In 1980, The World Health Organization declared “freedom from pain” to be a universal human right. Pharmaceutical companies, particularly in the US, capitalized upon this promise, offering patients chemical solutions to physical, emotional, and social problems. This effort proved successful. Between 2015 and 2016, almost half (45.8%) of the U.S. population had used a prescription drug in the past 30 days. Individuals have increasingly learned to cope with social problems with medical technologies such as prescription drugs.
And yet, those who use prescription drugs without a doctor’s oversight—nonmedically—run the risk of facing severe consequences, such as being labeled an addict and/or a criminal. These labels result in institutional punishment and control, including incarceration.
My new book The prescription-to-prison-pipeline tells the stories of eighty individuals who experienced such institutional consequences. Their experiences illustrate how medicalization and criminalization work together to produce and exacerbate inequalities along the lines of race, class, and gender. Rather than ameliorate endemic social problems, we see how medical and legal systems of classification and treatment often intensify the very issues they allege to address, especially by biologizing criminality.
Regulation of prescription drug use in the US is fraught with contradictions. For example, many licit prescription drugs are almost identical in chemical construction to other substances classified as illicit (for example, opium vs opioids, amphetamines vs methamphetamines). Prescription drug use is deemed legal and safe when used in certain contexts, but illegal in others. An individual can use a substance legally if prescribed it by a doctor, but if s/he continues to use that drug or obtains it from a source other than a doctor, it is illegal and punishable by law.
The same decade that the World Health Organization (WHO) declared “freedom from pain” as a universal human right, warranting liberal prescription of pain medication, the United States declared its “War on Drugs,” thereby criminalizing all other substance use. A drug is considered to be abused if one intends to use it for pleasure; however, opioids and other pharmaceutical drugs are designed specifically to activate endorphins or block the reuptake of serotonin—mechanisms to promote the biological production of pleasure. Finally, one who abuses a drug suffers from addiction— a medical condition that is genetically encoded in the brain and impossible to cure.
These contradictions are intentional. They position institutions and authorities to be the arbiters of truth and the associated consequences. People in power get to answer these questions and codify them in new laws, policies, and practices while those directly impacted by these decisions are rarely consulted in serious or meaningful ways.
As a result, the already disadvantaged—those experiencing trauma or abuse, mothers, people of color, the working-class, and poor—suffer even more under reductive and punitive systems of classification. Low-wage jobs often result in pain. There are many risk factors to such work, including physically strenuous labor, inflexible schedules, lack of paid sick leave or health insurance, and the need to work long hours (and often multiple jobs) to cover basic living expenses. Together, these factors increase the likelihood for negative health outcomes. They may also increase the likelihood of nonmedical prescription drug use and subsequent criminalization.
Such was the case for Aiden and Roger, two white men in their 50s who worked in construction most of their lives. Each had been prescribed pain pills after work-related injuries but continued using them to help sustain stamina. As Aiden described, “I’ve worked in asphalt for the last twenty years and it’s hot and it’s hard work. I don’t know, if you’ve had a long day and the next morning comes around pretty quick.” After a prescription for a back injury, he found other ways to get Vicodin “just to stay working… to stay medicated to stay working.”
Similarly, Roger worked “12-to-14-hour shifts lifting 5/8 inch-thick, 12-foot-long by four-foot-wide sheets of sheetrock all day long. It’s an amazingly hard job. It’s like 300 pounds apiece and I had to do it by myself.” He routinely came home from work physically exhausted, would go to bed early and wake up sore and in pain. Several times, he had materials such as sheet rock or metal beams drop on him at work. These incidents resulted in head trauma and concussions.
Like Aiden, Roger never complained about lingering symptoms, such as migraines and blurred vision for fear of losing his job. With only a high school degree, Roger felt that his job prospects were limited to manual labor. In order to make it work, he started taking “Ritalin, or the Adderalls.” It was like night and day. He described how “I’d take one, break it in half, and it’d get me through a 12-to-16-hour shift at work.” From his perspective, “the Adderall were really a necessary component… the job was beyond my physical capability, so I medicated to be able to perform.”
Of the 50 richest nations in the world, the US is the only country that does not provide universal healthcare coverage to its citizens. It’s also a place with a limited social safety net. As a result, people who work manual labor or jobs that involve repetitive motions, standing or sitting without reprieve, not only risk injury and chronic pain, but also are the least likely to have health insurance or access to preventative care. If they do become sick or injured, they risk losing their job, so many take their health into their own hands, self-medicating injuries and seeking out alternative ways to support their families.
Some employers even support this, going so far as to medicate employees on the job site to keep them from taking time off. Rachel, a 27-year-old white woman with some college education, describes how she was prescribed Percocet from a doctor at her workplace: “I used to work at this factory. I worked floor, the floor, 12 hours a day, 7 days a week. My legs and stuff would hurt a lot.” She explains how “You can get prescribed pills for working in them factories, because they know you’re standing on your feet every day. They prescribe you if it makes you be a better worker, but if you’re taking above what you’re supposed to take, which, most people end up having to anyways, it can mess you up at work.”
Rachel’s employer recognized that it was not sustainable to require employees to work 12-hour shifts on their feet 7 days a week. Employees were too tired and too prone to injury. However, instead of reducing hours and paying workers more, the employer decided that the solution was to medicate the injuries and medicate the exhaustion. The solution is simple—take a pill—rather than restructure the environment producing these harms.
Our medical and carceral systems not only takes this approach with work, but also with mothering, coping with abuse, trauma, or stress. Authorities of all kinds too often medicate or criminalize symptoms rather than addressing the underlying problems of structural inequalities and lack of social support.
In The prescription-to-prison-pipeline, I argue that that nonmedical prescription drug use and its treatment is in part the product of deeply flawed healthcare and carceral systems. While there are often well intentioned individuals who work in these fields, punitive approaches taken by these institutions exacerbate rather than remedy problems. Further, without addressing underlying structural problems—namely those created by poverty, racism, and heterosexism—these systems only intensify these harms. Drawing from the narratives of those incarcerated who used prescription drugs nonmedically, this book illustrates how they do so not only to cope with an unequal system, but also to resist institutions that classify, diagnose, treat, and punish.
Michelle Smirnova. The Prescription-to-Prison Pipeline: The Medicalization and Criminalization of Pain. Duke University Press 2023.