Points is excited to welcome Dr. Elizabeth Chiarello, Associate Professor of Sociology at St. Louis University, for an interview about her book Policing Patients: Treatment and Surveillance on the Frontlines of the Opioid Crisis. Policing Patients is a critical study on how logics of surveillance and punishment inform and often undermine medical practice in communities affected by the ongoing Opioid Crisis.
Please tell readers a little bit about yourself
I am a sociologist of medicine and law. I earned a Ph.D. in sociology from the University of California, Irvine where I studied social movement theory, organizational theory, law, and medicine. I also have a master’s degree in counseling psychology from the University of Oregon. I am really interested in how workers make decisions, especially how social, cultural, and political forces shape frontline decision-making in healthcare and criminal justice. Frontline workers like doctors, teachers, social workers, and police officers have a great deal of power over how resources and punishment are doled out in our society. Even though we tend to think about these workers as highly constrained by law and policy, too many restrictions can create contradictions that make room for discretion. I want to understand how workers use that discretion, how their choices affect patients, clients, and citizens, and how their decisions resolve or exacerbate social problems.
What got you interested in the history of alcohol, drugs, and pharmacy?
I wish I could tell you that this was all part of some grand career plan, but it happened entirely by accident. Shortly before I started graduate school at Irvine, I learned about pharmacists who were refusing to dispense emergency contraception. They called themselves “pharmacists of conscience” and claimed that they were refusing on moral grounds. They argued that they should have the same legal protections as doctors and nurses who have had “conscience clauses” that permit them to refuse to participate in an abortion. These pharmacists believed that emergency contraception was an abortifacient and fought for the same protections. I found myself troubled by their position. First, I wondered, “Who are pharmacists to refuse to dispense a medication that a physician prescribes?” Then, I thought, “Pharmacists are healthcare professionals whose work is grounded in science. Shouldn’t they have to accept scientific interpretations of how medications work?” (the medical definition of pregnancy is the implantation of a fertilized egg, but some religious groups believe that pregnancy begins at fertilization which makes a medication that expels a fertilized egg an abortion). Finally, I asked “Why isn’t everybody angry about this? Shouldn’t women be upset that pharmacists are making reproductive health decisions for them? Shouldn’t doctors be angry that pharmacists are impeding their ability to care for their patients?” It turns out that the instinctive questions I had were very sociological. I was asking about who has discretion and on what grounds, how conflict arises between professional, religious, and personal interpretations of medicine, and how power flows across medical hierarchies in ways that impact patients. I also wanted to know how medical, legal, fiscal, and moral factors shaped pharmacists’ choices. So I designed a project that compared pharmacists in different states with different laws, counties that leaned more liberal versus more conservative, and chain and independent pharmacies. But when I started interviewing pharmacists, I found that the primary thing they wanted to talk about was opioids. This was 2009, before the opioid crisis had fully reached the national agenda, so I was surprised, but I did what good researchers do: followed the data. And that is how I ended up a drug researcher.
What motivated you to write this book specifically?
After my Ph.D., I spent two years as a postdoctoral researcher at Princeton University where I had time to reflect on what I had learned and envision where my research should go next. By then, stories about the opioid crisis were splashed across every major newspaper and a narrative about the causes and consequences of the crisis was beginning to solidify. That is when I noticed that the fields of healthcare and criminal justice were coming together to tackle this crisis. As a sociologist of organizations, I found that surprising. These are different fields that attract different kinds of workers, operate under different logics, have different worldviews, use different kinds of resources, and aim to achieve different goals. Usually, these fields compete to claim social problems. That is evident in the processes of medicalization and criminalization. Alcoholism, for example, has been alternatively interpreted as “badness” (a moral failing or a crime) and as “sickness” (a disease). How the problem is defined affects which field takes it on and which field takes it on affects how it is defined and addressed. Both healthcare and criminal justice are hungry institutions eager to claim a variety of problems even if they don’t have solutions to them. But when it came to opioids, they were working together. I wanted to understand how (and if) those alliances worked. These fields were also sharing a surveillance technology—the prescription drug monitoring program (PDMPs)—state-level big data surveillance systems that tracked controlled substances (not just opioids). I wanted to understand how different fields used the same technology. So I designed a larger study that included physicians, law enforcement, and pharmacists across three states where the PDMP was located in a different place in the state bureaucracy—California, where it was in the Department of Justice, Florida, where it was in the Department of Health, and Missouri, the only state without a PDMP. I conducted 337 interviews (including the 95 I had conducted for my dissertation) using a maximum variation sampling strategy that I designed. The data I gathered was so rich, timely, and relevant that it clearly deserved a book-length treatment. I had never written a book before, but I was eager to communicate my findings in the accessible way that a book allows.
Explain your book in a way your bartender won't find boring.
There is a story that you have most certainly heard. It’s the one about how an evil drug company flooded our communities with dangerous opioids and got our friends and families hooked. Everybody knows that the opioid crisis started when Purdue Pharma peddled OxyContin, hoodwinked doctors into prescribing it, got patients hooked, and drove thousands of overdose deaths. But the author Chimamanda Ngozi Adichie tells us that there is danger in a single story.
It is not so much that a single story is wrong but that it is incomplete. When we zero in on a single story, we sacrifice complexity and context for simplicity and cohesion. A single story is dangerous because when we tell the wrong story, we arrive at the wrong solutions. Policing Patients tells a different story. It is the story about how efforts to stop the opioid crisis
have changed the very heart of healthcare. How people who go into the healing professions to treat patients have been forced to police them instead. It is a story about cops targeting doctors,
doctors acting like cops, and patients paying the price. I interviewed physicians, pharmacists, and enforcement agents and show how a “Trojan horse technology”—the prescription drug monitoring program—has enabled law enforcement to peer more deeply into healthcare practice and how the use of the same technology has helped to reorient physicians and pharmacists away from treatment and towards surveillance and punishment. The result? Patients have been thrust out of the healthcare system and into the most toxic drug supply this country has ever seen. I conclude with policy recommendations that would help expand providers’ capacity to care for their patients and would help route patients back into the healthcare system where they belong.
Did you uncover anything particularly interesting or surprising during your work on this project?
The most surprising thing was how readily healthcare providers embraced policing tools and policing practices. When I began researching pharmacists, they drew a clear distinction between medical gatekeeping and legal gatekeeping. They considered medical gatekeeping—making decisions based on medical science—their primary job. They were far more hesitant about legal gatekeeping—making decisions based on law. Pharmacists told me repeatedly “I am a healthcare provider, not a cop.” By the time I went back into the field a few years later, pharmacists had reframed policing and embraced it as part of patient care. They started to say that they were helping patients by surveilling them. The use of the PDMP—a law enforcement surveillance technology—helped foster this change. Without it, they were left with a set of red flags and gut feelings to determine whether patients were using opioids to treat pain, to feed an addiction, or to sell for profit. With it, they believed they had a much clearer understanding of what patients were doing. Under pressure from their employers to be efficient and pressure from law enforcement to be cautious, the PDMP enabled them to be both. The technology solved some problems for them, but they didn’t seem to understand how it created problems for the patient. It is hard to argue that surveilling patients and denying them care is good healthcare practice, but pharmacists somehow manage. I was also surprised to learn about how physicians use enforcement technologies. They use pain contracts that establish the rules of the game (most limit the patient to a single doctor and a single pharmacy and prohibit patients from going to the emergency department for pain relief); then they make sure that patients are following the rules by checking the PDMP and testing their urine. Some doctors go so far as to do random pill counts—they will tell the patient to show up at their office within 24 or 48 hours so they can count the number of pills remaining in their bottle. These behaviors more closely resemble those of a parole officer than a healthcare provider. It highlighted for me how much physicians and pharmacists have been pulled into the realm of law enforcement.
What do you think is the most important takeaway from your book?
There are two main takeaways. The first: Always look a gift horse in the mouth. I write about “Trojan horse technologies,” but the proverb has nothing to do with the Trojan horse. Horses grow more teeth over time, so their teeth indicate their age and, by extension, their value. A person who looks a gift horse in the mouth is ungrateful for the gift until they know how much it is worth. But imagine if the Trojans had looked their gift horse in the mouth, if they had mustered a healthy skepticism about this wooden symbol of victory. If they had asked who sent the horse, for what purpose, and, most importantly, what it contained inside. Healthcare is not alone in falling prey to the seduction of technology. Bright, shiny objects that promise to make tasks easier, fairer, and more efficient abound in education, criminal justice, and social services. Before accepting big tech’s claims, it would be wise to anticipate potential consequences of its use. There is good reason to expect technology to take on the flavor of the field in which it is used. The same technology could operate differently depending on whether it is placed in criminal justice or healthcare. However, Policing Patients shows that the use of a law enforcement surveillance technology in conjunction with other legal, political, and social pressures reshapes fundamental values and practices in medicine and pharmacy. Now that we have seen this play out, we can anticipate it in other fields, so leaders should explore all possible outcomes before inviting technology inside. That doesn’t mean they should reject technology altogether, but they should certainly put guardrails around how it is used.
The second is that targeting the healthcare system is not going to stop the overdose crisis. There was a time when overdose rates rose alongside prescribing rates. That has not been true for over a decade. Prescribing rates have gone down since 2012 while overdose rates have skyrocketed. If the answer to stopping overdose was cutting down prescribing, we would have solved the problem by now. Instead, not only are we losing more than 100,000 of our loved ones to overdose each year, but pain patients who have been tapered off of their medications and thrust into pain are resorting to suicide. Too many healthcare leaders have taken lowered prescribing rates as a measure of success. I think that University of Alabama physician Stefan Kertesz put it best when, in a critique of the Veterans Administration where he works, he said that by reducing opioid prescriptions, “We have not necessarily altered the course of death…but we have reduced the chance that we have touched the patient with a prescription before they are dead. Simply removing your fingerprints doesn’t make the patient more safe.” What we need instead are comprehensive solutions grounded in treatment, harm reduction, and prevention. The science is settled on many of these fronts. What is missing is the political will to implement what works and save lives.
Has this research led to your next endeavor—what else are you working on?
This project taught me that policed providers police patients. Fear of law enforcement motivates healthcare providers to protect themselves at the expense of patients. But how much do providers really know about law enforcement? To what extent is there a mismatch between the perceived and the actual enforcement environment? The healthcare providers I interviewed for Policing Patients had not been caught in law enforcement’s net, so their understanding of law enforcement was largely theoretical. I interviewed 94 enforcement agents who told me what they do at work. My next book project focuses on them. I will examine how they pursue providers, how different organizations work as allies and adversaries, and how different kinds of opioids including those used to treat pain and addiction are monitored. I also plan to interview physicians who have been arrested, incarcerated, and/or disciplined by medical boards to see how those targeted by law enforcement fare. Understanding the mechanisms of opioid enforcement will offer a framework for understanding other kinds of providers whose work is being criminalized today such as those who provide abortion, gender-affirming care, and in vitro fertilization. Healthcare providers are dancing on a shifting legal carpet. Before they surrender to their fears and hurt patients in the process, we must dig more deeply into how law enforcement works.
Based on your research and experience, what do you see as the future of the field (of alcohol, drugs, and pharmacy history)?
The future lies in synthesis. A lot of fantastic research traces the history of a single type or category of drug. My hope is that future work will do more to connect historical and contemporary treatment of different kinds of drugs. That is where sociological and socio-legal theory can make a difference. Theory about social movements, organizations, law, technology, and professions can serve as connective tissue that links seemingly disparate processes to each other. For example, how does the dynamic between the pain management movement and the harm reduction movement compare to the dynamic between the anti-abortion and abortion rights movements? How are laws designed to regulate drugs deemed dangerous such as opioids and benzodiazepines being used to regulate drugs deemed morally undesirable (by some) such as mifepristone? How do changes in legal regimes affect the way that healthcare professionals practice and how do they interpret and create law on the frontlines of care? Answering these kinds of questions promises to create a blueprint that can be used to analyze new cases, build new theoretical insights, and develop new pathways forward.