ASAM: Let them count pills.

ASAM has drunk the Kool-Aid. With the spectacular failure of law enforcement to stop drug diversion new guidelines from the American Society of Addiction Medicine says “clinicians should” require “recall visits for pill counts,” but in my opinion failure of prohibition should not dictate conscription of physicians into a law enforcement role.

I have written before about the delusion of pill counts. Not only does ASAM fail to document evidence of clinical utility, but the Guideline even fails to describe the procedure. And, by the way, I have yet to see a CPT code for pill counts, a procedure for which pharmacists, but not physicians, receive formal training.

ASAM would have us believe that by demanding on short notice that the patient come to the office with their supply of buprenorphine for us to count, that we can make sure they are not

  • Taking too much
  • Selling them
  • Giving them away

For such a ploy to give even the appearance of working the patient must have little time to fool us by implementing one of the strategies below. This probably means disrupting their work or personal life and limiting how far away from your practice they can live or work.

If you do drink the Kool-Aid yourself and engage in this futile activity inappropriate for a clinical setting, expect patients to avoid getting caught by

  • Searching the Internet for strategies which might include
  • Leaving out any additional they have set aside. Duh.
  • Borrowing or buying an emergency supply on the street or from a friend or relative.
  • Saving an adequate “pill count stash” (What makes you so sure patients take all that they buy?)
  • Substituting look-alikes
  • Telling you they are out of town (which might be true)
  • Telling you they will lose their job (which might be true)

Furthermore, can you be sure the law allows you to take possession of a controlled substance for which you have no prescription? Add this to the already considerable list of felonies medical practice entails.

Forcing a patient to submit to pill counts disrupts the lives of people trying to put their lives back together making it harder for them to get treatment and increasing the likelihood they will obtain diverted drugs themselves.

Maybe the folks at ASAM need to do a First Step: “We admitted we were powerless...” Doctors who want to pursue law enforcement should get a gun and a badge. Let pharmacists count pills.


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