Screening pain prescriptions for safe use with VIGIL
Special Pain Section
Some prescribers feel it is their duty to provide medications to patients for pain control, but it’s the pharmacist’s responsibility to screen the appropriateness of these prescriptions, according to David Brushwood, BSPharm, JD, Professor Emeritus, University of Florida College of Pharmacy.
Pharmacists should screen individual prescriptions instead of specific prescribers, specific patients, or specific drug products. “Pharmacists should not use generalizations like refusing to fill prescriptions from a certain physician or for a certain patient, or not filling prescriptions for a specific drug product (e.g., oxycodone),” Brushwood said. “Instead, pharmacists should focus on each prescription, and look at the entire context of it and how patient, prescriber, and medication-related factors all play a role in determining if it is appropriate or not.”
Brushwood developed a VIGIL screening process that he recommends for use by pharmacists when filling opioid prescriptions. Within the VIGIL process, providers are given a list of factors that may be associated with an increased risk of abuse or diversion, along with a list that may reduce this risk. Once all the factors are considered, patients are rated as being from low to high risk for abuse or diversion. The VIGIL process also includes a verification of the patient’s identification and patient-specific responsibilities.
Abbreviated VIGIL process
Step I: Verifying the prescription (receiving the prescription)
- Ensure that the formal requirements for content of the controlled substance prescription have been met under federal and state laws.
- Swipe the identification (ID) of the patient or person presenting the prescription.
- Confirm birthdate and address of the patient.
Step II: Risk stratification (prescription processing)
- Apply factors that increase risk of abuse and/or diversion.
- First-time patient in pharmacy
- Patient, pharmacy, prescriber all have different ZIP codes
- Patient has the same address as another patient who is also using C-II opioids
- More than three exact same prescriptions filled in previous 24 hours
- Patient has been prescribed C-II opioids by three or more prescribers in previous 6 months
- Patient also has been prescribed benzodiazepine and skeletal muscle relaxant
- Prescription presented for filling on weekend
- Prescription presented for filling between 6:00 pm and 9:00 am
- Apply factors that reduce risk of abuse and/or diversion.
- Patient age is older than 35 years
- Patient has received noncontrolled substance prescriptions monthly for past 6 months
- Patient is personally present in pharmacy
- Government or private insurance plan is paying for prescription
- Patient has 6-month history of receiving this opioid with no “too early” acquisitions
- Prescription directions are consistent with FDA-approved labeling (e.g., appropriate dosing frequency)
- If extended release/long acting, quantity is consistent with chronic use under approved labeling frequency
- &Prescription has been presented to pharmacy on date of its issuance
- Stratify patient into risk category.
- Low risk (standard care)
- High risk (special care)
Step III: Clarification of patient responsibility (prescription delivery)
- Swipe the ID of the patient or person receiving the medication.
- Patient or representative signs computer screen to signify acceptance of responsibilities.
- This medication will be used exactly as has been directed by the prescriber.
- This medication will be stored in a discreet and secure place.
- Alcohol and illicit drugs will not be used while this medication is being used.
- This medication will not be shared with any other person.
- The failure to meet any of these responsibilities may result in denial of future pain medications.
- Patient or representative agrees to responsible use on computer tablet screen.
“Prescription drug monitoring programs (PDMPs) are one of many tools that may be useful when screening prescriptions,” Brushwood said. He noted that PDMPs are a starting point and not an ending point when evaluating the appropriateness of prescriptions for controlled substances. “If a report comes back clean, pharmacists may set aside concerns—when in reality, the report should only be one of many factors that are taken into consideration,” he added.
Pharmacist–patient agreements (also known as contracts) and urine drug testing also “may be useful as they clearly lay out both the pharmacist and patient responsibilities,” said Brushwood. Urine drug testing is more of a prescriber strategy because it may be difficult for pharmacists to obtain and/or monitor these results.