Recent public attention to police brutality, systemic racism and oppression has brought calls for changes to a policing structure that manifestly fails to promote community health and safety. These run the gamut from radical defunding and abolition to reformed models of policing, where officers partner with trusted mental health professionals like social workers or psychiatric nurses. Social worker Dr. Sheila Vakharia of the Drug Policy Alliance* argues that this approach will “exacerbate our profession’s already fraught role as agents of social control,” and “will not fundamentally change even one of the myriad harms inflicted.”
As a nurse, I am a member of another “helping profession” that is simultaneously undervalued and tasked with solving an overwhelming number of health and societal problems. We are also frequently used by the healthcare system as agents of surveillance and control.
Nurses who work in hospital settings spend more time with patients than most other clinicians providing direct care, and often build the strongest, most trusting relationships. In the intensive care unit, for example, close monitoring by nurses is vital to detecting changes in a patient’s condition that require immediate intervention.
While our advocacy on behalf of patients is often extremely beneficial for those whose needs may be overlooked by others on the healthcare team, our near-constant monitoring of patients—in both inpatient and outpatient settings—can also inadvertently hurt them.
Our profession urgently needs to reckon with the ways that our role can be manipulated to police and control patients.
Dr. Vakharia’s ultimate conclusion—that “social workers should stop imagining new settings in which to work, and instead consider what it would take to create a world where our profession is rendered obsolete”—is not applicable to nursing, because even in a just society, people will still need healthcare. But our profession urgently needs to reckon with the ways that our role on the healthcare team can be manipulated to police and control patients.
My first nursing job was at a methadone clinic. Nursing duties included dispensing methadone doses and watching as patients swallowed them. We asked patients to open their mouths and lift their tongues to prove that they were not holding their medication before they left. We were expected to conduct sobriety tests if we or other clinicians believed that a patient was intoxicated when they arrived for their methadone.
On weekends, when we were the only staff at the clinic, we sometimes also conducted observed urine drug screens. We would count doses when patients who had take-home bottles were called back for random checks. We would watch patients hurry in at 6:30am, oftentimes late for a job that they needed to keep in order to successfully progress in the program. We would lock the doors at 2 pm, and were discouraged from letting a patient in late, even if they were running across the parking lot to make it in the door before the clinic closed.
While I don’t believe that the clinic’s overall approach was quite as punitive as others that I’ve heard about, many of these rules are set in stone by regulating bodies—and nurses are the designated agents of enforcement.
These tasks were deemed vital for the everyday functioning of the clinic, but unlike many other nursing duties, their ultimate purpose was not to promote patient health, but to police people who were prescribed a controlled substance meant to “control” their addiction. In fact, the “low-tolerance, high-threshold” model of many substance use treatment programs—especially those offering methadone—can actually impede patient success.
Rigidity was a feature of the job, even while the importance of clinician-patient relationships in healing was often discussed. This left nurses in a bizarre bind: We were expected by other clinical staff to closely monitor every aspect of a patient’s relationship with their medication and report any suspected deviations or diversions—but also looked to by patients to advocate for them if they believed they were being mistreated by the supervising physician or nurse practitioner.
All other clinicians, including the prescribing providers and counseling team, would approach us for insight about whether patients were taking medications as prescribed. Despite the security guards at the door, I found myself wondering if the nurses were actually the police of the clinic.
Nurses can and should push back against this framework.
As a nurse practitioner, I now work in a low-barrier buprenorphine program with no observed urine drug screens or random med-checks, no punitive policies for when patients use non-prescribed substances, and no hyper-strict clinic hours. As much as I prefer this type of setting and am heartened by more forgiving environments allowed for buprenorphine treatment, I also often think about the methadone patients left behind—patients who are more likely to be Black and Brown than those receiving buprenorphine.
The increased leniency afforded to buprenorphine treatment can inadvertently incentivize patients stable on methadone to attempt to switch to buprenorphine, which might not be ideal for them. It can also deter patients from trying to access methadone treatment at all. Patients for whom buprenorphine isn’t effective are left to choose between daily methadone dosing at a clinic that may closely mirror a probation office or going without treatment. For those with jobs, transportation issues, or family commitments that don’t allow daily dosing, going without might be the only option.
Nurses can and should push back against this framework. We are not law enforcement officers. We should reject duties that are known to dehumanize our patients and ultimately stand in the way of their healing. Our careful monitoring—which should be used to track a patient’s condition and provide necessary medical interventions as soon as possible—becomes policing when it is used because we distrust patients, because we think that they are trying to trick or manipulate us, because we don’t believe that their goals or priorities matter, because we think that we know better than they do what is best for them.
The current structure of substance use treatment in the US is built on these core beliefs, but nurses don’t have to ascribe to them.
Nurses have a valuable role to play in the future of compassionate, evidence-based substance use care that departs from current models of control and over-policing. Our skills are wasted when our job descriptions comprise observing urine drug screens and locking the clinic door in the face of a begging patient who was running one minute late.
Instead, we can look to nurses who do street-based harm reduction outreach, and research and write about the importance of safe supply and stable housing. We can improve our substance use curriculum so that new nurses are well-versed in harm reduction, low-barrier treatment, and drug policy. We can advocate for changes in methadone regulations to allow more flexibility in treatment, and we can reimagine new roles for ourselves that involve partnering with our patients rather than policing them. Nurses must be leaders in demanding better and refusing to be used as agents of control.
*The Drug Policy Alliance has previously provided a restricted grant to The Influence Foundation, which operates Filter, to support a Drug War Journalism Diversity Fellowship. Dr. Vakharia is also a member of the board of directors of The Influence Foundation.
Photograph by Helen Redmond