Policing Patients offers an invaluable, deeply sociological, meticulously researched examination of the opioid crisis in the United States. Many authors wring their hands over one or another aspect of the opioid crisis – inadequate pain management for suffering patients, lack of treatment and/or inappropriate treatment for opioid addiction, overzealous pharmaceutical company marketing of opioids, physician-run “pill mills,” street sales of tainted drugs, and the criminal justice system’s often inept attempts to intervene. Chiarello’s systemic approach, in contrast, explains that the current disaster has been jointly produced by the pharmaceutical companies, hospital and pharmacy organizations, physicians, law enforcement agents, and pharmacists as they pursue their own goals and respond to changing pressures and opportunities. (Gathering information about such a varied group is a substantial achievement all on its own.)
To be sure, there have been some bad actors, but that’s not the main story. Instead, Chiarello describes the pressures that have led both doctors and pharmacists to practice defensively and shows how this change in orientation has contributed to the opioid crisis. Members of both professions have increasingly oriented to rules and guidelines, attempting to carry out their work in ways that decrease the likelihood of regulatory attention and lawsuits. That way of working does not always serve their patients, though, both because patients’ needs for and responses to opioids can be quite variable and because the social circumstances that shape their interactions with medical workers can also be quite variable. Chiarello acknowledges both social and biological variability, but goes further to show how and why the work of pain management and the prescribing and dispensing of opioids have changed in recent years.
Deftly weaving together accounts of the experiences of pharmacists, physicians, and enforcement agents, Chiarello offers a compelling explanation of how the introduction of surveillance technology (specifically, prescription drug monitoring programs, or PDMPs) modified the work practices and relationships of all three professions. Legally required to report dispensing data to this “Trojan horse technology,” pharmacists and physicians gradually came to embrace and consult PDMPs because of the benefits they brought. Rather than offering the white lie that the drugs were “out of stock” when they suspected that patients were misusing drugs, for instance, pharmacists could now consult PDMPs to confirm their suspicions that patients were receiving opioids from multiple sources. The substantial negative changes – that doctors are now more reluctant to care for patients with chronic pain or addictions – outweigh the more modest positive changes – that pharmacists now regularly solicit information from physicians. Given that chronic pain and addiction are both relatively new medical specialties – established in 1993 and 2015, respectively – one might have expected them to be hot new specialties rather than hot potatoes.
Because PDMPs are not designed to help with diagnosis and treatment, working with them gradually shifted the ethos of core professions. Pharmacists and doctors too easily lapsed into rigidly following rules that protected their professional licenses and their employers, forgetting that guidelines can and should be used more flexibly to promote patient welfare. Even when they might have been inclined to bend the rules, their employers often had policies that prohibited such exceptions. PDMPs may be the right tool for the surveillance, but they seem to be the wrong tool for caregiving.
Not everyone is mesmerized by the new tools and rules, though. Chiarello uses several exemplars to show that better ways of working are possible and can decrease the suffering of the patients with long-term pain or opioid dependency. Yet the complexity of the field means that well-meaning, devoted professionals face formidable barriers if drug stores, hospitals, insurers, and drug companies continue to promote rigid rules and defensive medicine.
This provocative, thoughtful book raises a host of interesting questions. Given space constraints, I briefly consider just four.
First, although Chiarello makes a convincing argument about the effect of the new tool, similar changes can be seen in other areas of medicine. That suggests that the PDMP may be an accelerator of a more general trend rather than something entirely new. Important as it is that we now treat some forms of disease and some forms of treatment as crimes, we have more generally come to rely on the legal system and a wide swath of non-medical entities to define disease, decide which treatments are appropriate, and sanction people who violate the rules. That suggests that the responses to the so-called opioid crisis that Chiarello analyses are but one instance, albeit an important one, of a larger phenomenon.
Second, although we may not want to leave medical matters entirely in the hands of physicians and pharmacists, we surely want to be exceedingly careful about who gets enlisted to help discipline and govern healthcare. Chiarello’s account shows why we don’t want the criminal justice system deciding what’s a disease and how it should be treated. But other examples – reproductive medicine, mental health, stingy provision of care for poor people – show the pitfalls of enlisting legislatures in medical decision-making. A core challenge here is that the new tracking tools – that Trojan horse PDMP, for instance – are too easily co-opted by corporate interests, including pharmaceutical companies, retail pharmacies, or hospitals, clinics, and doctors’ offices. There’s a learning curve in stealth technologies, as Chiarello points out. But some actors have more opportunity and incentive to learn than others, as sociolegal scholars (think Marc Galanter or Lauren Edelman) have noted. Over time, these repeat players, often large organizations, learn to use the rules to their advantage and are often able to create or shape the rules. When a new tool like the PDMP is introduced, then, it is not primarily individual physicians or pharmacists who are best placed to make the tool work for them. They learn more slowly and generally do not reap massive benefits. Rather, it’s the retail pharmacies and medical organizations who are their employers and the insurance companies who pay healthcare bills who are best placed to take advantage of what the new rules offer. So, yes, the involvement of the hideously punitive criminal justice system is a threat to good medical care. But a more complete analysis would put this in the context of sweeping legalization of healthcare (and other arenas), the unequal distributions of power and wealth, and the advantages that accrue to repeat players.
Third, the book does not ask why highly skilled professionals like pharmacists and physicians so quickly sacrifice their discretion. Discretion is generally considered, by both social scientists and professionals themselves, to be part and parcel of what it means to be a professional. Lengthy training programs, residencies, and apprenticeships prepare people to use their judgment on behalf of those they serve. If this is a hallmark of professional work – and indeed one of the things that lures people into these occupations – why are physicians and pharmacists not putting up a fight?
Finally, returning to the PDMP. Although Chiarello’s account is deeply disturbing, we might spend a moment admiring the accomplishments of this small Trojan horse and considering whether appropriately designed stealth technologies might foster better diagnosis and treatment rather than simply improving surveillance. How about Trojan horses that hold caregivers and their employers accountable for pursuing accurate diagnoses, providing good care, retaining their patients, and consulting other caregivers about how to care for patients with complex problems? One might think that was the job of entities like the Center for Medicare and Medicaid Services or public health departments. But that would require that the objective be better health rather than reduced cost, perhaps an unlikely goal in the current era. Nevertheless, learning to repurpose stealth technologies or using them as models for how to do something good is a worthy goal. And if they can be crafted as Trojan horses, perhaps clever actors might be able to sneak them inside the walls of healthcare organizations and insurers.
