In Policing Patients, Elizabeth Chiarello examines the role of prescription drug monitoring programmes (PDMPs) in the opioid crisis in the US, arguing that they transform healthcare into patient surveillance. Samuel DiBella takes issue with the book’s minimal inclusion of patient perspectives and its critique of tech solutions without adequately addressing deeper systemic problems.
Policing Patients: Treatment and Surveillance on the Frontlines of the Opioid Crisis. Elizabeth Chiarello. Princeton University Press. 2024.
The cover of Policing Patients shows row after row of little white pills with a rogue CCTV camera occupying one of the spots. In its diagnosis of an unending opioid crisis, the book outlines the promise made by this visual sleight of hand: sociologist Elizabeth Chiarello argues that healthcare professionals have swapped care out for a kind of carceral surveillance. Surveillance is, we know, both a popular metaphor and practice. The depth of her data and its comprehensive coverage of how US pharmacists, physicians, and police all now rely on prescription drug monitoring programmes (PDMPs) are breath-taking. But is the exchange Chiarello describes really happening? I found myself reading Policing Patients with the wrong kind of vigilant attention.
Pharmacists can refuse to fulfil scripts if they think someone is drug-seeking or if the script is fraudulent. That said, that’s a difficult call to make about a person and a document you’ve never seen before.
Years of research on pharmacists who deny opioid prescriptions to patients drew Chiarello’s attention to the quiet roll-out of prescription drug monitoring programmes (PDMPs). She set out to understand pharmacists’ often overlooked role in patient care and their fierce commitment to precision. She thought that contraceptive provision would be pharmacists’ biggest headache. Through a decade of hundreds interviews across eight states, she realised instead that it was patient addiction. Chiarello documented how, as a response to the opioid crisis, PDMPs had changed pharmacists’ relationship to prescription-holders. She points out how overprescription of opioids for chronic pain and other illnesses initially created the opioid crisis, by encouraging addiction among patients. That cause, however, has given clinicians the false impression that just reducing the prescription rate for opioids will end the crisis.
This emphasis on enforcement appears in how pharmacists fill prescriptions. As care providers, pharmacists can refuse to fulfil scripts if they think someone is drug-seeking or if the script is fraudulent. That said, that’s a difficult call to make about a person and a document you’ve never seen before. PDMPs, which monitor how and with whom patients seek to fulfil prescriptions, make the confusing question “Is this person a patient or an addict?” seem simple. PDMP data does not make a case alone, but they direct eyes towards patterns. They help healthcare workers determine what “looks suspicious,” which saves them time and doubt in their labour process. And with the prod of federal funding, PDMPs are now used across all kinds of law enforcement agencies and medical providers.
The history of patient discipline and professional control by doctors goes a long way to explain how compatible surveillance practices are with medical care.
Chiarello believes PDMPs have made medical workers surveil patients more – bringing law enforcement approaches into healthcare. Key to her argument is her concept of “Trojan Horse technologies”: PDMPs “usher enforcement logics into healthcare. Physicians and pharmacists who use them begin to accept policing patients as a core task, though they do not consider their actions policing.” According to her logic, because PDMPs were first used by law enforcement, they are infused with that profession’s values and practices.
Making patient behaviours more visible to healthcare workers does encourage scrutiny. But how Chiarello frames this practice is questionable. Throughout Policing Patients, she proposes a disciplinary alliance between sociologists and historians – better able to understand the subtle effects of new technologies than policymakers – to improve healthcare for patients. But her Trojan Horse model ignores a basic concepts in the history of technology: “interpretive flexibility.” As historians looked closer at how technologies are made and spread, they realised just how estranged new adoptions are from old uses. Often, the way a technology is used strays far from its intended design.
Patients themselves are conspicuously absent from this study.
In a recent history of medical mediation technologies The Doctor Who Wasn’t There, Jeremy A. Greene shows how medical adoption of the telephone in the 20th century became a means to tether doctors to patient care, even as they experimented with telephones as a tool for diagnosis. I don’t think, however, that the inventors and promoters of the telephone had the proletariansation of medical doctors in mind at all. Rather, Greene suggests, the common use of a technology is determined by the conditions where it is used, an extension of professional authority coupled with a loss of control of the conditions of their labour. The history of patient discipline and professional control by doctors goes a long way to explain how compatible surveillance practices are with medical care.
Patients themselves are conspicuously absent from this study. Chiarello claims the unhelped patients and addicts in the opioid crisis are central to her book, but we barely hear from them. She points out that increased surveillance of prescriptions can, on the one hand, deny pain medication from people suffering from chronic pain who need it and, on the other, prevent addicts from receiving the addiction treatment they actually need. Denying a prescription is a simple way for healthcare providers to make pain or addiction treatment another person’s problem. But the extended harm that could occur in either case, hinted at in a handful of patient narratives, is beyond the scope of Chiarello’s study.
If we return and try to extend Chiarello’s Trojan Horse metaphor, things get confused. The Trojan Horse was a deliberate attempt at sabotage. Nowhere in Policing Patients is that clear. Police officers themselves didn’t build the software of PDMPs (or if they did, that history is not present). Nor did they force healthcare providers to adopt them. These professions have been tied together by the technology itself and their shared need to deal with the law, without legal training. PDMPs remove the requirements of legal interpretation from their work – this is the backbite of Lawrence Lessig’s “Code is Law.”
In the last decade of “techlash,” academics have become comfortable in calling tech solutions what they are – crude profit-seeking tools that appear to solve complex social problems. Policing Patients is another example of this style of critique. Rather than suggesting an end to PDMPs or a change in professional standards, Chiarello wraps up her writing with a series of harm-reduction interventions that would actually begin to end the opioid crisis, like increasing funding for addiction treatment and the provisions and training for the overdose medication naloxone. But there’s a deeper problem.
Chiarello ends Policing Patients by reminding us to always look a gift horse in the mouth. What if we do? The tale of the Trojan Horse is a compelling warning about false gifts. For PDMPs and techno-utopian tools writ large, the Trojan Horse metaphor implies volition on the part of its promoters, and it requires a gullible populace. What if, rather, and as seems often to be the case, we are well warned, but the potential boons seem too great to ignore? What if we feel wise in ignoring any naysayers? New technologies will continue to produce disastrous social effects until we find ways to put them under more scrutiny before we put them into use.
Note: This review gives the views of the author and not the position of the LSE Review of Books blog, nor of the London School of Economics and Political Science.
Main image credit: photobyphotoboy on Shutterstock.
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