Marie Barnard, Ph.D.
Leigh Ann Bynum, Ph.D.
Wesley Sparkmon, MPH
At the end of this case, students will be able to:
- Define intimate partner violence (IPV), elder abuse, and child abuse
- Estimate the prevalence of IPV, elder abuse, and child abuse in the United States
- Examine the impact IPV has on patients and its ramifications for patient care
- Identify methods to appropriately respond to IPV in a pharmacy setting
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.
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
- Sertraline 50 mg daily
- Ibuprofen PRN for pain
- 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.
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?
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) 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.
Related chapters of interest:
- Interprofessional collaboration: transforming public health through teamwork
- Saying what you mean doesn’t always mean what you say: cross-cultural communication
- Expanding the pharmacists’ role: assessing mental health and suicide
- Futures without Violence.
- The National Domestic Violence Hotline.
- National Health Resource Center on Domestic Violence.
- National Resource Center on Domestic Violence.
- IPV Health.
- Centers for Disease Control and Prevention. Preventing intimate partner violence.
- Centers for Disease Control and Prevention. Intimate partner violence victimization assessment instruments.
- Centers for Disease Control and Prevention. Intimate partner violence additional resources.
- MedlinePlus. Domestic violence.
- National Center on Elder Abuse.
- ElderCare Local Resource Locator.
- UC-Irvine Center of Excellence on Elder Abuse and Neglect.
- Centers for Disease Control and Prevention. Elder abuse additional resources.
- Child Welfare Information Gateway.
- Breiding MJ, Basile KC, Smith SG, Black MC, Mahendra RR. Intimate partner violence surveillance: uniform definitions and recommended data elements, version 2.0. Center for Disease Control and Prevention, National Center for Injury Prevention and Control; 2015. . Accessed April 23, 2021.
- Smith S, Zhang X, Basile K, et al. The National Intimate Partner and Sexual Violence Survey: 2015 Data Brief — Updated Release. National Center for Injury Prevention and Control, Center for Disease Control and Prevention; 2018:32.
- Bonomi AE, Anderson ML, Rivara FP, Thompson RS. Health outcomes in women with physical and sexual intimate partner violence exposure. J Womens Health 2007;16(7):987-97.
- Bonomi AE, Thompson RS, Anderson M, et al. Intimate partner violence and women’s physical, mental, and social functioning. Am J Prev Med 2006;30(6):458-66.
- Coker AL, Davis KE, Arias I, et al. Physical and mental health effects of intimate partner violence for men and women. Am J Prev Med 2002;23(4):260-8.
- Coker AL, Hopenhayn C, DeSimone CP, Bush HM, Crofford L. Violence against Women Raises Risk of Cervical Cancer. J Womens Health 2009;18(8):1179-85.
- Stene LE, Jacobsen GW, Dyb G, Tverdal A, Schei B. Intimate partner violence and cardiovascular risk in women: a population-based cohort study. J Womens Health 2013;22(3):250-8.
- Lagdon S, Armour C, Stringer M. Adult experience of mental health outcomes as a result of intimate partner violence victimisation: a systematic review. Eur J Psychotraumatology 2014;5(1).
- McFarlane J. Abuse during pregnancy: the horror and the hope. AWHONNs Clin Issues Perinat Womens Health Nurs 1993;4(3):350-62.
- Stene LE, Dyb G, Tverdal A, Jacobsen GW, Schei B. Intimate partner violence and prescription of potentially addictive drugs: prospective cohort study of women in the Oslo Health Study. BMJ Open 2012;2(2).
- Lopez EJ, Jones DL, Villar-Loubet OM, Arheart KL, Weiss SM. Violence, coping, and consistent medication adherence in HIV-positive couples. AIDS Educ Prev 2010;22(1):61-8.
- Maxwell L, Devries K, Zionts D, Alhusen JL, Campbell J. Estimating the effect of intimate partner violence on women’s use of contraception: a systematic review and meta-analysis. PLoS ONE 2015;10(2).
- Snow Jones A, Dienemann J, Schollenberger J, et al. Long-term costs of intimate partner violence in a sample of female HMO enrollees. Womens Health Issues 2006;16(5):252-61.
- Trimble DD, Nava A, McFarlane J. Intimate partner violence and antiretroviral adherence among women receiving care in an urban Southeastern Texas HIV clinic. J Assoc Nurses AIDS Care 2013;24(4):331-40.
- Decker MR, Miller E, McCauley HL, et al. Recent partner violence and sexual and drug-related STI/HIV risk among adolescent and young adult women attending family planning clinics. Sex Transm Infect 2014;90(2):145-9.
- Grace KT, Anderson JC. Reproductive coercion: a systematic review. Trauma Violence Abuse 2018;19(4):371-90.
- Barnard M, West-Strum D, Holmes E, Yang Y, Swain KA. Community pharmacists’ awareness of intimate partner violence: an exploratory study. Innov Pharm 2013;4(1):article 106.
- Barnard M, West-Strum D, Holmes E, Yang Y, Fisher A. The potential for screening for intimate partner violence in community pharmacies: an exploratory study of female consumers’ perspectives. J Interpers Violence 2018;33(6):960-79.
- Leeb RT, Paulozzi L, Melanson C, Simon T, Arias I. Child maltreatment surveillance: uniform definitions for public health and recommended data elements. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008. . Accessed January 31, 2021.
- Centers for Disease Control and Prevention. Violence prevention: Preventing child abuse & neglect. Published September 3, 2020. . Accessed January 31, 2021.
- Hall JE, Karch DL, Crosby AE. Elder abuse surveillance: uniform definitions and recommended core data elements for use in elder abuse surveillance. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2016. . Accessed January 31, 2021.
- Acierno R, Hernandez MA, Amstadter AB, et al. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: the National Elder Mistreatment Study. Am J Public Health 2010;100(2):292-7.
- Schofield MJ, Powers JR, Loxton D. Mortality and disability outcomes of self-reported elder abuse: a 12-year prospective investigation. J Am Geriatr Soc 2013;61(5):679-85.
- Dong X, Simon MA. Elder abuse as a risk factor for hospitalization in older persons. JAMA Intern Med 2013;173(10):911-7.
- Barnard M, White A, Bouldin A. Preparing pharmacists to care for patients exposed to intimate partner violence. Pharmacy (Basel) 2020;8(2):100.
- Barnard M, Sinha A, Sparkmon WP, Holmes ER. Reporting interpersonal violence and abuse: what pharmacists need to know. J Am Pharm Assoc (2003) 2020;60(6):e195-9.
- National Coalition Against Domestic Violence. Why do victims stay? . Accessed June 1, 2021.