34 When love hurts: caring for patients experiencing interpersonal violence

Marie Barnard, Ph.D.

Leigh Ann Bynum, Ph.D.

Wesley Sparkmon, MPH

Hyllore Imeri

Introduction

Interpersonal violence is a prevalent health threat. Intimate partner violence (IPV; also called domestic violence), child abuse, and elder abuse are all forms of interpersonal violence. Because of unique positioning as the most accessible healthcare professionals, pharmacists have a tremendous opportunity, and in some states, a legal obligation, to intervene when they suspect that a patient is a victim of interpersonal violence or abuse.

The Centers for Disease Control and Prevention (CDC) defines IPV as a form of abuse including physical violence, sexual violence, stalking, and psychological aggression (including coercive tactics) by a current or former intimate partner.¹ Approximately 1 in 4 women and 1 in 10 men experience physical violence, sexual violence, and/or stalking by an intimate partner in their lifetime in the United States.² IPV has a serious impact on health, including physical injuries and exacerbation of chronic diseases. IPV victims experience anxiety, depression, sleep disturbances, and post-traumatic stress disorder.^3–9 Pregnant victims are at increased risk for preterm delivery and miscarriage.⁹ Because of the multiple negative health impacts associated with IPV, victims access the healthcare system repeatedly. They are more often prescribed medications, including increased rates of potentially addictive medications, compared to women not experiencing IPV.¹⁰ Patients experiencing IPV have higher pharmacy costs and greater challenges with medication adherence.^11–14 Contraceptive sabotage and STI-related care-seeking are also more common in patients experiencing IPV.^12,15,16 Pharmacy interactions provide an opportunity to intervene in the cycle of violence. Pharmacists, who are trusted members of the health care team and can be seen without appointments in many community settings, are ideally situated to assist victims.^17,18

Child maltreatment includes both abuse, which can be physical, emotional, or sexual, and neglect.¹⁹ Most states have specific definitions of child maltreatment. Child neglect is the failure to provide for a child’s basic physical, medical, emotional, or educational needs, or failing to appropriately supervise a child.¹⁹ The CDC reports that at least 1 in 7 children experienced child abuse and/or neglect in the past year.²⁰ Child abuse can have a serious impact on health and increases the risk of future negative health outcomes.²⁰

Elder abuse can be physical, emotional, sexual, or financial, and includes neglect and abandonment. Elder abuse includes both intentional acts and the failure to act by a caregiver or another person in a relationship involving an expectation of trust that causes or creates serious harm to an older adult.²¹ In some states, elder abuse is included in statutes related to abuse of vulnerable individuals, which can include any adult with cognitive or other impairment that hinders their ability to make independent decisions. A US study estimated the one-year prevalence of elder abuse to be 10%.²² Victims of elder abuse are at increased risk of being placed in a nursing home, being hospitalized, and dying, even after adjusting for existing chronic disease.^23,24

Patients may disclose abuse or pharmacists may suspect a patient is experiencing abuse based on care interactions or medication patterns. Pharmacists must be prepared to care for these patients safely and appropriately, including using the CARD (Care, Assess for safety, Refer, Document) method when a patient discloses abuse.²⁵ Furthermore, it is imperative that pharmacists understand what, if any, their legal responsibilities are related to mandatory reporting in their practice setting. While most states make clear that physicians are mandatory reporters, reporting requirements for pharmacists vary widely. A review of pharmacists reporting requirements indicated pharmacists were mandatory reporters of IPV in 10 states, of child abuse in 11, and of elder abuse in 20.²⁶ More states may include pharmacists as mandatory reporters as they may identify ‘healthcare providers’ as mandatory reporters, but do not specify which types of providers.²⁶ These requirements change over time, and it is important for pharmacists to keep current with reporting requirements.

Case

CC: “I had a tooth pulled at the dentist today and it’d be great if you could fill this as fast as possible.”

Patient: LA is a 29-year-old female patient who is well known to you. She presents alone with a prescription for hydrocodone/acetaminophen (Norco).

PMH: Major depressive disorder

Medications:

• Sertraline 50 mg daily
• Ibuprofen PRN for pain

Interaction:

• Pharmacist: “Good morning LA, I will be happy to fill that for you. Just give me a few minutes to pull your profile up in our system.”
• LA: (appears nervous, looking over her shoulder) “Thank you. I really need to hurry back home before my husband gets there for lunch. Will this take long?”

Additional context: LA makes minimal eye contact and appears rushed and nervous. You see in the patient’s profile that she has no health insurance and a history of injury. You note that nine months ago she requested emergency contraception. She was in three months ago with a sprain to the wrist. She purchased a wrist brace at that time. Last month when she refilled her sertraline you noted that she had a black eye, but patient stated that she had fallen. As you prepare to counsel LA about the Norco and the potential interactions with OTC pain relievers, you notice some swelling and redness on her cheek, and she appears to be getting more upset with tears rimming her eyes. You ask her to join you in the counseling area to discuss the new prescription.

Case Questions

1. What might lead you to believe LA was exposed to IPV?

2. If this patient refuses to come to the counseling area with the excuse that she is in a hurry and she used Norco other times (so there is no need for counseling), what would you do?

3. If LA was accompanied by her husband, what would you do?

4. What questions would you ask LA once in the counseling area?

5. If the patient discloses that she has is experiencing IPV, what should you do?

6. Would you refer LA to other providers? If so, please give an example.

7. LA discloses that her husband hits, shoves, and threatens her regularly. She tells you that he hit her in the face with a shovel and that caused her to need to have her tooth removed. She told the dentist she had fallen on the shovel to cover up the abuse. Consider the state in which you practice. As a pharmacist are you required to report this incident?

Author Commentary

Interpersonal violence is a prevalent threat to the health and well-being of patients. Exposure to interpersonal violence impacts pharmacy-related behavior and care. Pharmacists are well-positioned to serve as a referral resource for patients experiencing abuse given their accessibility in the community environment. Developing relationships with community agencies and other clinical providers who address violence and abuse are important steps pharmacists can take to be prepared to serve their patients who experience these issues. It is important to realize that victims stay in abusive situations for many reasons, including financial dependence, child custody concerns, and shame.²⁷

Pharmacists can also be proactive and provide violence-related education and screening initiatives. These efforts normalize discussing violence and can signal that there is no shame in being a victim of violence. Disclosure is rare, but experiencing violence is not. Shifting to a prevention approach can be helpful. Education and screening initiatives are an opportunity for prevention education. This can change the culture that violence is not ‘deserved’ or ‘tolerated’ and signals that there is support and resources available. Hang posters, display brochures/safety cards for related agencies, and wear pins indicating your support for victims. These steps signal to victims that you care and are available to discuss abuse with them.

Patient Approaches and Opportunities

Pharmacists can prepare to respond to patient disclosures by practicing the CARD method: respond with Care, Assess for safety, Refer patients to local resources, and Document as appropriate for the practice setting. Pharmacists may have legal reporting requirements for interpersonal violence and should become aware of the requirements for their practice setting. Check your local requirements and resources for support on how to report interpersonal violence. In addition, pharmacists should identify local referral resources and prepare a practice protocol for abuse disclosures (examples available at the National Health Resource Center on Domestic Violence). The National Domestic Violence Hotline (1-800-799-SAFE[7233]) is a resource that can provide free, confidential help to victims 24 hours a day. Pharmacists can engage in prevention and education efforts by providing screening and educational materials and making patients aware that they are a safe and supportive healthcare provider with whom patients can discuss these issues.