Not long ago, I knew little about pharmacists and even less about the opioid crisis. But when I learned that pharmacists were refusing to dispense emergency contraception (a.k.a. Plan B or the “morning-after pill”), I was troubled. What right did pharmacists have to refuse to provide drugs?
From 2009 to 2011, I traveled to four states and interviewed ninety-five pharmacists. It was there, among towering shelves of medication in the recesses of chain and independent pharmacies, that I first encountered the havoc opioids have unleashed, and not just on patients but also on the professionals charged with helping them. Every interview began with the same question: What would you say are the key ethical issues pharmacists face in daily practice? I’d expected emergency contraception to be everyone’s first answer, since the drug had captivated the media. Stories of pharmacists withholding the drug filled the newspapers. As a sociologist, it was what had started me on the project in the first place. But emergency contraception was a minor concern for pharmacists. Across the board, their biggest struggle was opioids. And they had a lot to say.
I was fascinated by pharmacists’ stories about opioids—how they figured out which patients were misusing or selling medications and which patients needed them to treat pain, how they spotted “pill mills” and kept a blacklist of physicians for whom they would not dispense, how they managed complicated relationships with law enforcement who could be both friend and foe. I was struck by the Kansas pharmacist who kept a rifle on his counter after being robbed three times at gunpoint, by the Mississippi pharmacist who was frantically seeking guidance from law enforcement after he identified a suspected drug ring, and by the New Jersey pharmacist who told me that a federal agent waltzed into her pharmacy, gave her his card, and urged her to contact him.
These stories shed light on the complex relationships between pharmacists, physicians, law enforcement, and patients. And they revealed how the opioid crisis manifested daily on the frontlines of care. All of these elements fueled the perfect storm of law, medicine, and organizations. The pharmacist’s dilemma promised to answer so many questions about professional might, about relationships between medicine and criminal justice, and about the cultural and organizational context surrounding frontline work.
My research expanded to include physicians and law enforcement. Initially, I envisioned a tussle between law enforcement and health care over who would control the opioid crisis, but the people I spoke with quickly dispelled that illusion. Far from a sought-after prize, one that health care or criminal legal leaders could use to make their mark on one of the country’s biggest social problems, the opioid crisis in its infancy repelled all potential reformers, who tossed it quickly from one field to another. The battle for control would come once the crisis gained steam, but we weren’t there yet around 2010.
I interviewed the head of a prominent enforcement agency in New York City in 2012 and floated the idea that health care and law enforcement were competing to stake their claims on the overdose crisis. She laughed. She insisted that she didn’t want this problem but was forced to deal with an epidemic “created by doctors and by drug companies.” She felt poorly equipped to intervene. “My tools are not well-crafted for dealing with this. It is like hitting a fly with a hammer.” In her eyes, law enforcement should be the “call of last resort because we have the least tailored tools to fix it.” She went so far as to note that if doctors were doing their jobs, law enforcement would not have to step in. “Doctors drop the ball and criminal justice has to clean up the mess.” Hesitant but compelled to intervene, law enforcement tackled the crisis early on using the tools at hand, those designed for identifying and punishing so-called criminals.
One tool in particular caught my attention—a new surveillance technology designed to ensure appropriate opioid provision. Prescription drug monitoring programs (PDMPs) became popular in the mid-2000s. PDMPs are databases that track information about controlled substances dispensed in a state. Originally designed for law enforcement, the federal government has nudged this technology into health care. State leaders, desperate to curb overdose rates, adopted this surveillance technology to help restrict out-of-control opioid prescribing, which, they hoped, would reduce overdose deaths.
Both health care and law enforcement use PDMPs. Physicians and pharmacists use PDMP data to assess signs of drug misuse or drug diversion before prescribing or dispensing opioids. Meanwhile, law enforcement uses PDMP data to root out patients who misuse or sell prescription drugs and to identify physicians and pharmacists who over-provide opioids.
When I first heard about PDMPs, I thought pharmacists would hate them. In my earlier interviews, pharmacists spoke with frustration about time constraints, managers who insisted they do more with less, working fourteen hours on their feet without a break, and dispensing prescriptions in four minutes or less. Surely, navigating a new technology would consume their time and detract from what they really cared about—treating patients. I was wrong. It turns out that what pharmacists hate more than time constraints is uncertainty. Pharmacists are exacting people. There is a reason they go into pharmacy, a precise science akin to chemistry, instead of medicine, which looks more like an art. Pharmacists like to do the right thing. The problem is knowing what the right thing is. The PDMP offers guidance.
Although the PDMP was pitched as a law enforcement and health-care tool, it is really a law enforcement tool implemented in health-care spaces. PDMPs are rarely integrated into electronic health systems. They do not diagnose or treat disease. They do not offer ways to refer patients to treatment. They are surveillance tools above all. Today, statewide PDMPs exist in all fifty states. Moreover, forty-eight states participate in PMP InterConnect, a system designed to share PDMP data across states. PDMP use enables law enforcement to expand its reach into health care and to track health-care providers with an ease and accuracy never before possible.
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These technological advances come at a cost. Health-care providers who use PDMPs police patients in daily practice and consider enforcement central to their work. Providers’ ready acceptance of enforcement technology lays bare how enforcement logics infiltrate hospitals, clinics, and pharmacies. We can think of PDMPs as a Trojan horse technology. Law enforcement’s gift to health care ends up changing how health-care providers understand their work in ways that threaten health care as we know it.
Health care has long been a site of surveillance and social control, where unruly bodies and behaviors are identified and treated to conform to society’s norms. Minoritized groups such as women and people of color—along with people with moralized conditions, such as addiction and mental illness—have disproportionately felt the brunt of medical discipline. They are all too familiar with the policing function of health care.
What has changed is that surveillance has grown wider and deeper—more people are being surveilled than ever, and individuals can now be easily followed across institutional boundaries. Policing has also become easier, more systematic, and taken for granted. Health-care providers can obtain information more easily and are more likely to trust the algorithms that produce it. They police more people and do so more efficiently than ever before. This shift speaks volumes about how social forces shape care and punishment. Policing by physicians and pharmacists is the predictable consequence of a health-care system ill-equipped to handle pain and addiction; of a society saturated with myths about drugs and the people who use them; of federal policy consumed by a half-century-long war on drugs; and of a society rife with race, class, and gender inequality.
People in chronic pain need opioids to treat searing, near-constant pain; people with opioid use disorders also need opioids to avoid the agony of withdrawal. Sooner or later, both kinds of opioid users come into contact with the professionals who are tasked with combating the overdose crisis: physicians and pharmacists on the health-care side, prosecutors and investigators on the enforcement side. These professionals devise various strategies in the pursuit of safety, and sometimes their help hurts. Professionals face complicated questions on the frontlines of the opioid crisis: when to refuse to provide opioids, when to investigate physicians—and what will happen to patients if they do?
The opioid crisis changed everything: how health-care providers treat pain and addiction, how law enforcement conducts investigations, how patients view painkillers, and so much more. The term “opioid crisis” is shorthand for the rapid rise in drug overdose deaths since 1999. According to the most recent data from the CDC, opioid overdose kills over 200 people per day. This number is equivalent to a commercial airliner crashing, leaving no survivors, every day of the year.
In 2006, for the first time in U.S. history, prescription opioids accounted for more deaths than heroin, cocaine, and methamphetamine combined. Deaths from prescription opioids climbed steadily until they began to level off in 2010. That same year, heroin overdose rates began to rise until they surpassed prescription opioid overdose rates in 2018. In 2013 deaths involving synthetic opioids like fentanyl began to spike. By 2019 overdoses from fentanyl and other synthetics accounted for more than half of all overdose deaths and 1.5 times more deaths than either prescription opioids or heroin. Meanwhile, cocaine and methamphetamine deaths escalated until they each contributed to more deaths than prescription opioids in 2019.
After a small dip in overall deaths in 2018, the COVID-19 pandemic struck, and overdose rates hit an all-time high: 92,000 deaths in 2020, then 107,000 in 2021. The majority of these overdoses involved fentanyl or other synthetic drugs. Physicians were complicit in flooding drug markets with prescription opioids. When prescribing rates peaked in 2012, physicians were issuing 81 opioid prescriptions per year for every 100 Americans. Rates diminished after that, but did not return to baseline. In 2017 physicians still prescribed three times more opioids than they did in 1999. The picture is bleak. Overdose rates increase year after year and the drugs driving those deaths change too quickly for anyone to fully grasp. What brought all of this on?
If you know anything about the opioid crisis, you probably think that Purdue Pharma is to blame. As the story goes, Purdue manipulated regulators and physicians to get patients hooked on their drug, OxyContin, a powerful opioid used to treat pain. When people started dying with OxyContin in their systems, Purdue ignored the warning signs, pushed their drug even harder, and made billions doing so. OxyContin devastated a nation and made the Sacklers, one of the richest families in the United States, even richer.
But Purdue’s reign would not last. In September 2019, while facing 2,600 state and federal lawsuits, Purdue declared bankruptcy. For many families and activists, this was cause for celebration. The enemy had been vanquished. Yet this victory over Purdue is only truly celebratory if we imagine that the driver of the contemporary U.S. opioid crisis can be reduced to a single causal factor—a bad drug company selling addictive wares to an unsuspecting public.
This kind of fairy tale with easy-to-identify villains and victims resonates powerfully with Americans. After all, we have digested narratives about “good guys” and “bad guys” our entire lives. But we are less prepared to deal with complexity, to recognize that the good guys do bad and the bad guys do good. We are woefully ill-equipped to critique bad systems, to unpack how an ecology of laws, norms, politics, economics, organizations, and relationships affect the decisions people make. We fail to consider that people do bad things because the systems in which they operate invite bad behavior. If systems are failing us, we can’t just eliminate the so-called bad actor; we have to look at the rules of the game.
The Purdue story obscures more than it reveals; the truth is a far cry from this simple fairy tale. The true story of opioids is the saga of a society in which lines between illness and criminality are blurred, where punishers do the treating and healers do the punishing. A story in which the color of a person’s skin and the substance that they use affects whether they receive care, punishment, or punishment disguised as care. A story in which suffering people are denied relief under the auspices of protection and support. For many, this story is a living nightmare full of impossible choices, one in which heroes die and in which villains, who are all the more powerful for being nameless and faceless, prevail. A chilling story, yes, but one necessary to unravel the tidy image knitted together by simplistic threads of blame so that we can finally understand this modern social problem’s complexities and arrive at policy solutions that honor its subtleties.
We cannot understand the overdose crisis without understanding the people responsible for stopping it: the people behind the pharmacy counter, in the treatment room, and within the recesses of government bureaucracies—the gatekeepers to medical resources and the enforcement agents who investigate and prosecute them. By looking at the opioid crisis through the lens of frontline work, we can see how strategies to curb the crisis affect the daily lives of workers and patients in powerful, but unexpected, ways. Particularly central is the use of the PDMP. This technology affects how workers interact with each other and how they treat patients. Broader cultural forces shape it all.
When it comes to punishment, the narrative isn’t new, but the form is. Data-driven health care is the latest manifestation of the perpetual war on drugs, a failed political experiment that has done more to fuel mass incarceration than to reduce drug use. Criminal justice tools will not dismantle the opioid crisis. Placed in health-care providers’ hands, they are doing irreparable damage to patient care and public trust. Shared surveillance technology has ushered criminal justice logics into health care and blurred boundaries between policing and treating. When policymakers ignore the complexity of the overdose crisis and instead view it through a singular punitive lens, they shut off the most promising avenue for addressing the crisis: health care.
Excerpted from Policing Patients: Treatment and Surveillance on the Frontlines of the Opioid Crisis. Copyright © 2024 by Elizabeth Chiarello. Reprinted by permission of Princeton University Press.
Image: Dima Mukhin/Unsplash/Inquest
