Pill Counts — The Underrated Tool in Controlled Substance Monitoring

When it comes to controlled substance monitoring, most providers immediately think of PMP checks and urine drug testing. Those are critical, but there’s another tool that’s often overlooked—pill counts.

Simple, inexpensive, and fast, pill counts can be one of the most effective ways to detect misuse or diversion before it escalates into a major problem. Unfortunately, because they’re so basic, many clinicians underestimate their value.

Why Pill Counts Work

A pill count is exactly what it sounds like—asking the patient to bring in their medication so you can verify the number of pills matches the prescription and refill schedule.

Here’s why it matters:

• Early Detection of Overuse – Identifies patients taking more than prescribed.
  
• Evidence of Diversion – Missing pills may indicate the medication is being sold or given to others.
  
• Pattern Recognition – Repeated discrepancies are a red flag for unsafe prescribing or noncompliance.
  
• Low-Cost Compliance – Requires no lab, no complex equipment, and minimal staff time.
  

When to Perform Pill Counts

• Randomly – The element of surprise is key to accuracy.
  
• At Follow-Up Visits – Especially for high-risk patients or those on chronic therapy.
  
• For Cause – When red flags arise, such as PMP discrepancies or abnormal UDT results.
  

Best Practices for Pill Counts

1. Set the Expectation from the Start
   
   • Include pill counts in your Controlled Substance Agreement.
     
   • Tell patients this is standard for all controlled substance prescriptions.
     
2. Document Thoroughly
   
   • Record the date, the count, and whether it matched expectations.
     
   • If there’s a discrepancy, note your conversation with the patient and your next steps.
     
3. Be Consistent
   
   • Avoid selectively targeting certain patients—uniform application strengthens your legal standing.
     
4. Combine with Other Tools
   
   • Pill counts work best alongside PMP checks and urine drug testing for a full compliance picture.
     

A Real-World Example

I worked with a practice that implemented random pill counts after a series of suspected diversion cases. Within three months, they identified multiple patients whose counts didn’t match, leading to early interventions and, in some cases, referrals for substance use treatment. Just as importantly, the consistent application of the policy impressed auditors and strengthened their compliance profile.

Bottom Line

Pill counts may not be flashy, but they’re effective. They protect patients, deter diversion, and give you another layer of documentation if your prescribing practices are ever challenged.

In compliance, sometimes the simplest tools are the most powerful. Pill counts are one you can’t afford to ignore.

About the Author

Douglas J. Jorgensen, DO, CPC, FAAO, FACOFP

Dr. Doug is a physician, consultant, and national educator on medical documentation accuracy, patient engagement, and compliance strategy. He helps healthcare organizations develop systems that make patients active partners in their own medical records.