Reporting interpersonal violence and abuse: What pharmacists need to know.

OBJECTIVE: To examine and describe the reporting requirements for pharmacists related to interpersonal violence and abuse in the United States.
METHODS: A comprehensive search of state laws related to mandatory reporting of intimate partner violence and domestic violence (IPV), child abuse, and elder abuse was conducted. Identified statutes were reviewed to determine if pharmacists were mandatory reporters for each type of violence.
RESULTS: Pharmacists are specifically identified as mandatory reporters of intimate partner violence in 10 states, of child abuse in 11, and of elder abuse in 20. They may also have reporting requirements in more states as statutes sometimes identify health care providers as mandatory reporters, but do not specify which types of providers. Additionally, many states require reporting of child and elder abuse by anyone who is aware of or suspects abuse. IPV statutes mainly require reporting when treating wounds from gunshots, stabbings, and burns.
CONCLUSIONS: Pharmacists are accessible health care providers who should be aware of reporting requirements for their practice location and setting. They have mandatory reporting requirements in much of the United States, especially for child and elder abuse. They should seek specific guidance about their reporting requirements and reporting methods, as well as identify educational and local referral resources for victims they may encounter in practice.

Background

Interpersonal violence and abuse are highly prevalent threats to health. The Centers for Disease Control and Prevention (CDC), which defines intimate partner violence (IPV) to include physical violence, sexual violence, stalking and psychological aggression, perpetrated by a current or former intimate partner, estimate that 27.3% of women and 11.5% of men experience IPV in their lifetime. , The U.S. Department of Health reports that there were approximately 678,000 victims of child abuse and neglect in 2018. With an estimated prevalence of elder abuse at approximately 10%, even older patients are routinely at risk of abuse.

Violence across the lifespan has serious physical and mental health consequences. IPV’s negative impact on physical health ranges from acute injuries to exacerbation of chronic medical conditions. Mental health repercussions are common as well and include posttraumatic stress disorder, anxiety, and depression among others , IPV has also been shown to have a negative impact on medication adherence, results in greater health care costs, and increased use of primary care, hospital care, and pharmacy services compared with that by women who have not experienced IPV. , 8, 9, 10, 11 Child abuse can also have a serious impact on health and increases the risk of future negative health outcomes. Victims of elder abuse are at increased risk of being placed in a nursing home, of hospitalization, of death, even after adjustment for existing chronic diseases.13, 14, 15, 16

Guidelines, educational requirements, and training related to interpersonal violence are common for most health care provider groups, including physicians, nurses, physical therapists, and dentists. , Currently there are no specific recommendations regarding involvement of pharmacists in care related to interpersonal violence. One study found that pharmacists reported nearly no training regarding interpersonal violence and minimal awareness of reporting requirements, despite reporting that they have encountered victims in practice.

As the most accessible health care provider group, pharmacists are uniquely positioned to assist individuals experiencing abuse by connecting them with victim resources in the community. There are several factors contributing to pharmacist accessibility and their ability to assist individuals who may be experiencing abuse. Many pharmacists work in high-traffic retail settings such as grocery stores and other retail venues that are easily accessible and may be frequented by abuse victims shopping for necessities. Additionally, community pharmacists may be consulted without an appointment or triage. In some cases, the pharmacist may be the only health professional that a victim can access without raising alarm with the individual perpetrating the abuse. This has been particularly salient during the COVID-19 pandemic. Pharmacies have been specifically identified in some countries as a safe place to seek assistance related to abuse. Given pharmacists’ accessibility to the public, the ethical obligation (aside from the legal obligation in some jurisdictions) that pharmacists have to assist individuals experiencing abuse and to connect them with resources cannot be ignored. Indeed, the American Pharmacists Association Oath of a Pharmacist emphasizes that a pharmacist is primarily concerned with human welfare and relief of suffering.

Therefore, it is critical that pharmacists be aware of the reporting guidelines and requirements in their practice setting. This is challenging as reporting requirements vary across the United States by type of violence. The U.S. Department of Health and Human Services funded the development of a compendium of policies and statutes on IPV violence and health care. This compendium, developed by Futures Without Violence, did not specifically target requirements for pharmacists. Similar compendiums of child and elder abuse reporting requirements have not specifically addressed pharmacist reporting responsibilities. , As has recently been reported, there is no comprehensive database of U.S. laws regarding pharmacist mandatory reporting requirements related to violence and abuse.

Objectives

The objective of this project is to examine and describe the laws, policies, and regulations regarding the reporting requirements for pharmacists related to interpersonal violence and abuse in the United States.

Methods

A comprehensive search of laws, policies, and regulations related to requirements for pharmacists to report abuse in 52 states and territories was conducted. The search focused on 3 types of violence and abuse: IPV, child abuse, and elder abuse. IPV is frequently called ‘domestic violence’ and this term was included in the search. However, the CDC notes that the term domestic violence only includes violence perpetrated by partners with whom an individual cohabitates, whereas IPV is inclusive of partners regardless of living status. Identification of relevant statutes began with 3 existing resources. IPV reporting statutes are detailed in a Futures Without Violence compendium that was funded by the U.S. Department of Health and Human Services. Mandatory reporting laws for child abuse for each state are published by the U.S. Department of Health and Human Services Children’s Bureau. Reporting requirements for elder abuse are maintained in a policy database by RAINN (Rape, Abuse & Incest National Network), the largest antisexual violence organization in the U.S. Each of these resources serves as the starting point to identify relevant laws because it is updated regularly and provide citations for regulations related to health care providers and reporting requirements. The statutes identified for each state in these compendiums were then located and searched for reporting requirements. The statutes were reviewed to determine what the reporting requirements were specifically and who were included as mandatory reporters of each type of abuse. Legislation in each state that had been passed, after any law identified in the compendiums, was searched to determine if any updates or changes to the requirements had been made. If a statute referred to another code to identify which health care providers were included, these codes were reviewed to determine if pharmacists or pharmacy technicians were included. Pharmacy technicians were included in the review because assistants in other health care provider groups (i.e. physical therapy assistants) are specifically identified in some statutes as mandatory reporters. Each state’s mandatory reporting requirements were classified into one of 4 categories:

Pharmacists are mandatory reporters - the state’s mandatory reporting law specifically includes pharmacists.

Health professionals are mandatory reporters - the state’s mandatory reporting law requires health professionals to report abuse and pharmacists may be included as health professionals.

All persons or any person is a mandatory reporter - the state’s reporting law indicates that anyone with knowledge of or who suspects abuse is required to report.

No mandatory reporting - either the state has no mandatory reporting or the mandatory reporting law specifies who a mandatory reporter is and that list does not include pharmacists or any language that could include nonspecified health care providers.

Results

Table 1 includes a summary of the reporting requirements for IPV, child abuse, and elder abuse. Pharmacists are specifically identified as mandatory reporters of IPV in 10 states and territories, of child abuse in 12, and of elder abuse in 20. Pharmacists may also have reporting requirements in more states as statutes sometimes identify health care providers as mandatory reporters, but do not specify which types of providers. Further, many states require reporting of child and elder abuse by anyone who is aware of or suspects abuse. As a result, pharmacists have a reporting requirement for at least one of these kinds of abuse: in 31 states and territories for IPV, 45 for child abuse, and 47 for elder abuse. It is important to note that the terminology for each type of violence varies across the statutes. For example, some state laws identify IPV as domestic violence. Because the terminology and definition for each vary across states, it is important to examine the particular state’s statues for any given practice site. The specific statutes that detail the reporting requirements for each state, effective at the time of this review, are provided as an online appendix (available at ). These are provided for each kind of abuse–IPV, child abuse, and elder abuse. Each state defines each kind of violence differently. For example, most of the IPV reporting requirements are mandatory when treating gunshot and stab wounds, burns, and poisonings. Some states are specific about a gunshot only, while others may say any harm that could be caused by a criminal act must be reported. States vary in reporting requirements regarding child abuse, with some requiring reporting of even suspected neglect. Elder abuse statutes frequently include all vulnerable adults, not just those over the age of 65.

Table 1

States in which pharmacists have some reporting requirements related to interpersonal violence

State	Intimate partner violence and domestic violence	Child abuse	Elder abuse
Alabama	HCa	Pb	HC
Alaska	HC	HC	P
Arizona		HC	P
Arkansas	P	HC	HC
California	P	P	HC
Colorado		P	P
Connecticut	HC	P	P
Delaware		Ac	A
District of Columbia	P	HC	P
Florida	HC	HC	HC
Georgia	HC		HC
Hawaii		P	P
Idaho	HC	A	P
Illinois	HC		P
Indiana		A	A
Iowa	P	HC
Kansas	HC
Kentucky		A	A
Louisiana	HC	HC	A
Maine	HC		P
Maryland	P	HC	P
Massachusetts
Michigan	HC		HC
Minnesota	P	HC	P
Mississippi	HC	HC	HC
Missouri		HC	P
Montana	HC	HC	HC
Nebraska		A	HC
Nevada	P	P	P
New Hampshire	HC	A	A
New Jersey		A	HC
New Mexico		A	A
New York		HC	P
North Carolina		A	A
North Dakota		HC	P
Ohio		HC	P
Oklahoma	P	HC	HC
Oregon		P	P
Pennsylvania	P	P
Puerto Rico	HC	HC	HC
Rhode Island	HC	HC	P
South Carolina	HC	HC	HC
South Dakota	HC		HC
Tennessee	P	HC	A
Texas		P	A
Utah	HC	A	A
Vermont		P
Virginia	HC	HC	P
Washington		P	P
West Virginia	HC	HC	HC
Wisconsin		HC
Wyoming		A	A

HC = Health care personnel are required to report, pharmacists may be included.

P = Pharmacist is identified as a mandatory reporter.

A = All and any person required to report.

Discussion

Pharmacists are uniquely positioned to recognize or receive reports of abuse. As trusted members of the health care team, pharmacists need to be aware of their reporting responsibilities related to violence and abuse. A previous examination of the role of pharmacists reported on compendiums of statutes related to reporting, but did not conduct a new search of statutes and legislation. To the best of our knowledge, the current project is the first to comprehensively report violence and abuse reporting requirements for pharmacists. There is a need for future studies to examine how to prepare pharmacists to best serve patients experiencing interpersonal violence. Safety is the first and most important consideration and protocols are needed to safely manage disclosure in a pharmacy environment.

Training courses have been employed as a way to improve pharmacist preparation and ability to recognize and respond appropriately to interpersonal violence. Currently, at least 2 states require some form of training to focus on abuse and reporting. For example, Iowa requires pharmacists involved in primary care to complete 2 hours of training every 5 years in the reporting of abuse for the population they see most regularly within their practice, children or adults. Pennsylvania requires 3 hours of training on initial licensure and 2 hours of training on child abuse at every renewal cycle. Training for pharmacy technicians could also be valuable. Washington, DC includes registered pharmacy technicians with pharmacists as mandatory reporters of injuries received from the commission of criminal abuse.

The proactive steps that pharmacists can take include identifying local referral resources, becoming aware of mechanisms for required reporting, displaying patient education materials, and preparing to safely manage potential disclosures in a patient-centered manner. Additionally, it is critical that pharmacists review and stay abreast of the relevant reporting statutes to understand the specific reporting requirements for their practice setting. Attention to exactly what must be reported and which practitioners are required to report is important as these vary across the states. Screening, by pharmacists or technicians, may be a valuable approach for IPV in particular as patients have indicated that they would find this acceptable, and resources are available to facilitate this in clinical settings. Clear corporate policies regarding how to meet state reporting guidelines could be an important step in empowering and encouraging pharmacists to report abuse; however, such policies should not interfere with a pharmacist’s potential legal obligation to report suspected violence or abuse to the state or local authorities.

Provider status for pharmacists is an important issue in mandatory reporting statutes. Some states make it clear that pharmacists are included or excluded, while others refer to a statute that defines health care providers for that state, and it is clear there whether pharmacists are included or not. Still others leave it undefined if pharmacists would be included. As pharmacists advocate for provider status, mandatory abuse reporting requirements are an example of the kind of issues for which pharmacists will need to prepare.

Future studies are needed to examine the potential impact of continuing education and corporate policies related to abuse. Additionally, there is no literature regarding pharmacist understanding of reporting requirements or how they are being implemented in states that have reporting mandates in place. An implementation science approach could be used to examine factors associated with effective implementation of these requirements.

There are limitations to the current review. Sexual assault laws were not searched. This may be important for pharmacists, especially in the community pharmacy setting, as they care for patients who may be seeking emergency contraception associated with an assault. This review used existing compendiums of state laws as a starting point. While these were used as starting guides, searches of each state’s statutes were conducted. However, it is possible that additional statutes, regulations or policies were missed that address these issues or further explicate components of the identified statutes. Pharmacists should use this review as a guide to further identify and review the specific laws and regulations for their specific state and practice setting. ,

Conclusion

Violence is a serious threat to the health and wellbeing of all. Pharmacists are trusted members of the health care team and are uniquely positioned to serve as a resource to individuals experiencing abuse and violence. Reporting requirements for IPV, child abuse, and elder abuse vary across the United States. Pharmacists are mandatory reporters of child abuse and elder abuse across most of the country. Pharmacists should stay informed of legal and professional responsibilities to report known or suspected victimization. Proactive preparation is critical to best serve patients.