counseling impacts your credential in a real way.

Auditors and supervisors look for the same thing. A note that shows clinical judgment, informed consent, privacy steps, and safety planning.

That is why addiction counselor continuing education should not feel random. It should feel like practice reps.

You can build CEUs around what telehealth forces you to do well:

• documentation and clinical records

• ethics decision making

• confidentiality under HIPAA and 42 CFR Part 2

• crisis management and safety planning

• telehealth best practices for substance abuse disorder services

That content supports CASAC renewal. It supports substance use disorder counseling certification. It supports addiction counseling certification and drug counselor certification in the states that accept NAADAC style continuing education.

You do not need perfect. You need consistent.

And yes, you need documentation that tells the truth in a clean way.

Telehealth in substance use counseling is not going away. The chaos can go away. Your notes can make that happen.

Telehealth in substance use counseling works best when you treat the note like part of care, not paperwork.

Telehealth in substance use counseling gives access. Your skills turn access into change.

Telehealth in substance use counseling demands better documentation. Your system can meet that demand.