Value of pill/strip counts

Buprenorphine Post
robertsonjon
Posts: 32

Postby robertsonjon » Fri Feb 08, 2013 10:22 am

Call it cognitive dissonance, but since I like pill counts, I will take your post and run with it. Currently my clinic does random pill counts, about 10% of our patients are called in each month. I know I have discharged people who were trying, and I know I am prescribing to some who are diverting. My office manager has a very negative view of addiction patients, and I've let her run the counts. I think I should stop that now, and just use pill counts when we get a tip or bup negative on saliva test twice.

quote:
Originally posted by MChaplin

i work closely with a team of dual dx (addiction/psych) clinicians- we have people sign an initial treatment contract which is very clear about what is not tolerated- if there is irefutable evidence that they are selling (for example we had a pt asked to return for pill count the very next day who lived within walking distance and declined to come in), we discharge immediately with no recourse. If they violate with an opi dirty urine or repeatedly give cocaine dirty urines we have them sign a second contract which states what they did and what the consequences are- usually come in for treatment more frequently- sometimes that they complete a residential rehab. we do allow a third contract but if they violate again we discharge. We do allow people to reapply in 6 months with no guarantee of acceptance back into the program...btw we do urines every week for at least 4 weeks then we use our judgement- we do random urines when there is any concern and likewise do pill counts when there is a concern- if there is a plausible excuse for the pill count we wait and do it again- i think pill counts can play a role but like anything else i treat them as a piece of the puzzle- if someone is sketchy, i sometimes tell them i will only continue to treat if they will accept a vn- i find that people who accept a nurse generally are on the up and up- that may not work for many of you since insurance usually covers the nurse for the pt population i treat.


catschollmd
Posts: 16

Postby catschollmd » Fri Feb 08, 2013 10:22 am

check the LOT Numbers you can ask pharmacy to add it to RX label or after the fact call the pharmacy to get lot number

MChaplin
Posts: 183

Postby MChaplin » Fri Feb 08, 2013 10:22 am

i work closely with a team of dual dx (addiction/psych) clinicians- we have people sign an initial treatment contract which is very clear about what is not tolerated- if there is irefutable evidence that they are selling (for example we had a pt asked to return for pill count the very next day who lived within walking distance and declined to come in), we discharge immediately with no recourse. If they violate with an opi dirty urine or repeatedly give cocaine dirty urines we have them sign a second contract which states what they did and what the consequences are- usually come in for treatment more frequently- sometimes that they complete a residential rehab. we do allow a third contract but if they violate again we discharge. We do allow people to reapply in 6 months with no guarantee of acceptance back into the program...btw we do urines every week for at least 4 weeks then we use our judgement- we do random urines when there is any concern and likewise do pill counts when there is a concern- if there is a plausible excuse for the pill count we wait and do it again- i think pill counts can play a role but like anything else i treat them as a piece of the puzzle- if someone is sketchy, i sometimes tell them i will only continue to treat if they will accept a vn- i find that people who accept a nurse generally are on the up and up- that may not work for many of you since insurance usually covers the nurse for the pt population i treat.

steve bien
Posts: 55

Postby steve bien » Fri Feb 08, 2013 10:22 am

i elected to suspend suboxone treatment at least for a period of a few months. if he can continue a good track record with a counselor with consistent and genuine involvement i would take him back. thus far, though, his attendance in counseling has seemed only cursory and pro forma.
My take home: the anticipated drug screens here are pretty easy to pass and random screens are worth doing as are targetted pill counts. While i realize some of my meds are without doubt getting passed or sold from time to time, i have zero tolerance for what i think might be serious diversion.
Having been audited once ( no problems) i am aware that having policies and evidence that you are complying with your own articulated standards are key. less than that creates a bad reputation in the community as well as poor morale for office staff, not to mention putting oneself at risk. with that in mind, when someone violates a clear rule i feel a need to respond with more than a warning not to do it again.
steve

entjwb
Posts: 180

Postby entjwb » Fri Feb 08, 2013 10:22 am

Steve, I would have first done weekly UDS and if noncompliance is shown. I have no problem dismissing the patient. My patients are told on first visit. I will totally trust them until they prove to me to be untrustworthy. What you described has proved that. We have an obligation to treat patients who want the help. Each one we treat that doesn't want help, takes the place of someone who does. Amy patients knows the rules from the start and understand what can happen if they are not compliant. In actuality I don't dismiss them they did it it themselves. It can be called tough love. If they really want to change it will happen.

DrBallester
Posts: 84

Postby DrBallester » Fri Feb 08, 2013 10:22 am

After the first negative toxicology, I would have scheduled the follow-up on a weekly basis, if the toxicology remains negative in subsequent visits, maybe two more chances, immediate dismissal.

steve bien
Posts: 55

Postby steve bien » Fri Feb 08, 2013 10:22 am

how many of you would discontinue treatment for this person
1. has been on suboxone for 6 months, all negative urine screens in my office.
2. however, after i heard of an allegation by another patient that this individual was dealing i called him in for a pill count. he failed to respond to repeated calls including the number he specifically gave us for this purpose, saying that he was out of town, working
3. i requested his counselor to spring an unexpected urine screen on him; this was postive for oxycodone. he says this is the first time he has messed up
i am conflicted about this since my suspicion springs from hearsay. i also know that most hearsay of this sort is true. and i have a hard time construing the pattern of events any other way.
in addition, his participation in counseling has been inconsistent and half hearted. his therapists find him distant and unengaged.
thanks
Steve, Maine

hedwards
Posts: 296

Postby hedwards » Fri Feb 08, 2013 10:22 am

"if/when it's taken off the market by the feds."

Imagine the total disaster if this were to happen. I'm not sure even the feds are stupid enuf to do that.

wgrass
Posts: 58

Postby wgrass » Fri Feb 08, 2013 10:22 am

I don't count pills or wrappers. As a measure of compliance it's not worth spit, so not worth the time and wasted confidence.

But maybe I should. I find Suboxone film wrappers on my lawn all the time, near the road, when I mow the grass. I'd like to think my patients aren't litterbugs, but maybe if I collected the wrappers, it would keep them off the lawn. Then it would be worth the effort.

drpasser
Posts: 1404

Postby drpasser » Fri Feb 08, 2013 10:22 am

I don't not perform empty film wrapper counts on any where near a routine basis. When I do them, it's an exception and not the rule. I am not sure they help that much at all with preventing diversion. I am not naive enough to think that some of my meds don't end up on the street. I have yet, however, to hear of a specific example from any of the authorities whereby Films I Rxed are found elsewhere, except for in a pt's possession. If the pts want to be covert, they can and will and some stuff may get past me. I don't look at myself as the pill/wrapper count-compliance police. May attitude is that deceptive practices on the part of pts, only really hurts them.

I know others may say, that if too much bupe ends up on the street, that will potentially jeopardize all pts from receiving it, if/when it's taken off the market by the feds. I know that I cannot really do anything to prevent that, so I just accept it.

I'm not all that powerful.

Best
Kevin


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