Policing Patients: Treatment and Surveillance on the Frontlines of the Opioid Crisis is a Swiss Army knife of a book. It offers tools to explain the opioid–involved overdose crisis, the plight of pain patients, the contradictory roles of doctors and pharmacists, our dysfunctional health care and drug treatment systems, and how the Drug Enforcement Administration surveils and bullies anyone involved with an opioid prescription.
Author Elizabeth Chiarello, an associate professor of sociology at Saint Louis University, uses that lens to show how surveillance technologies alter the relationship between health care professionals and patients—from one of care to one of policing and punishment. Chiarello conducted research and interviewed dozens of people over the course of 10 years. You can read a brief excerpt from the book here.
A prescription drug monitoring program (PDMP) is an electronic database that tracks, stores and analyzes controlled substance prescriptions. They exist in all 50 states, recording physician prescribing and pharmacist dispensing practices as well as patient information. The DEA and other law enforcement organizations have access to all this data, and use it to investigate and prosecute cases of alleged overprescribing.
“Physicians and pharmacists police patients instead of treat them, actions that violate their professional oaths and that exacerbate instead of mitigate harm.”
“PDMPs changed the face of healthcare,” Dr. Chiarello writes. “Physicians and pharmacists police patients instead of treat them, actions that violate their professional oaths and that exacerbate instead of mitigate harm … Healthcare has long been a site of surveillance and social control … Minoritized groups such as women and people of color along with moralized conditions such as addiction and mental illness have disproportionately felt the brunt of medical discipline…”
In the second chapter,“Trojan Horse Technologies,” Chiarello unpacks the history and use of PDMPs and how providers like pharmacists engage in policing and justify it.
In interviews Chiarello conducted before PDMPs were widely established, pharmacists emphatically said they were uncomfortable with the idea. “I am a pharmacist, not a police officer,” they would tell her.
Just a few years later, she found that viewpoint was gone. Pharmacists understood that they were being watched by law enforcement via the PDMP, and that a single dispensing mistake could lead to a dire cascade of consequences. Like the DEA revoking their registration to dispense controlled substances, the revocation of their license by state pharmacy boards, or being criminally prosecuted and imprisoned.
Rather than kick up at the DEA threats, pharmacists too often use the PDMP to kick down at vulnerable patients by delaying or refusing to fill prescriptions. Some report “doctor-shopping” patients to law enforcement, reframing their punitive decisions as care and concern. One of the most destructive aspects of PDMPs is how they pit providers against patients.
Deaths involving prescription opioids rocked the United States in the early 1990s, which was the major impetus to deploy PDMPs. It shouldn’t be surprising that drug warriors turned to a tool of control and surveillance instead of making lifesaving medications like methadone and buprenorphine freely available on demand.
The notion that monitoring and restricting prescriptions would reduce overdose deaths misfired spectacularly—as even the architects of this policy suspected it would—leading to much larger waves of deaths related to heroin, and then fentanyl. Pain patients, denied critical medications, were left to suffer. Some have tragically died by suicide.
Chiarello’s book contains much insight. Some quibbles include its use of “opioid crisis” to describe what is better termed the overdose crisis. My main issue is that it isn’t critical enough of the DEA. Chiarello describes DEA diversion investigators as “reserved, thoughtful” and says they receive “less glory” than gun-toting special agents. No DEA agent deserves any glory. The DEA is in large part responsible for the overdose crisis. The drug war it spearheads has cost over a million lives lost to overdose since the late ‘90s. The agency should be abolished before it kills another million.
Policing Patients is an indispensable book for its critical examination of how technology can increase the reach and toxic power of law enforcement, harm patients, and compel health care providers to become cops. Chiarello sat down with Filter to discuss it; our interview has been edited for length and clarity.
“What law enforcement have done is repositioned themselves as helpers, and that happens in a couple of different ways.”
Helen Redmond: You write, “Law enforcement retains authority by shape-shifting from punisher to helper.” How do they do that, and can you give us an example?
Elizabeth Chiarello:Law enforcement has had to reposition itself and part of the reason is because organizations, just like people, have survival instincts. Even if the job that they’re doing is no longer necessary, they want to keep doing the work, even if the problem has moved into somebody else’s domain, or the problem isn’t really a problem anymore.
Jonathan Simon, who’s a law professor at Berkeley, talks about the idea of governing through crime. As crime rates go down, lawmakers don’t have to govern crime, but they govern through crime. By that he means that they scare people about the possibility of crime, and that’s the thing that keeps them in power. And so the same thing is happening here. When we think about drug use as badness, law enforcement has a major role to play. They are supposed to find people engaged in bad behavior and arrest them. But if those people are sick, then law enforcement doesn’t really have a role. And so what they’ve done is repositioned themselves as helpers, and that happens in a couple of different ways.
One way they’ve “helped” is by giving health care an enforcement tool in the form of the prescription drug monitoring program (PDMP). They have also done a lot of joint conferences with health care organizations and with public health as a way of keeping themselves essential. They have done things like provide Narcan, which is really great in terms of harm reduction, but all of this is helping to reposition law enforcement as people who are helping, even though the way that we frame the problem has changed.
HR: You interviewed DEA agents. What was the experience like?
EC: I thought, I am never going to get to talk to anybody in the DEA, how would I even contact somebody in the DEA? I wanted to talk to them because they’re such a big part of this story. I remembered from my first round of interviews with pharmacists that one of them was married to a narcotics officer. I thought, if I could get to him, he might know somebody at the DEA. I called him like a million times and he finally agreed to meet up with me.
He put me in touch with his buddy who is a special agent, which is kind of the classic DEA agent. You know, when you see the guys wearing flak jackets that say “DEA, “who are carrying guns and busting down doors? I met with him and his diversion investigator partner and they were very skeptical of me at first. They asked me about articles I had written and some very specific questions. But after they vetted me, they were very open to sharing their experiences. They connected me with other DEA agents across the country.
I went into this knowing so little about drugs. My background is in reproductive health, and that’s what I thought I was studying when I started this project. I would do an interview with somebody in law enforcement and I would really be on their side. I would be like, yes, we’ve got to take these bad doctors off of the street. These crimes are egregious, these doctors are trading sex for drugs, that is outrageous! But then my next interview would be with a physician and I’d see that there are all of these other elements happening in their work that we’re not thinking about. And so it was really helpful to do the research the way that I did it, where I was toggling between people working in really different kinds of organizations and trained in different ways with different perspectives. It gave me this very holistic understanding of the crisis, especially coming from a pretty uninformed position.
HR: What do diversion investigators do?
EC: Diversion investigators are this lesser-known, administrative side of the DEA. They don’t carry guns, they largely deal with paperwork, and their job is to make sure that prescription opioids, controlled substances, are being used for medical purposes. They are responsible for overseeing all of the DEA registrants—that includes doctors, pharmacists, pharmacies, hospitals, anybody who might be dispensing or prescribing opioids. They also oversee the entire closed system of distribution which goes from the manufacture of controlled substances all the way to distribution. And for the longest time, they were very undervalued at the DEA. They dealt with “kiddie dope;” the idea was that prescription opioids were just kiddie dope. They’re not kicking down doors and dealing with gang members and cartels. So they were really devalued until the opioid crisis started ramping up. With prescription drugs at the center of the crisis, they became extremely important.
“PDMPs were built for law enforcement and when they move into health care, they don’t suddenly become a health care tool.”
HR: Can you explain the origins of prescription drug monitoring programs?
EC: PDMPs were originally designed for law enforcement. New York has the oldest, it was developed in 1918. California’s PDMP is the oldest continually operating system and it was developed in 1939. They were always designed for surveillance and enforcement purposes. But most of the PDMPs that we have today were adopted over the last 20 years or so.
The majority of them have been paid for through Harold Rogers grants that come out of the Department of Justice. They gave states money to either set up the PDMP or to run it for some portion of time in order to enhance what the PDMP could do. And so law enforcement has a clear vested interest in PDMPs operating, otherwise they wouldn’t have put millions and millions of dollars into these systems. PDMPs are not subject to the same privacy protections as other health care data. They are an end run around the Health Insurance Portability and Accountability Act (HIPAA).
PDMPs are two-tiered surveillance technologies. They allow health care providers to monitor patients, but they also allow law enforcement to monitor health care providers and patients. In some states they have to get a warrant, in other states they have to get a subpoena. In some states, they have a direct log-in.
The PDMP gives law enforcement easy access to information that they otherwise could get, but would have to get in a far more difficult way. That’s why I call PDMPs Trojan Horse technologies. They were built for law enforcement and when they move into health care, they don’t suddenly become a health care tool. They usher enforcement logics into the health care space, and what I show is they actually help to transform health care practice into something that more closely resembles law enforcement.
HR: Are you in favor of abolishing PDMPs?
EC: Regardless of how I feel about the PDMPs, I think they are here to stay. There are just too many stakeholders who are interested in them. I think the best we can hope for is to refurbish them and to create stronger constraints in terms of law enforcement access.
Health care providers say to me, “I really like the PDMP, it gives me information that I otherwise didn’t have.” And I say to them, of course, you want to know what medications your patient is taking. And pharmacists don’t even have access, usually, to the patient’s diagnosis. Both physicians and pharmacists want to have this information, but it could be incorporated into the electronic health record without law enforcement also having access. I think creating stronger firewalls around PDMP data, but then also training physicians and pharmacists to be better at providing care to people who use drugs, would make the PDMP less of an enforcement tool and more of a health care tool.
HR: Why are there problems getting opioids at the pharmacy, and what is the role of pharmacists as gatekeepers?
ER: The problem of getting opioids at the pharmacy…. So this is a thing that has actually changed quite a bit over time. When I first started interviewing pharmacists, it was before the PDMPs were in regular use. I would ask pharmacists: There are three types of people who might come in here looking for opioids—there are people in pain, people with substance use disorders, and then there are people who are diverting medication, who are selling their drugs—and sometimes these are the same people, right? These aren’t mutually exclusive categories, but legally, you are only able to dispense to people who are using them for pain. So how do you tell the difference? How do you know who you’re dealing with?
And when I first started interviewing them in 2009, they didn’t have a great answer. Pharmacists used things like a gut feeling, the way that a patient made them feel when they walked through the door. They used things like whether the patient paid cash, other kinds of red flags, like how far the patient’s home was from the pharmacy, or how far the doctor’s office was from the pharmacy. A lot about appearance and behavior, the way that they talked to the pharmacist. And so they would use all of those things to get a read on the patient, and then if they chose not to dispense it, they normally would say that the drug was out of stock. The pharmacists did that because it was a pretty convenient way to avoid a big confrontation and the patient had no way of double checking. That was a way of deterring patients.
“If pharmacists are looking at patients with suspicion and trying to figure out whether they are trying to break the law, that comes into conflict with what they’ve been trained to do as medical gatekeepers.”
By the time I interviewed them after the PDMP was in place, they were far more confrontational. They would say things like, “I’ve looked you up in our statewide database and I see that you have gone to 10 different doctors in the last two months and you’ve gotten over 400 pills. I just can’t dispense this to you.” It not only diffused that specific interaction, it also sent a message to the patient that they were being tracked and that they probably shouldn’t come back to this pharmacy.
Pharmacists are incredibly important for making sure that the drugs you’re taking don’t interact with other drugs, that what the doctor is prescribing is actually the right medication and the right dose is being administered. If those things are wrong, you could be injured or even die. So we need pharmacists there to be medical gatekeepers. But there is this question of whether they should also be legal gatekeepers, which of course they are, because they’re required to be by the Controlled Substances Act.
But if they are looking at patients with suspicion and trying to figure out whether they are trying to break the law, that comes into conflict with what they’ve been trained to do as medical gatekeepers. And so when I first started interviewing them, those roles were really in tension, but by the time I reinterviewed them, they had consolidated them to a single role. Now they understood the legal gatekeeping process as medical gatekeeping. They would say, “I’m helping patients by surveilling them, because that’s what I was trained to do.” And so initially they had some cognitive dissonance but they had reconciled that over time, and the PDMP was a big part of helping them do that.
HR: You argue in your book that “Pharmacy-based methadone will not be possible unless pharmacy chains make significant changes to pharmacy operations.” I don’t agree. Methadone is already in pharmacies and has been dispensed to pain patients for decades. If opioid use disorder patients are able to pick up a prescription once a month with no observed ingestion, I don’t see how that adds a ton more work for pharmacists?
ER: I think you and I agree that the clinic system is not optimal. There are a lot of problems with the clinic system, but getting from a clinic-based system to a pharmacy-based system is going to be an uphill battle for exactly the reasons we were talking about earlier, which is that organizations are interested in survival.
And so even if we decide that the clinic system is no longer serving us, there are a lot of people that the system is serving. People who work in opioid treatment programs (OTPs) and organizations like the American Association for the Treatment of Opioid Dependence are invested in the clinic system. There are a lot of stakeholders who benefit from OTPs who are not eager to go by the wayside.
So the question is, how do we get from the clinic system that we have now, that can do a lot of harm, to a pharmacy-based system that expands access to care and that hopefully destigmatizes care by integrating methadone into mainstream pharmacy? It’s a big leap to go from our current system to a complete take-home system. I think we’re likely to see baby steps along the way. And so even in a transitional period, it would create a lot more work for pharmacists, where you have to observe patients the first couple of times they take the medicine.
Pharmacists have been so overloaded, they’re already short-staffed and short on time. And then they started doing flu shots. Then COVID came along, and then they had to do COVID vaccinations. Pharmacists are really up to their neck in work, and they’re not interested in taking on more. I agree with you, in the ultimate form [non -witnessed ingestion] it wouldn’t be that much more work, but it’s these intermediary steps that I think could create some barriers.
Image via Picryl/Public Domain
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