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INTRODUCTION

Human trafficking has received increasing national and global attention over the last decade as a serious human rights violation and growing form of modern day slavery.¹ While there currently is no consensus on estimates of the total number of human trafficking victims in the United States, the number most likely reaches into the hundreds of thousands when estimates including both adults and children involved in both sex trafficking and labor trafficking are combined.² Recognizing the gravity of the situation, health care providers and organizations involved with trafficked persons have been called to “increase their capacity to identify and refer people in trafficking situations and provide sensitive and safe services to people post-trafficking.”¹ It is known that many missed opportunities for intervention on behalf of trafficking victims exist, with many of those opportunities presented in health care settings. Pharmacists and pharmacy technicians, as accessible health care providers in the community and in health care systems, have the potential to play a key role in supporting and intervening on behalf of human trafficking victims if appropriately educated and empowered. Unfortunately, the profession of pharmacy has lagged behind other health care professions in providing a unified call for awareness and response to human trafficking.³ Because health care providers are one of the few professionals that are likely to interact with trafficking victims while they are still in captivity,^4-6 pharmacists and pharmacy technicians must be prepared to recognize the signs of human trafficking and to act quickly and appropriately for the good of the trafficking victim.³

The pharmacist has a unique role in the US health care system, functioning as one of the most accessible of health professionals.⁷ Appointments are often not required to see a pharmacist, and both pharmacists and pharmacy technicians can encounter hundreds of patients in a single day, especially when working in community settings. In many states, pharmacists are mandated by law to counsel patients on every new prescription, allowing for pharmacists to interact individually and privately with patients when other health care visits may be more open to family members or caregivers. Many pharmacies are equipped with private or semi-private spaces that allow the pharmacist and patient to have a confidential conversation. Ambulatory care pharmacists in health care systems and community pharmacies meet with patients one-on-one to carefully review and optimize medication regimens and may also work in interprofessional teams to address medication challenges. Pharmacists working in a health care system have a valuable opportunity to utilize an electronic medical record as a part of their care process, potentially illuminating trends in a patient’s health care record.

Interprofessional teams may consist of a provider such as a physician, advanced practice nurse, physician assistant, pharmacist, social worker and other professions including physical and occupational therapists, working together to provide care to patients. Health systems are becoming increasingly reliant on interprofessional teams utilizing pharmacy services to improve the patient experience of care, improve the health of populations, reduce the per capita cost of health care for populations, and improve quality ratings.^7,8 Because pharmacist participation on health care teams has been shown to result in more effective care for patients,⁸ it is critical that pharmacists – like other health care professionals – be educated and competent in recognizing and caring for victims of human trafficking.

As health care team dynamics change, pharmacists now “work directly with providers and patients to provide services not simply associated with dispensing of drugs, but also with medication and disease management”⁷ and in improving patient outcomes. As an example, the addition of a pharmacist on a care team has shown evidence in improving patient A1C, LDL-cholesterol, adverse drug reactions, blood pressure measures, and other therapeutic outcomes.⁷ When humanistic outcomes were examined, significant improvement was also found in medication adherence, patient understanding, and general quality of life⁷ for patients who had worked with a pharmacist. As pharmacists and pharmacy technicians embrace expanding roles in interprofessional care teams, they must be prepared to collaborate with clinical and social services colleagues to meet an increasingly wide variety of patient needs.

This Continuing Education article will provide initial guidance to practicing pharmacists and pharmacy technicians on the recognition of human trafficking, and what subsequent action steps can be taken to best support victims of trafficking. This information is necessary for pharmacy students, pharmacy staff, and practicing pharmacists in nearly every area of pharmacy practice.

Human Trafficking Background

To most appropriately and sensitively support their patients, it is important for pharmacists and pharmacy technicians to be aware of the different characteristics of the different types of human trafficking. Human trafficking is most often divided into the categories of sex trafficking, labor trafficking, and organ trafficking.^1,2,9 Labor trafficking includes both debt bondage and forced labor.⁹ Organ trafficking is yet another form of human trafficking, although it often receives less attention than sex trafficking and labor trafficking.¹⁰ Organ trafficking is a lucrative global illicit trade, holding a critical place with transnational organized crime groups due to high demand and relatively low rates of law enforcement.¹¹ Organ trafficking exploits vulnerable populations, those known as “donors,” and benefits typically first-world beneficiaries, those known as “recipients.”^10,11 Organ donors may suffer a lifetime of health consequences and organ recipients may also suffer health consequences from receipt of an organ that wasn’t necessarily screened to be an appropriate match for them.¹⁰ Organ donors may have been a victim of sex trafficking and/or labor trafficking, creating a multilevel and complex exploitation scenario. While it is difficult to estimate how much organ trafficking – also known as “transplant tourism” – generates annually, Global Financial Integrity (GFI) has estimated that the illegal organ trade conservatively generates approximately $840 million to $1.7 billion annually.¹² The characteristics of trafficking victims vary largely depending on the type of trafficking^1,2,9 and are partially described in Table 1. Commonalities among all types of sex trafficking include the fact that victims enter and remain in labor or commercial sex through force, fraud, and/or coercion by the traffickers.

Identify: Identifying Victims of Trafficking in the Pharmacy

Pharmacists and pharmacy technicians must be aware of the signs of a trafficking situation to appropriately identify a potential trafficking victim. A study by Baldwin and colleagues (2011), in which survivors of trafficking were interviewed about their interactions with the health care system, supported anecdotal reports that human trafficking victims in the United States do indeed interact with health care personnel. ¹³ These personnel reportedly included providers of primary care, sexual and reproductive health care, dental care, and traditional or alternative remedies.¹³ While there is no “typical” type of trafficking victim, there are certain patient behaviors and accompanying trafficker behaviors that might alert health care professionals to a potential human trafficking case.^6,13 The guiding action steps for identification and support of victims of human trafficking are outlined in Figure 1, which explores considerations for identifying, questioning and intervening in a situation that might involve human trafficking.

It is important for pharmacists and pharmacy technicians to be educated to recognize potential signs of human trafficking. The A-M-P model of identifying human trafficking, recommended by the National Human Trafficking Resource Center¹⁴ and outlined in Figure 2, proposes one method for identifying perpetrators and victims of human trafficking. This method can be used by pharmacists and pharmacy technicians as they critically observe a potential trafficker’s actions, means, and purpose. If a trafficker takes actions including inducing, recruiting, harboring, transporting, providing, or obtaining individuals for the purpose of commercial sex or labor/services via force, fraud, or coercion, this establishes a potential situation of human trafficking. If at least one item from each of the three columns is observed, this warrants concern for human trafficking.¹⁴

A trauma-informed approach by pharmacy staff is useful in identifying, questioning, and intervening in a human trafficking situation to properly address trauma’s consequences and to facilitate healing. According to the Substance Abuse and Mental Health Service Administration (SAMHSA), a trauma-informed approach realizes the widespread impact of trauma and understands potential paths for recovery, recognizes the signs and symptoms of trauma, responds by fully integrating knowledge about trauma into practice, and seeks to resist re-traumatization.¹⁵ A trauma-informed approach is critical in guiding pharmacists and pharmacy technicians in their goals of identification, questioning, and intervening in a trafficking situation to ensure that additional harm is not inflicted on a potential trafficking victim.³

To embrace a trauma-informed approach, it is important to understand how to define trauma. SAMSHA recognizes that individual trauma “results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.”¹⁵ Key assumptions in a trauma-informed approach include what are known as the “Four R’s” – a basic realization about trauma and how it affects people, a recognition of the signs and symptoms of trauma, a response that integrates knowledge about trauma into policies, procedures, and practices, and lastly a desire to actively resistre-traumatization. ¹⁵

In realizing the impact of trauma, pharmacists and pharmacy technicians must understand how trauma can affect not just individuals but also families, groups, organizations, and communities. It is important to recognize that coping strategies utilized to survive adversity and overwhelming circumstances in the past or present may play a role in mental and substance use disorders. Recognizing the signs and symptoms of trauma and that they may be gender, age, or setting-specific, is also important. A trauma-informed approach includes pharmacy staff responding appropriately by changing their language and behaviors to take into consideration the experiences of trauma among their patients. Resisting re-traumatization in the pharmacy setting requires a commitment to not inadvertently create a toxic environment that might feel unsafe and re-traumatizing.

Trauma-informed health care providers are more likely to empathize with the trafficking victim and communicate in a gentle and nonjudgmental manner.¹⁶ A trauma-informed approach has also been shown to be more effective in determining what approach might be most helpful and appropriate to rescue a trafficking victim,¹⁶ allowing the pharmacist or technician to contextualize the answers that are provided by the suspected victim.¹⁴ A trauma-informed approach will ultimately empower the trafficking victim by communicating choices and a message of hope. While a trauma-informed approach is recommended, it should also be recognized that the patient may not have had ample time to trust the pharmacist or provider if their relationship is new. Suspected victims can still be questioned sensitively, even if the interaction remains superficial and does not progress to a trauma-informed level. The priority for pharmacy staff is to identify victims and know how to get them to a safe place and connected with services; this includes referral to appropriate providers for mental and physical health issues.

In addition to utilizing a trauma-informed approach in their practice, pharmacists and pharmacy technicians must be aware of the signs that a patient might be a victim of trafficking, which include: indications of delayed medical care, body language indicating fear or anxiety, presentation with sexual health concerns or other health concerns, signs of physical abuse or neglect, mental health concerns, and irregular prescription-filling patterns.

Delayed medical care

Pharmacists and pharmacy technicians must stay attuned to patients who show signs of having received delayed medical care for an illness or injury. Individuals who are and were trafficked consistently present a delay between the onset of their illness or injury and their subsequent visit to a doctor.^6,13 Since many uninsured patients in the United States routinely delay medical care, in many clinical and pharmacy settings a history of delayed care is often not unusual enough to arouse suspicion. However, in the context of other signs and circumstances, including evasive behavior by the patient and controlling behavior by the accompanying person, delayed care may serve as a red flag to prompt further inquiry.^9,13 Several specific presentations should be red flags to pharmacy staff, including severe sexually transmitted infections or urinary tract infection symptoms from lack of care, severe full-body skin infections (eg, impetigo), broken bones that have never been reset (eg, jaw, fingers, wrists), and severe mouth or jaw infections. These are conditions that can come up during casual patient encounters and be recognized by a pharmacist or pharmacy technician. Trafficking victims may come to a pharmacy to discuss treatment and, when asked how long their symptoms have persisted, reveal they have delayed care significantly longer than one would expect. By taking a more detailed history about the presenting condition, along with a brief social history assessing home and work environments, pharmacists may be able to reveal a potential trafficking situation.^9,13 Pharmacists and pharmacy technicians are in an ideal position to recognize the signs and symptoms associated with conditions arising from delayed care. Because consultation with a pharmacist is accessible and free of charge, patients can remain completely anonymous while talking with them.

Body Language

Pharmacy staff must be aware of body language that might indicate that a pharmacy patient is a victim of trafficking. As trafficking survivors themselves described in a study by Baldwin and colleagues (2011), a patient’s body language, affect, and attitude all may convey her or his status as a trafficking victim.¹³ A victim of trafficking may appear fearful, anxious, and submissive;^9,13,17,18 they may also avoid eye contact and may even appear confused or disoriented.^19,20 Trafficking victims may be unable to recall their address and may lack identification documents when they present at the pharmacy or the health care system.¹⁸ As with women who suffer intimate partner violence, the presence of an overbearing or controlling companion should trigger concern of pharmacy staff. Victims of trafficking may be escorted to and from pharmacies, with the escort in some cases talking for the patient rather than letting them speak for themselves.^18,21

Sexual Health Concerns

Pharmacists and pharmacy technicians must be attuned to pharmacy patients who present with certain sexual health concerns, as these could serve as an indication that a patient is a victim of trafficking. Trafficking victims may appear in the pharmacy being treated for multiple sexually transmitted infections and may report that they do not know how they contracted the disease.^18,21 They may also present to the pharmacy for treatment after an abortion or to purchase emergency contraception.^18,21 The use of oral contraceptives in young women or girls may be another potential indication of trafficking to which pharmacy staff should be attuned.¹⁸ Survivors in a study by Baldwin and colleagues described medical encounters that should arouse suspicion among health professionals:

“A sex trafficking survivor reported that one physician treated her repeatedly for reproductive tract infections and also performed an abortion. She expected him to inquire about the high-risk behaviors causing her condition, but he never did; nor did he address contraception, safe sex, or her general welfare. This physician’s indifference to his patient’s condition may have reflected a pre-existing relationship with her trafficker—a situation that several survivors reported.”¹³

Trafficking victims may also experience rectal trauma, urinary difficulties, and infertility from untreated sexually transmitted disease.²²

This is a situation in which pharmacists should take the opportunity to have conversations about high-risk behavior with their patient, especially when the other care providers may not. If the high-risk behavior is not a result of trafficking, it is still a worthy intervention that can open up a conversation about safer sex or more suitable contraception methods.

Common Health Issues

In addition to sexual health concerns, there are other common health issues seen in victims of human trafficking. These health issues are a result of inhumane living conditions, poor sanitation, inadequate nutrition, poor personal hygiene, physical and emotional abuse, dangerous workplace conditions, occupational hazards, and lack of quality health care.²² Trafficking victims may suffer chronic back, hearing, cardiovascular or respiratory problems from laboring in dangerous sweatshop, construction, or agriculture conditions. ²² They may experience eye problems from working in dimly lit sweatshops. ²² Malnourishment and serious dental problems are common and may be especially serious for child trafficking victims who may experience delayed growth and/or rotted or poorly-formed teeth. ²² Trafficking victims may present with undetected or untreated diseases such as diabetes or cancer, or infectious diseases such as tuberculosis. ²²

Signs of Physical Abuse and Neglect

Pharmacy staff should be aware that victims of trafficking often present to the pharmacy with signs of physical abuse and/or neglect. Victims of trafficking may be observed with frequent injuries and other signs of physical abuse; they may be vague or inconsistent in their description of how these injuries occurred. Additionally, it is also possible that trafficking victims may appear malnourished or sleep deprived.¹⁸ A victim of trafficking may be seen always wearing the same clothes, regardless of weather or whether the clothing is appropriate for the weather, and may be observed with few or no personal belongings.¹⁸ Trafficking victims may appear to have been subjected to torture, presenting with broken bones, contusions, dental problems (eg, loss of teeth), and/or cigarette burns.²¹ Additionally, some victims of trafficking may present with branding, scarring, or a tattoo that indicates that they are “owned” by someone. Not all trafficking victims will present with these signs, but they should serve as a red flag for pharmacy staff who are trained in recognizing a trafficking situation. Although many of these medical conditions are often addressed by other providers, it cannot be certain that other providers are recognizing or questioning these signs. In some cases, the pharmacist may be the only health care provider with whom a trafficking victim interacts.

Mental Health Concerns

Pharmacists and pharmacy technicians should be aware that mental health concerns are common in victims of human trafficking, and along with other signs may indicate that a patient is a trafficking victim. Trafficking victims may present with acute episodes of intense anxiety, depression, dissociation, self-injury, and suicidality as a result of the psychological trauma.^23,24 The majority of the research on the mental health needs of trafficking victims has focused on the high prevalence of post-traumatic stress disorder in this population,²³ but some victims of human trafficking have also been found to suffer from other anxiety and mood disorders that include panic attacks, obsessive compulsive disorder, generalized anxiety disorder, and major depressive disorder.²³ A study by Zimmerman and colleagues (2006) found that survivors of human trafficking reported the following anxiety and depression symptoms: nervousness or shakiness inside (91%), terror/panic spells (61%), fearfulness (85%), feeling depressed (95%), and hopelessness about the future (76%).²⁵ While many pharmacy patients experience mental health concerns (and on their own these symptoms are not indicative of a trafficking situation), along with other signs they should alert pharmacy staff that a patient may be victim of trafficking.

Prescription-filling Patterns

Irregular and distinctive prescription-filling patterns may also be an indication that a patient is a victim of human trafficking. The frequent filling of medications to treat sexually transmitted infections and the purchasing of pregnancy tests or of emergency contraception may be signs of a potential human trafficking situation. Trafficking victims may have no insurance coverage and may pay for prescriptions and over-the-counter medications with cash. They may call for early refills on their medications and may have prescriptions that are routinely lost or stolen. Research has shown that trafficking victims are more likely to use complaint-based episodic acute care services (eg, minute clinics, urgent care centers, and emergency departments) rather than long-term comprehensive primary care services.²⁶ This could manifest as a patient presenting to the pharmacy with prescriptions from many different clinics for various medications and conditions.

Although there is a lack of research that supports best practices for pharmacists in improving the identification of human trafficking victims, recommendations given to other health care professionals can be adapted for pharmacy practice.³ Figure 1 outlines strategies that pharmacies may use to improve identification of human trafficking victims.^1,6,9

Question: To Better Understand the Situation

It is important for pharmacists and pharmacy technicians to be aware of appropriate questions that can be used to identify victims of human trafficking. The Department of Health and Human Services (HHS, 2015) has provided guidance for health care providers who suspect a potential case of human trafficking and wish to screen a patient whom they determine may be a victim.²⁷ As with victims of domestic violence, it is important that the pharmacist or pharmacy technician not begin by asking directly if the patient has been abused or held against their will; one should begin with screening questions, as opposed to questions about violence or abuse.¹³ If at all possible, the pharmacist or pharmacy technician should enlist the help of a staff member who speaks the patient’s language and understands the patient’s culture, and should be aware that traffickers may pose as a victim’s spouse, family member, or even as their employer.²⁸ Access to a language phone line is recommended for pharmacies that do not have staff who speak languages other than English, or for patients who do not share a language with any pharmacy staff. When at all possible, the pharmacist should try to speak to the patient separate from the individual escorting them to the pharmacy in a private setting.

HHS recommends the following screening questions:²⁷

• Can you leave your job or situation if you want?
• Can you come and go as you please?
• Have you been threatened if you try to leave?
• Have you been physically harmed in any way?
• What are your working or living conditions like?
• Where do you sleep and eat?
• Do you sleep in a bed, on a cot or on the floor?
• Have you ever been deprived of food, water, sleep, or medical care?
• Do you have to ask permission to eat, sleep, or go to the bathroom?
• Are there locks on your doors and windows so you cannot get out?
• Has anyone threatened your family?
• Has your identification or documentation been taken from you?
• Is anyone forcing you to do anything that you do not want to do?

Additional medication-specific questions leading to information about home life could include:

• Where do you store your medications?
• How do you keep track of your medications?
• Who is in charge of handling your medications?
• What are you taking this medication for?
• How did your provider tell you to take these medications?
• Tell me about your visit with the provider who prescribed this.

Intervene: Bringing the Trafficking Victim to Safety

It is critical for pharmacy staff to be well-versed in appropriate methods of intervention so as to not further endanger a victim of human trafficking with an inappropriate intervention strategy. Once a victim of trafficking has been identified and a conversation has started, the pharmacist or technician may be appropriately positioned to guide the trafficked person to safety. If the pharmacist is appropriately trained and educated on the considerations regarding helping a trafficking victim find safety, with a plan in place that includes collaboration with law enforcement agencies and/or other local trafficking support services, and there is immediate availability of housing for the trafficking victim, the pharmacist may be able to act. It is important to recognize, however, that reporting an instance of human trafficking can be very dangerous for the trafficking victim and their family; dynamics between traffickers and their victims may be extremely complex and complicated.

During a conversation with the trafficking victim, the pharmacist or technician can offer assistance in the form of helping the individual contact the National Human Trafficking Resource Center.¹⁴ It is important to note that the victim cannot be forced to report; the only case in which reporting by the health professional is mandatory is in the case when the victim is a minor.²¹ The pharmacist or technician can also assist by connecting the trafficking victim to local resources including law enforcement in some cases, and by serving as an empathetic and comforting supporter throughout the interaction and resource moving forward. In a study of trafficking victims from New York City’s Rikers Island correction facility that focused on their experiences with the health care system, it was revealed that empathy, reading body language, and remaining nonjudgmental were among the top pieces of advice for health care professionals who wished to better serve trafficking victims.²⁹

HHS recommends that pharmacists and other health care providers contact the National Human Trafficking Resource Center (NHTRC)¹⁴ hotline to determine if they have encountered victims of human trafficking, identify local resources available in their community to help victims, and help to coordinate with local social service organizations that protect and serve victims.²⁷ The NHTRC is a national toll-free hotline available to answer calls from anywhere in the United States, 24 hours a day, 7 days a week, every day of the year, and can be reached by dialing 1.888.373.7888; this hotline also has an option to text.¹⁴ If the trafficking victim is able to make contact with the National Human Trafficking Resource Center, the staff member who answers the call can support the victim to safety. Once in a safe location, the victim can choose to pursue a certification process that is supported by the Victims of Trafficking and Violence Protection Act.^30,31 This certification may provide the trafficking victim with documentation that can assist with their remaining in the United States. If the victim is already a US citizen or a minor, they do not need to apply for certification because they are already eligible.^30,31

When a trafficking victim is undocumented, deportation will likely be of great concern and a possible barrier to reporting a crime. In response to this reality, the US Department of Justice created the trafficking visa, also known as a “T Visa.” The T Visa allows the trafficking victim – and certain family members – to remain in the United States legally if the victim complies with requests for assistance in the investigation or prosecution of acts of trafficking.³² Recipients of the T Visa are eligible for legal employment and can become lawful permanent US residents after 3 years.³² Despite the availability of this visa, there are barriers that exist to receiving it and not every trafficking victim may be eligible. Even with the availability of the T Visa, the undocumented immigrant cannot be completely assured that they will not be deported if denied the visa, and it is important for the pharmacist or pharmacy technician to not make any assurances about immigration status.³²

Any individual who suspects a trafficking situation but has not been able to provide resources to the trafficking victim may choose to report the suspected trafficking incidence anonymously to the hotline via an online portal that can be accessed through the Polaris website: https://humantraffickinghotline.org/report-trafficking.² This portal gathers basic information about the suspected trafficking situation, including the date and time where the situation was observed or the timeline of the ongoing situation, the address of the situation, and the gender, estimated age, nationality, and documentation status of the potential victim.

Human Trafficking Myths and Facts

Organizations including Polaris² and the NHTRC¹⁴ provide education on a broad spectrum of trafficking-related topics, including trafficking myths vs facts. Pharmacists, pharmacy technicians, and pharmacy students should become familiar with the differences between myths and facts when it comes to human trafficking. One common myth is that human trafficking is always or usually a violent crime. In reality, most human traffickers use psychological means to control their victims rather than physical means; these means may include manipulation, trickery, defrauding, or threatening victims into submission.² Another common myth is that only undocumented foreign nationals are trafficked in the United States. In reality, many trafficking victims of both sex and labor trafficking are US citizens who are legally living and working in the United States.² Many people believe that trafficking only happens in industries that are illegal or underground, while in reality human trafficking cases have been reported and prosecuted in industries that include factories, cleaning services, restaurants, and other common, legal and visible industries.² Another common myth is that human trafficking always involves transporting a person across state or national borders, as human trafficking and human smuggling are often confused. In reality, human trafficking does not require any movement as victims may be recruited and trafficked in their own hometowns.²

Discussion

In assessing the contribution that pharmacists and pharmacy technicians can make to broader anti-trafficking efforts, two recent developments are important to consider.^3,33 First, collaborative responses to address human trafficking are incorporating medical and public health perspectives to a greater degree than in the past³⁴ and pharmacists must be willing to support their public health role in these responses.³ Additionally, mandatory reporting of human trafficking by health care professionals has been incorporated into the law in a growing number of jurisdictions in the United States,^35,36 and pharmacists must know the requirements of their state.³ While mandatory reporting of human trafficking by health care professionals could potentially benefit some trafficking victims, it is important to recognize that there are also potential risks with this practice. According to Atkinson and colleagues (2016), requirements to report human trafficking may involve heightened risks due to the vulnerability of trafficked persons related to their mistrust of authorities and fear of their traffickers.³⁷ Laws must be drafted to comprehensively include definitions of both sex and labor trafficking while at the same time including provisions to ensure that trafficking victims are connected to services that can meet their needs, for the benefits of mandatory reporting to be realized.³⁸ Even if pharmacists and pharmacy technicians are not required to report human trafficking, they must be prepared to identify and support these victims.

Pharmacists and pharmacy technicians should be familiar with the resources available for victims of human trafficking. Organizations including Polaris² and the NHTRC¹⁴ provide resources as well as support for trafficking survivors. Polaris² operates the National Human Trafficking Hotline and BeFree Textline, resources that serve to connect survivors with critical support they need to get help and stay safe. Polaris shares strategies and resources with public and private sector entities to increase safety for trafficking survivors across the United States.² Polaris maintains national and global directories of resources for trafficking victims as well as trainings for businesses and agencies that wish to support trafficking prevention and intervention.² Polaris also provides legislative guidance on initiatives that strive to eliminate human trafficking.²

Standardized education and best practices for health professions educators – including pharmacists and pharmacy technicians – are desperately needed. A mixed-methods study by Powell and colleagues revealed the need for standardization of human trafficking training content to assure correct information, trauma-informed and patient-centered care, and consistent messaging for health care professionals.³⁹ Some successful education programs have included police officer and physician presenters, and have included information on the recognition of trafficking victims, as well as background and local information regarding trafficking, and discussion regarding referral options.⁴⁰ Researchers including Powell and colleagues (2017) argue that evaluation metrics for training must be developed to demonstrate behavior change and impact on service delivery and patient-centered outcomes for trafficking victims.³⁹

Community pharmacies should have all personnel trained on actionable steps to support trafficking victims.³ These actionable steps include a step-by-step plan for what to do if a pharmacy staff member is concerned about a particular patient, prominent posting of local and national trafficking resource phone numbers within the pharmacy itself, and contact information for local resources for trafficking victims.³ Community pharmacists are often required to abide by the guidance and leadership of their corporate offices. Attention to the issue of human trafficking by corporate pharmacy leadership in major pharmacy chains, and subsequent encouragement of pharmacists who work in these pharmacy chains to provide care to potential victims of human trafficking, is necessary.³ Pharmacists who work in health care systems should be encouraged by health care system leadership to maintain clear communication with other system staff to aid potential victims of human trafficking. Each health care system should provide training for their staff on trauma-informed and collaborative approaches to safely support victims of trafficking.³ A summary of recommendations for practicing pharmacists and pharmacy technicians in all settings can be found in Figure 3.

Content on the trauma-informed recognition and subsequent assistance of human trafficking victims by pharmacists would be well placed in the curriculum of PharmD academic programs nationwide to ensure that new practitioners have the tools needed to safely help victims of trafficking to safety.³ Pharmacy students must be adequately educated on the characteristics trafficking victims may present with, as well as the questions to ask when one is suspicious of potential trafficking.³ The education should include discussion of the harms of reporting a trafficking crime without the victim’s consent, as well as tools to find local services that may be of assistance to victims.³ Education on trauma-informed care as well as supporting victims of human trafficking should be standardized by the American Association of Colleges of Pharmacy, and its inclusion should be part of the accreditation criteria.³ This information should also be disseminated to currently practicing pharmacists, pharmacy technicians, and other health care professionals in the form of online and in-person continuing education credits. ³ Content for currently practicing pharmacists and pharmacy technicians should be standardized by a national pharmacy organization such as the American Pharmacists Association.³

Conclusion

Pharmacists, pharmacy technicians, pharmacy staff, and pharmacy students must be educated on how to identify and support victims of human trafficking so that they can work effectively with their communities to bring these individuals to safety. Up to this point, the information about recognition and support of human trafficking victims has been directed toward nurses, physicians, nurse practitioners, and other primary care providers. Using evidence-based strategies provided to other health care providers with appropriate adjustments to apply them to pharmacy settings is currently the best strategy to improve identification and support of victims by pharmacists.³ The education components should be nationally standardized and include content for pharmacy students, practicing pharmacists, and pharmacy technicians. Clear step-by-step plans and appropriately posted resources in the pharmacy are key to pharmacy personnel being able to recognize and appropriately assist victims.³ In the future, research focusing more specifically on the presentation of victims of human trafficking in pharmacies, and appropriate responses, is imperative to ensure pharmacists and pharmacy technicians are providing the best possible support for victims of human trafficking. ³

References

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