Articles, Blog

Examining the Opioid Epidemic’s Impact on Professional Work | Liz Chiarello || Radcliffe Institute

December 17, 2019

– Thank you, Meredith, for that
characteristically stunning introduction. I’m afraid it’s all
downhill from here. It’s such a pleasure to
speak with you all today. Before I begin, I’d like
to express my appreciation to the Radcliffe Institute
for hosting me this year, to the National Science
Foundation for supporting this research, and of course
my undergraduate research team without whom this
research would not be possible. To give you a little
bit of background, I’m a medical sociologist
and sociolegal scholar. So I do research
at the intersection of health care and law. And I’m particularly interested
in the cultural context of professional decision-making. So when providers
are making decisions about prescribing or dispensing
medications, to what extent are they influenced by
their organizational policy, by their political environment,
and by their legal environment? And relatedly, I’m
interested in how the decisions that
they make and affect inequality in health
access and also exposure to the criminal justice system. So my current project
uses the opioid crisis as a case for understanding
how health care providers make decisions about politically
controversial drugs and what the impact looks
like on patient care. Last month, while facing 2,600
state and federal lawsuits, Purdue Pharma, the maker of
OxyContin, declared bankruptcy. For many families and activists,
this was cause for celebration. The enemy had been vanquished. The dragon had been slain. And the people were
finally liberated from 20 years of pain and loss. But this victory over Purdue
is only truly celebratory if we imagine that the
driver of the contemporary US opioid crisis can be reduced
to a single causal factor, a bad drug company
selling addictive wares to an unsuspecting
public, a company that used shoddy science to convince
regulators to give them a market advantage, that they
then use to hoodwink physicians into carelessly
prescribing their drugs, leaving a trail of destroyed
lives in their wake, nefarious people who sold drugs
so powerful and so addictive that people were helpless
to escape its grasp. This kind of fairy tale with
easy-to-identify villains and victims resonates
powerfully with Americans who live in a society that
privileges singular answers over complex ones
and that prefers to attribute social ills
to bad actors instead of bad infrastructures. I came here today to share
a different kind of story, a story that accounts for the
nuanced and varied factors that have contributed to
the opioid crisis. This story is far
from a fairy tale. For many, it 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 story of a society in which the lines
between illness and criminality are blurred, where the
punishers do the treating, and the healers
do the punishing, a story in which the color of a
person’s skin and the substance that they use affect whether
they receive punishment, care, or punishment disguised as
care, a story in which suffering people are denied relief under
the auspices of protection and support, 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 the deep interrelated
complexities of social problems and arrive at policy solutions
that honor their subtleties. The overdose crisis is
both a devastating tragedy for those whose loved ones
are caught in its grip and a constructed
social problem, one shaped by institutional
power dynamics that affect how we define, elaborate,
and respond to this issue. In other words, the
so-called opioid crisis and our approaches
to confronting it are a distinctly
cultural phenomena. Contemporary approaches
to the opioid crisis are dominated by two
fields, health care and criminal justice, that
bring very different worldviews, tactics, and resources to bear,
and that are independently inadequate to tackle a
problem of this magnitude. My research examines how
these disparate fields manage the same social problem, the
implications for how these fields operate– so how might
these fields look different as a result of dealing
with this social problem– and implications for
patient care and exposure to the criminal justice system. I’ll begin by discussing
the origins of the US opioid crisis. Then I will share
original research findings on how technological
solutions are impacting the fields of health
care and criminal justice and shaping inequality
and health care access and exposure to punishment. I’ll conclude with a set of
policy recommendations designed to intervene meaningfully
into the crisis. Our story begins with a
series of troubling trends. The number of drug
overdose deaths has risen precipitously
over the past 20 years. In 1999, there around
17,000 drug overdose deaths. By 2017, that number had
quadrupled to 70,000, making drug overdose the leading
cause of accidental death in the United States. Around 17,000 overdose
deaths, or 24,000 in 2017, involved a
prescription opioid, things like oxycodone,
hydrocodone, and codeine. Physicians were complicit
in flooding drug markets with prescription opioids. Physicians prescribed about
three times more opioids in 2017 than they did in 1999. These are the facts. But there are three
major problems with how these facts
have been presented in the public discourse. One problem is that
despite receiving a hefty share of the
blame for overdose deaths, this iatrogencic, or
physician-caused pathway, is only part of the story. In 2017, twice as
many overdose deaths were attributed to heroin,
synthetic fentanyl, and other synthetic
opioids as compared to prescription opioids,
which represents a 16-fold increase from 1999. This suggests that there exists
a second non-medical pathway to overdose death that cannot
be explained exclusively by Purdue’s unethical
business practices. A second problem is that,
what many leaders consider a 20-year problem is in
fact a 120-year problem, an extensive duration during
which the policy pendulum has swung repeatedly between
punitive and rehabilitative approaches to opioid addiction. And this swing of
the pendulum is related to broader trends
in racialized drug policy, whether the focus is on
Chinese laborers and opium, Mexican migrant workers and
marijuana, or African Americans and crack cocaine,
we see time and again that the
criminalization of drugs is a mechanism for
criminalization people, particularly
those people who belong to poor minority groups. Throughout the last
century, the lens through which addiction
has been refracted, whether one of badness
or one of sickness, has been formed through
racialized and class notions of moral worth. A third problem is that
the language and imagery used to frame this social
problem warrants skepticism. What’s been called
an opioid crisis or even an opioid
epidemic is, in fact, the confluence of two crises,
an overdose crisis and a pain crisis at the
intersection of which lie problems of pain
addiction and diversion. And by diversion, I’m talking
about the sale of prescription drugs through illicit markets. Pain is rampant in
the United States. In 2011, the
Institute of Medicine reported that at least
116 million Americans suffered from chronic pain. But determining whose
pain is legitimate and which patients
deserve resources has been a decades-long
political enterprise. In the 1960s, anti-opioid
sentiments were so prevalent and the policy pendulum has
swung so far towards punishment that cancer patients were dying
in pain while the drugs that would have relieved
their suffering were available but inaccessible. These inhumane practices
mobilized the British hospice movement in the late 1960s and
the US pain management movement a decade later, both
movements pushing the pendulum towards treatment. When OxyContin was
released in 1996, it was a godsend for
chronic pain patients. Its 12-hour slow-release
formula enabled them to sleep through
the night, and it carried much lower
risks of organ damage compared to its competitors. However, Purdue Pharma
gained a market advantage by convincing the Food and
Drug Administration to allow them to label OxyContin
as less addictive than other opioids, which
we now know is not true. They also tapped
physician thought leaders to market the drug. And they targeted
physicians who are known to be especially
heavy opioid prescribers. Meanwhile, the Joint Commission
on Accreditation of Health organizations– this is the
organization that accredits hospitals– labeled pain the
fifth vital sign, and begin using patient
satisfaction surveys about pain treatment as a factor
in hospitals’ reimbursement rates. Collectively, these business
practices, social movement efforts, and regulatory
changes gave way to a liberal
prescribing moment that catalyzed the tsunami of
opioids that began to flood illicit markets in the 1990s. Today, the heyday of
opioid prescribing is over, and the pendulum has once again
swung back towards punishment, leaving providers aware
of their legal terrain. Legally, physicians are
beholden to the 1970 Controlled Substances Act that
requires physicians to prescribe in
good faith, meaning for a legitimate medical purpose
for an established patient, while it also assigns
pharmacists what’s called a corresponding
responsibility to avoid dispensing drugs for
non-medical purposes. The questions physicians
and pharmacists face– to prescribe or
not to prescribe, to dispense are
not to dispense– occur within a medical context
in which pain and addiction are incompletely medicalized and
options for treatment are few. Both conditions are nominally
framed as illnesses. But their most
effective treatments are rarely covered by
insurance, and most physicians lack the knowledge and resources
to effectively treat them. For addiction, criminal
justice solutions have entered the breach
and have taken three forms. First, criminal justice
agents are increasingly performing health care work. Police are administering
naloxone, a drug overdose antidote, and they
are participating in programs like PARI, which
stands for Police Assisted Recovery Initiative, through
which people surrender their drugs to the police
as a first step to receiving treatment services. Second, criminal justice
spaces like prisons and jails have become de facto
treatment spaces because many policymakers buy
into myths about addiction, such as the idea that
only by hitting rock bottom can people turn
their lives around, as if addiction were a choice. So incarceration
ends up standing in for other more effective
forms of treatment. Third, and this is the
one I’m going to focus on, criminal justice technologies
are being implemented in health care spaces. Notably, 49 states,
all but Missouri, have adopted statewide
Prescription Drug Monitoring Programs, PDMPs that
track controlled substance dispensation in the state. What is a PDMP you ask? PDMPs, prescription drug
monitoring programs, contain aggregated pharmacy
dispensing data that’s entered at the point of care. So if you go to a
pharmacy, and you have a prescription
for oxycodone, the pharmacist dispenses
that, but then they send a record of that
dispensation along with all of the other
controlled substances that they’ve dispensed
either that day or that week to accompany
that partners with the state to put all of that information
into the prescription drug monitoring program. So the PDMP gets
information about all the controlled substances
dispensed throughout the state, and then it feeds that
information back to physicians and pharmacists who can
use that information to make decisions
about whether or not to dispense to a patient. So here is an example of
a traditional PDMP report. It’s basically an
Excel spreadsheet. And it has information about
a patient’s drug history– so the kind of drug they’ve
taken, the amount, where they’ve gotten it, which
doctors they’ve gone to, which pharmacies they’ve
gone to, et cetera. So I want you to think for a
moment if, based on these data, you would choose to prescribe
an opioid to a patient. Now, I’m guessing that
many of you have no idea. Partly because
you’re not a doctor or you’re not that
kind of doctor and partly because this
information is very difficult to read, and not just
because it’s blurry. Processing these data requires
a lot of cognitive work that takes far more than the 20
minutes that physicians usually get to spend with
their patients. Well, I have great news for you. The PDMP has been evolving. It’s gone from PDMP 1.0,
this wholly unreadable Excel spreadsheet, to PDMP 2.0, which
does more analysis for you. It shows you scores for
narcotics and sedatives and stimulants. And sometimes it even contains
an overdose risk score. And sometimes it’s
in color, so you can see that they’re
in the red, and then you know what you’re
supposed to do. All right. If this looks
familiar to you, it might be because these exact
same kinds of algorithms are being used in the
criminal justice system to assess the risk that
incarcerated people, if released, will
engage in public harm. In fact, the same company that
runs 45 out of the 49 US PDMPs also offers a suite of criminal
justice surveillance tools, including this one,
risk intelligence. This is designed
to help employers avoid hiring people with
criminal justice convictions– so much for banning the box. We’re not done yet. We’re starting to see
prototypes of PDMP 3.0 that integrates information like
arrest records into the PDMP so that, before
prescribing opioids, providers can see
if a patient has been arrested for a drug crime. But wait, there’s more. PDMPs are not used exclusively
in the health care system. They’re also used
by law enforcement to track both patients
and providers. In addition to seeing
the same kinds of data that providers can
see, law enforcement can also see information about
prescribing and dispensing. So they can create charts and
graphs that look like this, and they can identify, well,
who is the highest prescriber in the state of Mississippi? Or who is the highest dispenser
in the state of California? PDMPs then are two-tiered,
big-data surveillance systems. They constitute a critical
point of intersection between the fields of health
care and criminal justice because workers
in each field use the database in their daily
work albeit to different ends. But what’s the use of shared
surveillance technology mean for professional work and
for patients’ access to care? I began exploring this
question when I first heard about PDMPs in 2011. I just completed the
project that Meredith spoke about where I
interviewed 100 pharmacists throughout the US about
how they made decisions about dispensing opioids. And I should note for a
minute that pharmacists are far more important
than most people think. I think most people think
that pharmacists do nothing more than put pills from big
bottles into little bottles. And they also think that
pharmacists do exactly what the physician tells them to do. And I am here to tell you
that that is not the case. Pharmacists practice under
their own professional license, and they get to make
decisions about the care that they provide. Although, many of their
decisions are refusal. They can’t give you
something different than what the doctor prescribed. But they can refuse to give
you what the doctor prescribed. So in our highly
pharmaceutical society, our highly pharmaceuticalized
society where there’s a drug for everything
that ails you, pharmacists serve as gatekeepers
to prescription drugs, which gives them significant power. When I asked pharmacists
how they made decisions about whether to dispense
opioids, many of them mentioned a gut feeling
that they took as indicators that something wasn’t right. Of course, my
sociological imagination led me to wonder what was
behind those gut feelings? Were pharmacists
just really good at differentiating between
pain, addiction, and diversion? Or were they really reading
race, class, and gender and making decisions based
on cultural stereotypes? Since I already had data on
how pharmacists made decisions before the PDMP, I
decided to re-interview a subset of those
pharmacists and also expand the scope of the project to
include physicians and law enforcement. So that resulted
in 182 interviews that I conducted
between 2009 and 2019 with health care providers
and enforcement agents primarily in three states
California, Florida, and Missouri. So I’m going to share with you
data from this project today. What I found was surprising. Not only has PDMP use
changed pharmacist behavior. But the use of
this technology is blurring boundaries
between health care and criminal justice. Both fields are
changing, but they’re changing in different
and interrelated ways. I’ll discuss what
these changes look like by highlighting four
interrelated processes, technological expansion,
technological encroachment, transformation, and channeling. So let’s begin with
technological expansion. To combat the opioid
crisis, enforcement agents have developed more
expansive toolkits for identifying and
punishing crime. Essentially, they’ve added
new dimensions to routine work without fundamentally
changing the work itself. There is a steep learning
curve for both investigators and prosecutors who are doing
cases against providers. PDMPs serve as
tools of efficiency. They help enforcement agents
identify problematic behaviors and decide which
people to target. To just give you a sense of
what the enforcement environment looks like, providers can be
investigated by a wide range of enforcement agencies. These include but are
not limited to the DEA– the DEA is a hybrid
organization. So they can go after providers
criminally with the goal of putting them in jail. They can also go after
them administratively. And when they do
that, they’re going after the DEA
registration number, which is what allows a provider to
either prescribe or dispense controlled substances. A second type of organization
is a professional board, so the Board of Medicine
or the Board of Pharmacy. These are organizations that
are responsible for licensing professionals. And so they can go after
them administratively. They can revoke or suspend
or discipline their license. And then third, you
have organizations that can go after
providers for fraud. Those are organizations like
Health and Human Services, Office of the Inspector
General at the federal level or Medicaid Fraud Control
Units at the state level. And so they can go after
these providers criminally, or they can seek to limit
their national provider identifier, which
is what allows them to bill government insurance. Any one of these cases
can be career-ending, and they often have
a domino effect. So if you lose your
medical license, you also lose your
DEA registration. But if you lose your
DEA registration, there’s a good
chance you’re also going to lose your license. And nobody is going to hire
you if you can’t prescribe controlled substances,
if you can’t bill government insurance. And so any of these
is really troubling. Providers that are navigating
thorny legal territory when making decisions
about opioid prescribing and dispensing– now, this requires some changes
for the investigators too. Many investigators who are used
to doing illicit drug cases suddenly find themselves
doing prescription drug cases. These aren’t about
illicit drugs. They’re about prescription
drugs being used illicitly. So investigators have to
develop new strategies. It’s not enough just to see
that somebody has OxyContin. You have to figure out
why they’re using it. It’s not enough to say that a
physician is selling OxyContin. You’ve got to figure
out why it’s being used. Eric, a police officer
in Southern California describes how he susses
out this information when he finds prescription drugs
during a traffic stop. He says, “You want
to nail them down and ask them, hey,
what drug is this? If they tell you
something bogus, be, like, OK, because their
defense is going to be, it was prescribed to me
legally by my doctor. You want to ask, well,
what’s your doctor’s name? They’re going to make it up. Oh, it’s Dr. Smith. Well, what we’re doctor
Smith’s directions? They’re going to say,
you know, I’m supposed to take it five times a day. Well, again, you’re locking
them into a statement. They’re going to
have to show you in court that Dr. Smith
prescribed them Vicodin where they’re supposed to
take it five times a day. And the jury is going to
see that, wow, he’s lying, he’s lying, he’s lying.” People who get medications
for chronic pain typically know their doctor,
they know their pharmacy, they know the instructions
for how they’re supposed to be taking these medications. By contrast, people who have
substance use disorders or who are diverting drugs often get
drugs from multiple physicians and pharmacies. So they don’t know which bottle
the enforcement agent has in his hand, and that
makes it very hard for them to defend themselves. Cases against
providers are similarly complicated because
investigators can’t just show that the provider
sold the drug. They have to show that providers
are knowingly furnishing drugs with no legitimate
medical purpose. So how can investigators
show that providers are behaving inappropriately? Provider cases typically begin
in a reactive way in response to a report from
either an anonymous tip line, other providers,
neighbors, family members, or other agencies. Before the PDMP, law
enforcement might receive a tip. And so then they would look
at all of the pharmacies in the area surrounding a
particular physician’s office, and then they would
go from pharmacy to pharmacy to
pharmacy gathering all of the prescriptions that
this physician had written. Now you can imagine, this is a
very time-intensive strategy, and it yields
incomplete results. The PDMP makes this
a whole lot easier. Now, investigators can run
analysis on patient data and look for provider outliers. Mike, who’s a federal
agent in Missouri describes his strategy. He says, “I’ll just start
looking through that Excel spreadsheet,” which is
the PDMP, “and ordering it by different criteria. OK, well, how many people
with the same address are getting narcotics
prescriptions from the same practitioner? How many individuals are
getting just an obscene amount of oxycodone?” Once they identify
problematic trends, they use the PDMP report
like a treasure map to get the actual prescriptions
from the pharmacies. Like investigators, prosecutors
experienced a steep learning curve when they begin
doing doctor cases. As a result, many
prosecutors are hesitant to take on these cases. They’re long, they’re
resource-intensive, and they’re politically risky. For prosecutors who do
take on these cases, PDMPs are useful
because they help them to identify potential
witnesses in provider cases. Jack, a prosecutor
in California who had done multiple
investigations of physicians describes how he’s
used the PDMP. He says, “We were looking
for potential witnesses who could explain to us what went
on in this physician’s business. So I looked at CURES.” CURES is California’s PDMP. “And I’m, like, I’m going
to find every person that was going to her for a
regular period of time and then dropped off. Why? Because either they died,
or they went to rehab. Because you don’t get 120
Vicodin for three years and then suddenly just stop. So I could have my investigating
officer run the names and say, hey, go out
and pound the pavement and see if these people
are willing to talk. And I think we got six or
seven former patients of hers who had gone into
rehab and who are now willing to be witnesses.” Technological
expansion, then, makes it easier for enforcement
agents to perform effectively and efficiently. And it facilitates
a second process that I call technological
encroachment. Technological encroachment
is the process by which big data surveillance
technology transports logics or ideals from
one field into another. Technological encroachment
has occurred in response to the overdose crisis
as hospitals, clinics, and pharmacies have
implemented PDMPs and have begun requiring health
care providers to use them. This is also a requirement
in some states at this point as well. But this technology does
more than inform health care providers about their patients’
drug acquisition behaviors. It carries with
it punitive logics that are typically associated
with criminal justice rather than health care. A helpful way to think about
technological encroachment is to envision a PDMP
as a Trojan horse. You have two fields, criminal
justice where the technology is constructed and
health care where the technology is implemented. Going with this metaphor,
the horse is the technology, and the Greeks are the
logic of criminal justice that are embedded
within the technology. When the Trojans–
health care leaders– wield this gigantic Trojan
horse within their walls, they don’t realize that this
beautiful symbol of victory is accompanied by Greeks
who want to kill them. Now this is where the
metaphor breaks down a bit. The logics do not leap
out like Greek soldiers, but rather, reveal
themselves slowly over time through routine use of
this new technology. Technological encroachment
then is a hegemonic mechanism by which criminal
justice achieves dominance over health care. These criminal
justice logics become taken-for-granted elements
of health care practice. This results of a third
process, the transformation of the health care field. Pharmacy and medicine respond
to technological encroachment by reorienting themselves
around criminal justice logics of surveillance and punishment. Workers in both
fields begin to behave like hybrid medicolegal
agents as they engage in medical and
legal gatekeeping. This transformation is
evident in how providers shift their roles, routines,
and relationships, all of which are now suffused with
criminal justice logics. Providers use the PDMP to
assess whether the patient is struggling with a substance
use disorder, is in pain, or is diverting drugs. Physicians and
pharmacists are torn between two competing roles,
that of medical gatekeeper who is focused on an
individual patient’s health, and that of legal
gatekeeper, who is focused on
policing the patient in the name of public safety. PDMPs help providers
to adopt the trappings of legal gatekeeping, something
that pharmacists were far more comfortable with
starting in 2012 when PDMPs were widely
available then in 2009 when they were not. When I interviewed Sarah, a
chain pharmacist in California, she stated unequivocally, “I
am not in the police business. That’s the least
fun part of my job is feeling like
you’re a police.” Like many pharmacists
at that time, Sarah clearly defined
policing patients as outside of her
professional purview. By 2012, pharmacists
had grown far more accepting of the legal
gatekeeping role. In fact, many of
them considered it fundamental to their
professional practice. Kevin, an independent
pharmacist in South Florida explained, “I think
it’s an enforcement tool to find out a patient’s
history, something I never would have had access
to if I couldn’t see all the information on there. Most patients aren’t
going to tell you. They’re not going to give
you that information.” So the technology helps him
to engage in legal gatekeeping by providing him
with access to data that he would not
otherwise have. Medicine has undergone
a similar shift, but physicians often
reframe surveillance as part of treatment
rather than seeing it as part of enforcement. When I asked Blake, a pain
management physician in Kansas City if he considered
PDMPs enforcement tools, he replied, “I’m going to
call it monitoring and not prescribing to anyone
who’s abusing or misusing the medications
that I prescribe. If it were policing, I would
have a punishment rather than a withholding. Withholding a medication is
not putting somebody in jail. It’s not fining them. It’s withholding a
benefit that they may have received
if they had followed the prescribed regimen. So I’m not policing. I’m monitoring.” Physicians like
Blake resist the idea that they’re policing
patients and instead reframe their surveillance
actions to make them fit within
their schemas of what doctoring should look like. As providers embrace
new roles, PDMPs also help them to
incorporate surveillance into their daily routines. Pharmacists use red flags,
things like appearance and behavior, to determine
whether or not they’re going to dispense opioids. When they identify
red flags, they often opt out of dispensing. However, when they
have the PDMP, it changes how they
say no to the patient. Prior to the PDMP, pharmacists
took themselves out of the equation by saying that
the drug was out of stock. From the patient’s perspective,
an out of stock drug is one that a pharmacist can’t provide,
not one that they won’t. Pharmacists are
far more assertive when armed with a PDMP report. Laura, a California
chain pharmacist who I interviewed
in 2013 explains how she uses the PDMP data
to confront the patient. Before, it was more,
like, I’m not comfortable. Well, why aren’t
you comfortable? And now we’re, like, because
you went to these two other doctors, you filled it
at this independent pharmacy. You filled it at this
other retail pharmacy. And now I’d be, like, within 30
days, you filled 480 tablets. That’s a little too much. And now they’re, like, OK. However, sharing PDMP
information does more than simply reflect patients’ drug
acquisition patterns back to them. It also signals to the
patient that the pharmacist is monitoring them, that
they know where they’re getting drugs and how much. And it can be a
means of deterring patients who are getting drugs
for non-medical purposes. Compared to pharmacists
whose key enforcement tool is the PDMP,
physicians have options. PDMPs are part of an arsenal
of enforcement tools including pain contracts, urine drug
screens, and random pill counts. Pain contracts typically
confine patients to a single physician
and a single pharmacy and require patients to use only
those drugs that the doctor has prescribed. To ensure that patients are
adhering to the pain contract, physicians use PDMP reports
along with urine drug screens to corroborate or contradict
patients’ self-reported drug use. Josh, a physician and a leader
in a state medical association explains how he uses the PDMP
in conjunction with other tools. “OK, so I’ve given you five
prescriptions for opioids. Time to check the PDMP again. Oh, this is interesting. You filled opioids, but
we did a urine test, and there are no
opioids in your system. Or you can say, I gave you
these prescriptions, which should be enough for the pain
that we’ve discussed, yet, you’re in here after having
gone to three other physicians. So from a practice
standpoint, it can provide useful information,
particularly if the patient isn’t being honest.” Do you see how suspicious
these providers are of their patients? They’re thinking this patient’s
not giving me the information. This patient is not
being honest with me. Think about what that does to
the fiduciary relationship. Surveillance becomes part of
health care providers’ routines as they embrace legal
gatekeeping roles and employ technology
that renders surveillance easy and automatic. PDMPs also help
health care providers to re-imagine and reconstitute
relationships with one another and with law enforcement. Physicians and
pharmacists are positioned in the hierarchy
in which physicians exercised significantly
more formal power. However, the Controlled
Substances Act requires pharmacies to
make sure that physicians are prescribing appropriately. This can be a tricky obligation
to fulfill because pharmacists don’t normally have
access to information like the diagnosis
or the treatment. Prior to the PDMP,
pharmacists often encountered resistance
when they called physicians to discuss a prescription. Jim, a chain pharmacist
in northern California sighs as he tells
me, “Whenever I have to call to talk to a
doctor about a medication, they generally don’t
want to listen. Sometimes they say, I’m the
doctor, you’re the pharmacist, you do whatever I say.” Organizational
policies requiring PDMP use help pharmacists
to counteract resistance when calling physicians. Traci describes how this has
changed her interactions. “When my chain
implemented a checklist, physicians weren’t happy. They were, like, what is this? I’ve never seen this. Why are you asking
me so many questions. And basically, we’re
just, like, we needed to make sure the patients are– not legitimate, we
don’t use that word, but under the correct care. We just need everything
to be documented now. So now they’re
kind of used to it. But yeah, they were
pretty hostile.” Pharmacists circumvent
traditional power dynamics by using their store
policy and now state law to justify their need for
patient information while, at the same time, sending the
physicians subtle messages that they’re being
monitored and that their prescribing practices
might be a problem. Beyond re-situating
relationships between health care
providers, PDMPs also help create closer
relationships between providers and enforcement agents. PDMPs help to form an
alliance between pharmacists and enforcement agents. Prior to the PDMP,
pharmacists did not consider drug monitoring
part of their job. Recall Sarah who
stipulated that she was not in the police business. Even when pharmacists did try
to ally with law enforcement, they often had little to go
on, a gut feeling or a red flag or two, not really enough
to motivate law enforcement to take action. With the advent of the
PDMP, however, pharmacists conceive of their relationship
with law enforcement much more positively. For example Darryl, a
California chain pharmacist claims, “One of our
primary functions is we’re the drug controllers. So in truth, we’re
partners with the DEA because their whole
job is to control all of the drugs, the
legal and the non.” I don’t know about you. For me, it was very surprising
to hear pharmacists thinking about themselves as allies
with traditional enforcement agents like the DEA. Law enforcement agents
report similarly positive relationships with pharmacists. In fact, they
consider pharmacists some of their best sources
for initiating investigations. Joe, a California
Sheriff’s deputy told me, “We usually get our tips
from pharmacies when it comes to a patient, doctor-shopping. We arrested a lady recently who
went to 126 physicians in one year and got over
10,000 Dilaudid pills. The pharmacist said, hey,
I ran a CURES report when she came to fill the script. It’s out of control. You’re going to
need to look at her. So we did, and we arrested
her for doctor-shopping.” This suggests that
pharmacists are not only gatekeepers to
health care resources, but they’re also gatekeepers
to the criminal justice system, responsible for moving patients
along the treatment-to-prison pipeline. Physicians are a
different story. Even though physicians
have readily embraced enforcement
tools and logics, they have not equally
embraced enforcement agents. Physicians are aware of
potential enforcement action against them, and
they conduct their practices accordingly. However, physicians are far less
likely to report proactively contacting law enforcement
about their patients. When Blake described a patient
with a positive drug screen, I asked why he didn’t reach out
to the police or to the DEA. He responded, “If I see
a positive drug screen, I think that’s a medical issue. That’s between a doctor
and their patient. And I don’t think
it’s even legal for me to call law enforcement
to say, hey, this patient is doing this drug. I’m not calling law enforcement. I’m just no longer prescribing
if I suspect diversion.” Health care providers’ adoption
of enforcement activities paired with fortified
relationships between pharmacists
and enforcement agents raise questions about
what these changes mean for health care provision
and health care access. To understand
these implications, we turn to a fourth
process, channeling. Health care providers constantly
encounter patients struggling with pain and substance
use disorders, yet, they have received new
tools to surveil and punish, but not to treat those
under their care. Health care providers respond
to this treatment-poor enforcement-rich
environment by using the PDMP to channel patients
out of the health care system and into the criminal
justice system. In doing so, they
expose patients to cumulative
inequality, inequality that builds up over time within
and across the fields of health care and criminal justice. There are two types of
channeling, direct and indirect. Direct channeling is when health
care providers contact law enforcement about a patient. It’s relatively rare. Far more common is
indirect channeling. When providers refuse
to prescribe or dispense regulated prescription
drugs, they expose patients
who are physically dependent on those drugs to
dangerous, unregulated, illicit markets that carry a far
higher likelihood of injury and overdose. Providers are not exclusively
responsible for illicit drug use. I’m certainly not saying that. But by pushing patients out
of the health care system, they simultaneously nudge
them towards riskier markets while sacrificing an opportunity
to help a sick patient. PDMPs have been touted as health
care tools, ways for providers to identify and correct
risky patient behavior, but they’re rarely reduced
that way in practice. Instead, providers generally
use PDMPs to justify refusing to provide care. Pharmacists use PDMPs to
indirectly channel patients out of the health care system
and into criminal justice. Prior to the PDMP,
pharmacists made decisions based on their
interpretations of patients’ behavior and social cues. Today, pharmacists trust
PDMPs to accurately depict patient behavior,
so they use the PDMP data to refuse to dispense. Physicians engage in
channeling by setting restrictive standards for pain
patients under their care. The legalistic pain
contracts that physicians require pain patients to sign
subject them to regular drug screening. If prescribed drugs fail to
show up in the patient’s urine or if illicit drugs
appear, the physician has reasonable cause for
dismissing that patient from the practice. Collin, a primary care
physician in Missouri explains how he addresses
PDMP data with patients. He says, “I would
say, look, there’s pretty good evidence that you’re
seeing a lot of other doctors. And because of that, you’re
in violation of the contract we have with you. We just have to
investigate a little bit. But if they’re truly
shopping around, we say, look, don’t
want a part of this. I’ll see you for
your hypertension, and I’m not going to give
you opioids anymore.” Although physicians do not
always dismiss patients after a single infraction,
this possibility looms large for patients
under opioid care. Being dismissed from
a physician’s practice can have dire consequences. Patients on high
opioid doses struggle to find new providers due to
changes in the pain management landscape. Today’s physicians
who received training in the shadow of
the opioid crisis typically believe that
opioids are dangerous and that they
should only be used as drugs of the last resort. These physicians hesitate to
take so-called legacy patients, patients who have been
on high dose opioids for a prolonged period
of time, leaving these patients struggling
to find physicians who will treat them
without forcing them to taper their meds. For patients, tapering
can mean the difference between engaging
in daily activities and being immobilized by pain. Instead of channeling
patients suffering from pain and/or addiction into the health
care system, which providers are ill-equipped
to do, providers relinquish them to
unregulated markets, thereby, increasing the
likelihood of patient harm and entanglement with the
criminal justice system. This results in an exacerbated
form of cumulative inequality that carries across health
care and criminal justice and has different consequences
depending on the patient’s social position. It is well-documented
that race, class, and gender discrimination
limits access to pain medication and
addiction treatment. And these same forms
of discrimination shape the likelihood of
arrest for drug crimes, acceptance into diversionary
programs, like drug courts, length of sentencing, and
post-incarceration life chances. There are significant racial
and socioeconomic factors undergirding the opioid crisis. And poor people
and people of color are taking the brunt
of providers’ actions. In many ways, the opioid crisis
has turned professional worlds upside down, which
raises questions about who we want our
health care providers to be. If they attempt to embody both
punitive and healing roles, how might their
enforcement requirements impede their fiduciary
obligations to patients? The four processes
I’ve described here, technological expansion,
technological encroachment, transformation,
and channeling are part of the mechanism by which
social problems transform social fields, and by
which the opioid crisis is blurring the boundaries
between health care and criminal justice. Surveillance technology
exacerbates the criminalization process. As our world becomes
increasingly digitized and as big data surveillance
technologies become taken-for-granted aspects
of lived experience, surveillance facilitates
enormous potential for social control
and inequality. Sociologist Sarah
Brayne has demonstrated that the growing links speaking
between criminal justice and other social fields
results in system avoidance. That is, they’ve
motivated people to avoid social spaces
like hospitals, libraries, and welfare or offices
out of fear of arrest. This has devastating
implications for the urban poor
who already suffer from severe social inequities. So where do we go from here? To find meaningful and
effective solutions, we need to begin by
reframing the problem. Our leaders are treating
the opioid crisis as a medical problem and
creating policy solutions in the health care arena when
the actual problem extends far beyond the bounds of health care
and implicates a wide variety of social fields. Only when we account for
the nuances of drug use and the contours of
drug criminalization will we be able
to create policies geared towards meaningful
and sustainable solutions. To that end, I will conclude
with some concrete actions we can take. First, we should set boundaries
around how PDMP data is used. There are a wide
variety of stakeholders who see the potential utility
and profitability of PDMP data. Once created, a
database like this takes on a life of its own. So we need to put
safeguards in place to protect patient privacy
and limit the commodification of these systems. Second, we need to equip
health care providers with harm-reduction tools. If a person is drowning, and
somebody throws them a life preserver, they don’t stop to
think well, who threw that? Where did that life
preserver come from? Or is this really the
right life preserver? Or maybe I’m going to wait
for a better life preserver to come along before they
clean to it for dear life. Our health care
providers are drowning in the daily challenges
of the opioid crisis. And the only life
preserver that we have thrown them is a criminal
justice surveillance tool. We can do better than that. We need to expand our mental
health and substance use treatment infrastructures
by training physicians how to treat pain and
substance use disorders and expanding
Medicare and Medicaid. We can make better
use of pharmacists, our most available, the most
underutilized health care providers, by encouraging them
to take on the mantle of harm reduction and equipping
them with the resources to treat pain and addiction. Third, we need to
upend the practice of treating through crime
by re-centering health care and public health as the
pathways by which individuals struggling with substance use
disorder can get treatment. We need to establish direct
mechanisms of care provision that do not require
police involvement. For example, imagine a 911
for mental and public health emergencies staffed
by psychologists and social workers
that is incorporated into city and state
budgets and is not contingent upon grant funding. They’re already doing
things like this in Sweden. Finally, we need to target
the psychosocial factors that cause drug crises. Medicine and criminal
justice are vast fields, but they offer blunt tools for
addressing social problems, like homelessness, unemployment
and underemployment, educational inequality, domestic
violence, food insecurity, and hypersurveillance that
give rise to drug crises. Only by expanding
our social safety net and ensuring care
for all people can we hope to disrupt the
cycle of overdose and death. Law has a tendency to lag
behind social problems. Today’s lawmakers are so busy
litigating yesterday’s problems that they fail to plan for
the problems that lie ahead. And law moves slowly,
at a glacial pace, while social problems are adept
and adaptable, changing quickly and without warning. In a 20-year period,
the United States went from 17,000 overdose
deaths to over 70,000. In four short years, the
driver of these deaths went from prescription drugs, to
heroin, and synthetic fentanyl. Meanwhile, the victory
that we’re celebrating is over the
pharmaceutical industry. We’ve entered a new
chapter in our story. Purdue may have been vanquished,
but the social conditions, economic incentives,
and regulatory holes that facilitated its
rise to power persist. Today’s opioid crisis is little
more than the latest iteration in a cycle of moralized
racialized drug panics that have occurred
over the past century. Our myopic policy
approaches to drug crises make it impossible to escape
these cycles because funding is tied to specific drugs and
too narrowly defined outcomes. At the federal level,
there is an enormous wave of funding to address
the opioid crisis. But our crisis is not
about a class of drugs. It’s about tears in
our social fabric that leave gaping holes in resources
for marginalized communities and about the failure to address
the psychosocial underpinnings and rampant criminalization
of drug use. Instead of trying to
eradicate opioids, we must find a way to
dramatically reduce human suffering. Only then will we
truly break free. [MUSIC PLAYING]

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