[This article is excerpted from the book Policing Patients. You can read Filter’s interview with the author here.]
Pharmacists’ choices about whether to dispense opioids depend on how they categorize patients, a process sociologists call “social sorting.” Pharmacists sort patients by posing the same questions physicians ask: What kind of patient is this? Is this a patient who is in pain, has an opioid use disorder, wants drugs to sell, or is some combination of the three? “Deserving” patients have physical pain; “undeserving” patients do not. Pharmacists must figure out who they are dealing with and act accordingly.
Awash in uncertainty, pharmacists find themselves pulled in two directions—toward careful and cautious dispensing by law enforcement and toward fast, efficient dispensing by their employers. Yet they must decide, again and again, day in and day out, who deserves opioids, knowing that one misstep could place them in law enforcement’s crosshairs. Potential errors are twofold: (1) they might over dispense to patients who are addicted to or are diverting medications, which could result in the loss of their pharmacy license or an arrest; or (2) they might under dispense to patients in pain, which could cause trouble with their employers and harm the very patients they have sworn to serve.
Pharmacists welcome monitoring programs because they resemble health-care technology, but they don’t see that PDMPs sneak policing into pharmacies.
Despite having so much at stake, pharmacists spent years without the tools to make the right decisions. The prescription drug monitoring program (PDPM) offered insight where they had once been flying blind. Pharmacists welcome monitoring programs because they resemble health-care technology, but they don’t see that PDMPs sneak policing into pharmacies. Like the ancient Greeks who crept out of the gift horse when the Trojans were asleep, pharmacists’ regular use of PDMPs invites enforcement logics into their practice. In the past, pharmacists made haphazard, time-consuming, and ambivalent decisions about who got opioids. Today, that process is far smoother. Policing patients has become routine.
The main differences in pharmacy work before and after the PDMP lie in how pharmacists decide who is deserving, how they protect themselves from law enforcement, and how they communicate their choices to the patient.
Before the PDMP, pharmacists lacked information about patients and acquiring more was a slow, painstaking task that risked angering physicians, pharmacy managers, and patients. They did not have time to closely scrutinize hundreds of prescriptions a day without falling impossibly behind. Pharmacists made decisions based on the patient they saw in front of them and how those patients made them feel. They drew on stereotypes about people who looked unclean or unkempt and relied heavily on their intuition. None of this made pharmacists feel confident about their decisions.
Most pharmacists relied on a set of “red flags,” social cues that signaled that patients might be using drugs for the wrong reasons. Pharmacists observed appearance and behavior; they noted when patients paid cash or asked for specific colors or shapes of drugs. They reasoned: “Who, except people who sell drugs, cares if their pill is a rectangle or an oval?” Patients who looked bedraggled or had track marks on their arms were considered suspicious, as were patients who were overly friendly.
“Honestly, when you’ve been in the business as long as most of us have at my age, it didn’t take long just to watch the person, listen to him to know whether this is something that we really want to be pursuing,” a 63-year-old pharmacist who worked outside of Wichita, Kansas, told me. “I mean when they come in and they’ve never been here before and they want to know your life history and they’re talking and just Mr. Chitty Chatty, the flags just start waving.”
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 (cropped) via Stockcake/Public Domain
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