Counts

[Sloane]

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I would like to get some input, from those who prescribe opiates, about random pill counts. I have been covering for a colleague who writes for a lot of opiates, and I would like some of the patients to be called in for a random count.

How much time to you give the patient to get to your office?

Experience and advice is appreciated.

Thanks.

 

[Aether2000]

It has to be a practical request. People who are working or in transit, cannot simply drop everything to rush into the physician's office. Usually 24 hours with some provision to fit their schedule (eg lunch) with a guaranteed rapid in and out is in order. Also, if they are remote or have transportation issues to your office, then a trip to the pharmacy that filled the medications may be permitted such that the pharm tech counts the pills.

Because of the implications of pill counts and the potential extreme inconvenience, my suggestion is that they be used sparingly, and used particularly when you cannot verify any other way. For instance, people reported as selling drugs....obtain a pill count mid prescription instead of the first or last week.

 

[Tenesma]

pill counts are quite impractical...

most diverters will have a full back-up bottle or will just purchase the right amount for the pill count and return them after the pill count...

patients have all kinds of excuses (leaving town to visit uncle joe for 2 weeks, they are currently in Florida, stuck at work for a 12 hour shift), etc...

pill counts make sense just not logistically possible...

before we get to pill counts/drug screens - what about screening the patient before they get pills including a FULL neuro-psych eval...

 

[Sloane]

Thank you for your responses. The 24 hour window is reasonable and makes sense.

Also, I agree 100%, having a work-up that reflects a "low-risk" prior to writing for any opiate medications is smart practice.

This situation is different. I am covering for someone else, for a short time period thankfully, and need advice on what to do with the patients who already obtain opiate prescriptions from that other physician.

 

[ghost dog]

pill counts are quite impractical...

most diverters will have a full back-up bottle or will just purchase the right amount for the pill count and return them after the pill count...

patients have all kinds of excuses (leaving town to visit uncle joe for 2 weeks, they are currently in Florida, stuck at work for a 12 hour shift), etc...

pill counts make sense just not logistically possible...

before we get to pill counts/drug screens - what about screening the patient before they get pills including a FULL neuro-psych eval...

Tenesma makes a good point about screening (UDS) before prescribing opioids. I typically do this for higher risk pts (per the opioid risk tool), although some may universally screen.

I find that it is useful to perform pill / patch counts randomly when a patient is coming in for medication refill (i.e. the pt should have a small amount of med left). If there is a problem with diversion / binge behavior, it will be detected sooner or later. Typically sooner if opioid abuse is the issue. Some may not like this approach, but I find it acceptable in my practice.

A more cost effective approach to the psych evaluation may be the :
PHQ-9 questionnaire for depression, SISAP, and various other standardized questionnaires such as the FABQ. Quick and dirty.