Buprenorphine Pill Counting: Make Believe Medicine

I just found this in PCSS on Adherence, Diversion and Misuse of Sublingual Buprenorphine:

"Pill counts: Having the patient bring in the bottle for a pill count at every visit helps to monitor the rate at which the pills are being consumed.

"Unannounced monitoring: Both urine testing and pill counts can be done ‘randomly’. The patient is contacted and must appear to give a urine test and have a pill count within a specified time, for example 24 hours after a phone call. Of course, pill counting can also be subverted, and anecdotal reports of “pill renting” are common."

Sounds like a great idea. Anybody can count, even doctors. Your OBOT patient dutifully brings the bottle for their last buprenorphine prescription. If you prescribed just enough to get the patient through that visit, the bottle should be empty. If the bottle still contains pills you admonish the patient for non-compliance and/or reduce their dose accordingly. If you ordered enough to last beyond that visit, you can count the remaining pills to make sure just enough remain to last through the appropriate date. If too many remain you again admonish and reduce, but if too few remain, you can say "gotcha" and discharge the patient for presumption of diversion or, heaven forbid, for taking more than prescribed.

Even the PCSS seems to acknowledge that patients are not stupid by admitting that you may more likely catch the patient in such a transgression by calling them back unexpectedly to appear 24 hours after a phone call, and that what they call "pill renting" may occur. The unexpected call back should catch the patient who has sold all or most of the prescription soon after purchase. But as the guidance suggests the enterprising "patient" need only "rent" or purchase the necessary number of pills to present for counting, and sell them again.

The problems with this strategy extend far beyond pill renting, however. To paraphrase the adage, addicts of a feather flock together.  I suspect the pretend patient who sells all or most of her buprenorphine can easily find enough to rent or buy back, but I have also treated many patients along with friends, spouses, siblings, parents and children. Let's say both husband and wife want buprenorphine, but only one has insurance. The husband gets treatment, claiming to need 16 mg daily, but shares half the pills with the wife. No need to rent or buy back anything. The pills may still be in the same bottle.

I hope I do not need to explain that having too many pills will not likely occur. All the patient must do is leave the requisite number of pills elsewhere when you do the count. If this happens you should evaluate your patient for dementia.

If you insist on pretending that random call  backs for pill counting tells you anything at all, consider that the likelihood of catching a diverter diminishes rapidly with time. The longer you wait, the lower the count should be, and the fewer pills the patient will have to come up with to avoid detection.

Now consider some other factors: The fact that you should inform your patient of the possibility of pill counts at the start of treatment all but eliminates the likelihood of surprise. Then consider the excuses for not getting back to the office for the count (I'm lucky if I can get some of my patients to keep regularly scheduled appointments.):

"I can't miss work/school."
"I have to take care of the kids/grandma/grandpa."
"My car broke down."
"I'm sick."
"I'm traveling out of town/state/country."

or the excuses for having too few pills:

"The dog ate them."
"My brother stole them."
"The doorman/police/customs confiscated them."
"I dropped them down the toilet/drain/sink/well/man hole."

"so could you please order me a replacement prescription. I'm so glad you called."

And suppose your patient lives 3 hours from your office.

There's more: Pharmacists are trained and licensed to count pills. Physicians are not. Physicians diagnose and treat illness. Law enforcement officers and agents should pursue diversion. Is there a CPT code for counting pills? Does any third party payer reimburse for counting pills? This is not to say that physicians should write unlimited prescriptions for controlled substances. We should not. For my part I make it clear to patients that I will not order replacement prescriptions unless the patient provides me with a receipt from law enforcement stating the number of pills confiscated. Then I attempt to account for the possibility the confiscated pills may be returned to the patient later. Several patients have left my practice after I refused to replace "lost" prescriptions. But of course they, like the patient you discharge for failing the pill count test, will find another source, legal or illicit, for buprenorphine.

I never cease to be amazed at the willingness of physicians to do whatever is demanded of them (getting paid for or not) without thinking. Sign this form. Sure. Sign this contract. OK. I don't even need to read it. Count pills. Any time. Reminds me of my all time favorite lawyer joke, which I believe may be misdirected. After all, lawyers only advocate; they don't decide the verdicts:

Why do we use lawyers instead of rats for medical research?
-Lawyers are  more plentiful.
-You can develop an emotional attachment to a rat.
-There are still a few things you can't get a rat to do.

It seems to me the last reason at least might apply to many of us in the medical profession more than to lawyers.

I have seen no evidence that pill counts impact diversion. The logistical problems outweigh any potential impact. Physicians should abandon this futile pretense, leaving diversion control to law enforcement, and pill counting to pharmacists.