When I entered a tiny pharmacy 11 miles outside Jackson, Miss., in 2009, the pharmacist, Raymond Bauer, was distraught. Patients were coming “out of the woodwork” to fill opioid prescriptions written in other states. Mr. Bauer feared he was caught in a drug ring. “I’m getting prescriptions from clinics from Houston, Texas,” he said. “I’ve got people coming to this little podunk town from Louisiana by the dozens for thousands of units of hardened narcotics: oxycodone, other stuff, too.”
Mr. Bauer did everything he could to confirm that the prescriptions were legitimate. He called doctors to verify that they had written them. They had. He called the Texas Medical Board, the organization that licenses and disciplines physicians to check on the doctors’ standing, and eagerly awaited a response. “I’m hoping that the board says, ‘These guys are all clear.’” In the meantime, he had no idea what to do.
Pharmacists were among the first health care professionals to see signs of America’s impending opioid crisis. Years before soaring overdose rates made national news, pharmacists like Mr. Bauer faced an influx of patients who asked for early refills on painkillers, traveled long distances from their homes and paid in cash — all red flags for potential drug misuse. Patients claimed their filled opioid prescriptions were mysteriously lost or stolen, problems rarely seen with blood pressure or thyroid medication.
A more inconspicuous arm of the health care system than doctors and nurses, pharmacists are the ultimate gatekeepers to medications and devices. Some of these medications, like painkillers, testosterone for gender-affirming care and the abortion medication mifepristone, have become politically fraught. Ethically obligated to put patients first, pharmacists can refuse to dispense medications that they deem medically inappropriate — they are responsible for catching deadly medical errors like wrong drugs, incorrect doses or potentially dangerous drug interactions.
Pharmacists are trained to think in terms of medicine, but the opioid crisis pushed them to think in terms of crime. I spent a decade interviewing 170 pharmacists across the nation for my book on the opioid crisis. When I began my research in 2009, most pharmacists told me they resisted monitoring patients for criminal activity. Even though it was part of their job, they lacked proper training.
Today, however, pharmacists regularly police patients by reframing enforcement practices as care. One pharmacist told me that he now views his role as that of a gatekeeper, tasked with making sure patients are not misusing or selling drugs.
Three changes created this shift: Overdose deaths became a national crisis. Law enforcement agents grew more effective at targeting physicians and pharmacists they thought were over-providing opioids. And legislatures and pharmacies pressured pharmacists to use prescription drug monitoring programs, known as P.D.M.P.s, big data systems funded in part by the U.S. Department of Justice.
P.D.M.P.s are surveillance technologies initially created for law enforcement. They generally compile personally identifiable information about all controlled substances (not just opioids) dispensed to patients in a state and feed it back to law enforcement and health care providers. Law enforcement uses P.D.M.P.s to track physicians, pharmacists and patients, and health care providers use them to track medications patients receive. P.D.M.P.s lack privacy protections applied to other health care data.
Use of P.D.M.P.s changed pharmacists’ routines and relationships by incorporating surveillance into patient interactions. When pharmacists refuse to dispense opioids to patients who need them or call the police on patients, they route them toward illegal drug supplies or into law enforcement territory. The result: People with substance use disorders are dying at alarming rates, and some patients with untreated chronic pain are turning to suicide. Pharmacists protect themselves from becoming law enforcement’s targets, but they put their patients in harm’s way.
Before P.D.M.P. use became the norm, pharmacists decided whether to dispense medication based on patients’ behavior and appearance and their sense that something was amiss. Now, pharmacists use these same red flags to decide whether to check the P.D.M.P. database, and they are more willing to confront the patient with what they find. When declining to fill a prescription, some pharmacists cite information gleaned from the P.D.M.P., such as how many doctors the patient has seen and how many pills they received in a month. This information sends a clear message to patients: You are being watched.
The police call pharmacists, too. I found in my research that when police ask pharmacists to share the information, they often comply. Pharmacists may justify this practice as a form of care that keeps patients safe. But patients are not safe.
Overdose rates have skyrocketed, even though opioid prescribing has declined. Over 100,000 Americans overdose each year, most on illegal fentanyl. Chronic pain patients desperate for relief are easily mistaken for people who are misusing or selling drugs. When I asked pharmacists what resources they had to help people with opioid use disorders find treatment, they too often told me they had none.
Pharmacists have a critical role to play in stopping overdose. While pharmacists will always be required to make tough calls about dispensing opioids, there are actions they can take now to help patients and realign their profession with its stated goals.
Pharmacy leaders should stock the addiction medication buprenorphine (which is allowed in pharmacies, although many don’t carry it) and join the fight to put methadone in pharmacies (currently, the medication can only be provided in opioid treatment programs), as these are the most effective medications to treat opioid use disorder. They should also work with doctors and insurance companies to ensure that chronic pain patients receive access to care.
Pharmacies should also carry naloxone, the medication that reverses overdose, and provide sterile syringes to people who need them, which are harm reduction strategies that prevent death and injury. When it comes to prevention, pharmacists should support universal access to health care to help address problems before they spiral out of control.
We can’t police our way out of the opioid crisis. Pharmacists have much to offer patients who struggle with substance use disorders and chronic pain. They should expand their scope of practice into treatments where they can best uphold their ethical commitment to put patients first.
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