From the IPS Opioid Manual:
Pill counts may be implemented as part of the prescribers compliance program however notification should be given in advance that such is a requirement for continued therapy. Pill counts may be routine (having the patient bring all their controlled substances with them to the follow up appointment), random (patient selected for a random pill count), or targeted (suspicion of overuse or selling of the medications). The targeted pill counts are best used from 1-2 weeks after the patient fills the prescription since if they are selling all or part of the medication, it is
usually very soon after prescription filling. A reasonable amount of time (eg. 24 hours) should be used for the patient to show up at the office or the prescribing pharmacy for a pill count. Generally, as long as the pill counts at a pharmacy are not frequent, the pharmacies will cooperate.
Pill counts may be useful when:
 There is a past history of substance abuse via overuse or current suspected overuse
 Suspicion of selling the medications or giving them away
 Clinic receiving reports by friends or family of patient overuse or selling
 Patient appears confused about the prescribing instructions
 A negative result for a prescribed controlled substance on a clinical lab monitoring test (eg. UDS) and the patient claims they take less than prescribed (if true, prescribing should be adjusted downwards)
 INSPECT shows early refills but patient claims they are taking the medications as prescribed
Pill counts should be performed in the office using a pill counting plastic or washable platform and spatula. The pills should not be physically touched by the staff and only placed on a washed platform to avoid cross contamination with other opioids (cross contamination may show up in clinical laboratory monitoring). The staff must be assured that the pills, patches, or capsules presented are of the correct identity, therefore should double check the imprint on the pill with a standard pill identifier database. In cases where there are multiple imprinted numbers, a call to the pharmacy is preferable to assure they actually dispensed these medications since some patients having pill counts will try to buy enough or borrow enough of the same pill from others to get by the pill count.
A significant deviation from expected vs actual pill count of >25% suggests the patient has lost control over their use or security of the pills or that they are selling the medications. If substance abuse is suspected, tighter controls (more frequent follow up visits, fewer pills prescribed with each prescription, changing to a less abusable medication, etc) may be employed however if selling or giving away the medication is suspected, then discontinuing medication prescribing would be appropriate.
Limitations on pill counts:
 Patient may be able to repurchase off the street the pills necessary to complete the count
 Old pills mixed in the same bottle as new pills proves problematic since they may come from different suppliers and have different identity marks
 Cross contamination of the pills on the pill counting platform possible
 Fragmentation of pills may occur
 Pharmacies may not be cooperative requiring the patient to travel back to the clinic.
 Angry or hostile family or friends may pilfer part of the patients supply then call in to the clinic to report they are selling the meds knowing this will trigger a pill count. The patient may be falsely implicated via a pill count. However in any case, this would suggest loss of security or control over the medications by the patient.
