Value of pill/strip counts

Buprenorphine Post
Jeremy K
Posts: 109

Postby Jeremy K » Fri Feb 08, 2013 10:22 am

I really appreciate everyone's contributions to this thread. It is fascinating and instructive to see the range of opinions and practices about pill/strip counts etc.

I do unused strip counts, the pts being instructed to bring them in the packaging from the pharmacy so we can see how much was dispensed at the time (some pts pick up partial Rx's due to cost). I guess I put myself somewhere in the middle/muddle: I do think I have some responsibility to the pt and the community to make diversion tougher than it could be. But any 'system' can be beat, admittedly.

Does anyone have any insight into the attitudes towards this on the part of:
1. Nationally recognized experts in addiction treatment
2. DEA agents who may have commented about this during site visits
3. State medical boards ?

Also: has anyone ever been contacted by a pharmacy or LEA (Law Enforcement Agent) with information that strips were found sold on the street and traced thru the bar code demonstrating that they were from a Rx you had written for one of your pts? I would welcome this information and hope that I would receive said notification in such a case.

hedwards
Posts: 296

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

"weeding out the resellers"

And how did they get you to buy into the notion that that's an appropriate role for a physician?? Isn't that what DEA has failed miserably at? Having said that, no, you are not doing all you can to prevent diversion. You could make each patient take each dose in front of you, possibly dispensing it yourself.

Don't do pill/wrapper counts.

fishdoc
Posts: 111

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

Perhaps I am being naive, but it seems to me that if I give, for example, a prescription for 60 films for 30 days, and require the patient to return with 60 wrappers, then I am doing all I can to prevent diversion. My patients bring back the empty wrappers and show me the unused film wrappers at each visit. They are told that we also check the serial numbers on the wrappers.

While I understand that the patient could have an agreement with another person to whom they are selling the Suboxone and then buying back the wrappers, this seems to me to be the best option for preventing diversion.

I have sent many patients home to get the wrappers they forgot to bring. I will write a 1 day prescription until the wrappers are presented. The few who refuse to bring the wrappers back frequently have UDS that are positive for very high concentrations of bupe but no metabolites! Needless to say they are dismissed from the practice.

I find the combination of UDS, wrapper counts and random saliva testing very reliable for weeding out the resellers.


deegee
Posts: 137

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

Lots of interesting comments. I vote against pill counts. I used to do them, but patients often have an excuse (out of town, working) even though the "agreement" says they need to respond in 4 hours. In reality that's absurd. Maybe they're not out of town, but just taking the time to round up some strips for the count. If they actually leave work for a pill count, that's kind of destructive to their life. Taking the time to mark strips and note numbers might help in a small community but seems like a real time sink and we're really not supposed to handle patient's meds. As far as using serial numbers for the count, I think it's been addressed that they very likely won't be in sequence, whether really from the pharmacy or picked up on the street, so again, pill counts are not that useful.
Are patients enemies or not? The terms stack the argument, but if a patient is selling the drugs I prescribe, then that patient is an enemy. If they are deceiving me, they are an enemy. This is a "war on drugs", is it not? Thus the term enemy is used, although not my favorite. Nor is the term "drug addict" for that matter. In any case, I do urine testing every visit. It's less valuable for the actual bup, than it is for relapsing.
I've also seen urine testing with bup but no metabolite, as well as metabolite and no bup. First case may be added to the urine. Second case may be they stopped taking meds a few days ago because they ran out or something.
Ultimately, my best tool is my relationship which I try to keep professional but with me clearly on the side of helping my patients, yet intolerant of deceit. Sorry for the long post.

Jeremy K
Posts: 109

Postby Jeremy K » Fri Feb 08, 2013 10:22 am

Dr P

No need to apologize, no offense taken. I very much value your judgment on these very difficult issues as well as that of so many others who comment here. And I don't know if I would say KY was any more erudite, but I can think of some other adjectives... :-)

drpasser
Posts: 1404

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

I understand, sorry for saying the word paranoid. It was uncalled for and I apologize.

What you're saying does make sense.

I've never heard of the Lipid Profile deal, and never order them. I have never heard it's a requirement here. Mizzippi is obviously much less erudite than KY.

Best
Kevin

Jeremy K
Posts: 109

Postby Jeremy K » Fri Feb 08, 2013 10:22 am

Dr P

I appreciate what you're saying, and certainly I want to refine my practice to be most helpful to my patients. But in reality both the Fed and state gov'ts have power to influence what I do. For instance: the KY state board has a list of recommendations concerning Suboxone prescribing. It lists (among other things) ordering a lipid profile on all Suboxone pt's. I have no clue why they say that. It is not illegal for me to fail to do so. However, should the state board investigate my practice, it states on their website that the list of recommendations is what they will use when they investigate. So clearly it behooves me to order a lipid profile on all my Suboxone pt's.

Similarly, it behooves me to have some sense of what the DEA agents who will (eventually) 'inspect' my practice will be interested in. If other Suboxone prescribers have found DEA agents to be interested in whether UDS's are done, what's included, and what actions are taken in response to them, I'd like to know that. Also if they care about pill counts. If, OTOH, they couldn't care less about either, I'd like to know that as well, particularly if pill counts and UDS's are as useless as some commenters here maintain.

drpasser
Posts: 1404

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

Pill counts/Film counts are not the same as checking urine drug screens.

The DEA is mandated to do inspections, not monitor if we do counts.

Let's try and be less paranoid about the DEA, and more pt centered in terms of what's indicated for our safe and effective OBOTs.

Dave
Posts: 187

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

Pill counts are worthless. If a patient has been prescribed 3 pills a day but takes only one and sells the rest, how would you possibly know it? He will tell you he has no more because he has used them as prescribed. If he has been using street opiates most of the time, he could stop a few days before his appointment with you and take a few of prescribed bup so his urine looks OK and he doesn't go into withdrawal before his appt. The majority of his prescription can be sold, and how would you know? As Dr. Edwards has said, "DON'T COUNT DRUGS."

Jeremy K
Posts: 109

Postby Jeremy K » Fri Feb 08, 2013 10:22 am

Thanks all for the replies. "DON'T COUNT DRUGS"? Hmm...I'd be interested if anyone has any 'war stories' re DEA agents' comments about this. Do they check to see if pill/strip counts are being done? In re the issue of accusations that the count is being done inappropriately by staff, my staff on their own decided to always do counts by two staff at the same time. Also: I still am having trouble figuring out how a strip count that consists of counting and marking the film packets so they will be spotted if an attempt is made to use them in a count repeatedly can be 'beaten'.

I think at least some of my patients appreciate having the accountability of the counts, and the UDS's. I assume the DEA and my state board would look askance at me if I didn't do them. Hence I intend to continue to do them.


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