VIGIL helps pharmacists screen controlled substances
Goal is controlling diversion
In the early 2000s, David Brushwood, BSPharm, JD, gave a series of presentations on prescription drug abuse designed to help pharmacists determine the difference between a drug-seeking patient looking for the next narcotic fix and a legitimate pain patient. Based on his experience with the lectures, Brushwood, Professor of Pharmaceutical Outcomes and Policy at the University of Florida College of Pharmacy, created the VIGIL system, a controlled substance prescription screening tool that can be easily used in the daily practice of pharmacy.
“The goals of the program are to ensure that all patients who need medications get [them] with personal respect and professional competence, [that] drug diverters and abusers are denied access, and to ultimately shrink the gray area between legitimate prescriptions and purported prescriptions,” Brushwood told Pharmacy Today.
The VIGIL system involves the following five components: verification, identification, generalization, interpretation, and legalization. These five components are designed to help pharmacists classify patients by risk, as follows:
Verification: Is this a responsible opioid user?
- Talk with the patient.
- Avoid filling Schedule II (CII) opioid or hydrocodone/acetaminophen prescriptions for the first time without verifying the prescription with the prescriber.
- Find out the legitimate medical purpose for the medication.
- Provide a partial supply if unable to verify the prescription.
Identification: Do I know for sure who this person is?
- Require a government-issued photo ID or a reasonable substitute for anyone, including any family member, picking up CII or other narcotic prescriptions.
- Photocopy the ID or write down the information.
Generalization: Do we agree on mutual responsibilities and expectations?
- Use statements with patients such as, “I am your pharmacist and I agree to promptly and respectfully provide medications and services if certain rules are met.”
- These rules may include the patient agreeing to keep all controlled substances under lock and key, not sharing the medications with anyone, agreeing to only using one pharmacy to fill controlled substances, and agreeing that the prescriber may be contacted if refills are too early or if emergency supplies are needed when there is no real emergency.
Interpretation: Do I now feel comfortable allowing this person to have controlled substances?
- Use a brief questionnaire available online such as the Opioid Risk Tool or Screener or Opioid Assessment for Patients in Pain to predict misuse or abuse by patients.
- Obtain family or friend participation and feedback regarding success of therapy based on patient functioning.
Legalization: How can I stay squeaky clean in meeting my legal requirements?
- Follow all state and federal laws for controlled substances with no exceptions.
- Conduct medication histories and provide education for all chronic pain patients.
- Document everything you have done.
Scoring the risk
Based on a variety of factors that are rated on a point scale, pharmacists can use the VIGIL system to classify patients by level of risk and care. Patients classified as “low risk” (0–4 points) require standard care, “medium risk” (5–9) patients require special care, and “high risk” (10+) patients require extra care.
The VIGIL system factors in “red flags” that add points to a patient’s overall score and “green flags” that subtract points. Examples of red flags include the following: males between 16 years and 45 years old (2 points), lost or stolen medications more than once in the past year (3 points), more than two prescribers of opioids in the past 6 months (2 points), or more than 20% too early on opioid refills more than once in the past 6 months (2 points). Green flags, where points can be subtracted, include the following: if the prescriber is a board certified pain management specialist known to the pharmacist (–2 points), the patient uses insurance and never pays cash (–2 points), or the patient has a nonproblematic Prescription Drug Monitoring Program report (–2 points).
Pharmacists can use VIGIL as a guide for counseling pain patients. For low-risk patients, verifying an ID may be acceptable. For those who are medium risk, limiting the quantity dispensed and/or implementing a medication use agreement with the patient may be reasonable. More labor-intensive interventions may be needed for patients who fall in the high-risk category, such as requesting the prescriber to forward patient records to the pharmacy for review. Most importantly, pharmacists should use their common sense and best judgment when dispensing controlled substances to help reduce abuse, noted Brushwood.