Pill Counts: A Tool for Medication Adherence and Diversion Reduction

By: Jody Lutz

Reading Time: 4 minutes

Date: 05/22/2018

Filed Under: Opioid Prescribing Guidelines, Pill Counts

Patients with chronic pain are frequently asked to agree to medication adherence activities, like pill counts as a part of an opioid therapy plan. We dig into what pill counts may look like, how they are facilitated, and the potential pitfalls they present.

Pill count

What is a pill count? Routine or random?

A pill count is fairly-self explanatory. For a routine pill count, a practice will require a patient to bring her prescribed medication with her to a clinic visit. When the patient arrives, the physician, nurse or medical assistant will physically count the number of pills and compare that to the prescription's instructions.

In theory, this methodology manually reconciles the number of pills available to confirm the patient is following the doctor’s instructions and the controlled substance is potentially not being misused.

Opioidrisk.com provides a detailed explanation of the steps to perform a pill count:

  • Request that the patient bring all unused pills to an appointment in the original container.
  • Notify the patient the day before or the same day as the appointment.
  • Check if the number of pills in the container match what the expected number would be if the patient followed the prescribed dosage.

The patients at highest risk may need unscheduled "call backs" in which they are asked to bring their medications for a pill count within 24 to 36 hours of the phone call (Batki, et al, 2005).

A reduced number of pills may indicate diversion or regular use beyond the prescribed amount, for example, due to misuse or undertreated pain. Too few pills could also be due to occasional inappropriate excessive use, as in chemical coping or intentional misuse. An increased number of pills may indicate inappropriately low intake, possibly related to over sedation or other side-effects, or that the prescription dose needs to be re-evaluated. Other possible reasons for a wrong pill count include loss of medication, misunderstanding of directions, etc. This underscores the importance of establishing an open provider-patient relationship.

The theory behind a random pill count is that a patient prescribed a controlled substance is called by the prescribing physician's office at random and required to bring all prescriptions into an appointment within an allotted time frame (typically within 24-48 hours of receiving the call).


Why should I perform pill counts?

Random or routine pill counts may be required by state opioid prescribing guidelines or a practice's Informed Consent or Treatment Agreement.  For example, Kaiser Permanente ‘s Opioid Medication Agreement states in part, “At times, you might also be asked to bring your opioid pills, in their original bottles or containers, with you for counting. We want to make sure you are taking the right amount of this medication for your safety. We provide this care and monitoring to everyone on a long- term trial of opioids."

The pill count is not without flaws. There has been lengthy discussion about the black-market economics of “pill renting.” Simply put, an underground network where a patient “rents” their pills to pass a pill count. Some sources quote the nominal amount of $1 per pill as a common rental fee. After the pill count is passed, the rented pills are returned to the dealer.

This article, although a few years old examines this trend:

Pill counts and pill rental: unintended entrepreneurial opportunities

In light of pill renting schemes, confirming that the pills presented in the Rx bottle are what they are supposed to be should be considered part of the pill count paradigm. Resources such as the app idmypill allows users to snap a picture of their pill with an iPhone for identification. WebMD and Drugs.com both also provide a pill identifying feature. It is important to consider, that just physically presenting a pill to fulfill a numeric requirement may not be suffice to determine what's actually in the Rx bottle.


How will a pill count affect patient care?

When pill counts are conducted they must be documented in the patient’s chart. An example of a pill count documentation form can be found here.

What happens if a patient fails a pill count? Depending on the practice, patient dismissal to an ongoing discussion regarding medication reconciliation seems to be within the broad range of answers.

A pill count policy essentially is put in place to act as another means to ensure that patients receiving controlled substances are taking their medication as directed and to demonstrate proper medication accountability. Due to the nature of the medications commonly prescribed in pain management, it is essential that these be taken as directed by the prescribing practitioner. The main goal of a pill count is to prevent diversion, misuse and abuse.

Pill counts should not be seen as a silo, but a segment of the overall risk assessment and as part of the ongoing treatment plan – one that utilizes PDMP data, toxicology screening and risk evaluation as established by practice protocols. The overarching goal being, successful treatment of a patient’s pain – while taking steps to minimize the risk of abuse or misuse while complying with applicable clinical best practices.

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