Abstract
The ongoing cultural, political, and linguistic shift from a moral toward a medical model of problematic substance use has often been framed as a victory by frontline workers, advocates, and individuals with lived and living experience: reframing from a deviant behavior, a choice made by accountable actors, a reckless and hedonistic obsession—corrected through punishment—to a disease, a health issue, a chronic condition requiring treatment and care. Recasting our actors as patients or clients rather than addicts or offenders suggests critical shifts in worthiness, deservingness, and culpability. However, as Michelle Smirnova argues in The Prescription-to-Prison Pipeline: The Medicalization and Criminalization of Pain, although this shift may look like progress on the surface, it is in many respects merely a costume change. The underlying structural assumptions, motivations, and eventual outcomes for individuals remain fundamentally the same.
The premise of Smirnova's “pipeline” begins with the social stratification of pain. Individuals of lower socioeconomic status are more likely to experience pain of all types: physical pain, associated with manual labor and low‐wage jobs; mental pain, resulting from the stress of managing multiple competing demands and barely getting by; the emotional pain of coping with trauma, grief, depression, and anxiety. Prescription medications are often offered readily to low‐income individuals, rather than more costly or time‐intensive treatments (e.g., talk therapy) or even services to address underlying causes of suffering (e.g., housing instability, un-/under-employment, lack of parental leave or affordable childcare). The author terms this quick‐fix approach as “pharmacological solutions for structural problems” (p. 58).
Not only do these “solutions” fail to resolve any underlying issues, but the resulting cultural reliance on prescription medications has created a nexus of power within the medical profession. As Smirnova argues, prescribers (e.g., doctors and psychiatrists) have exclusive authority to designate “legitimate” substance use and distinguish it from “misuse/abuse.” This distinction is particularly relevant for prescription drugs, which are often perceived as safer and less stigmatizing, despite their chemical similarity to illicitly produced and distributed substances (e.g., illicit methamphetamines and prescription medications to treat attention deficit disorders). Thus, the power of classification is retained by medical professionals, not individuals and their own embodied experiences of drugs as useful and effective.
Smirnova counters this narrative by highlighting stories and quotes gathered from research interviews with individuals incarcerated in Missouri prisons. However, these interviews also underscore the fact that the boundary between use and misuse can be blurred, such that some individuals who use substances to fulfill productive aims—stimulants taken by a college student to study for exams, or painkillers taken by a construction laborer who had a difficult day on a site—can be given a social “pass,” while other individuals are vilified and incarcerated. Even diagnostic criteria for a substance use disorder, as the author points out, are grounded in capitalist ideals of gainful employment and contribution to society, also common aims of treatment programs. Thus, “legitimate” use depends on who is using a substance—often including factors such as race and class—and to what end; in essence, who profits from its use.
Many of Smirnova's participants shared experiences of irresponsible or capricious prescribing practices by medical professionals and general mistrust of doctors. Nonetheless, lacking the power to question or object, they found themselves having to defer to medical authority for labeling of symptoms and guidance for treatment. This power structure thus traps individuals in a vicious cycle: one is required to receive a diagnosis for treatment services to be reimbursed, yet the chronicity of a substance use disorder diagnosis by definition suggests the expectation of relapse, much as the structure of the criminal legal system (in particular, community corrections and continued monitoring of individuals on probation or parole) includes an expectation of recidivism. In either case, these structures provide justification for surveillance and control and reify internalization of labeled identities as offenders and addicts.
On one hand, the perspective of substance use disorder as an objective, biological fact positions it outside of the actor's control: an incontrovertible genetic destiny, a “lifelong disease, not unlike diabetes or asthma, which runs the risk of relapse without proper maintenance and care” (p. 88). On the other hand, this also places the responsibility for disease management in the individual's hands (under supervision of qualified experts), aligning with the emphasis of many treatment programs on identifying faults, modifying behaviors, and surveilling other patients: the locus of the problem is within the individual, not the drugs. In fact, posits Smirnova, it is greater than either. Treatment programs too often fail to recognize the structural forces that contribute to a person's likelihood of using drugs or being arrested, instead blaming the individuals, who in turn are taught to shoulder the blame themselves.
Smirnova’s conceptualization of these twin systems of medicalization or pharmaceuticalization and criminalization as a “pipeline” funneling already‐marginalized citizens into systems of increasing surveillance and control is well researched, thorough, and incisive. The book constructs a compelling argument through synthesis of recent relevant theoretical and empirical works, but also by stepping back and allowing incarcerated individuals to share their own histories. Alongside strength and resilience, these stories also contain hurt and pain, and it is heartbreaking to hear participants blaming themselves, despite their situatedness—“trapped at the nexus of intersecting forms of inequality” (p. 23)—and the repeated failures of institutions and systems to provide meaningful supports.
Fortunately for readers who may find themselves outraged at these injustices, the book concludes with potential solutions. It is appropriate that the responsibility of righting these wrongs is placed at the policy and systems levels, given that the book endeavors to remove the onus of action from individuals and the drugs themselves, where blame has traditionally been laid. Specifically, the author suggests reinventing a health care system that provides meaningful, accessible, and affordable services; dismantling the punitive approach to substance use, which increases likelihood of fatalities, disenfranchises millions of citizens, and inculcates individuals with deeply internalized stigma; recognizing the racist, capitalist origins of the War on Drugs; understanding the pain of poverty and other forms of oppression; and accepting that substance use is a rational approach to pain, particularly in situations where the underlying conditions cannot be easily treated (whether these conditions are an individual's health or a broken social system). Smirnova's suggestions are ambitious, but apt.
I read The Prescription-to-Prison Pipeline as a sociologist and a substance use researcher, but also as a person in recovery from addiction (including to opioids) with a history of criminal‐legal system involvement. I had not previously had grounds to question the relative costs and benefits of the medicalization of problematic substance use, having personally benefited from both treatment and harm‐reduction services, but found nothing in Smirnova's argument that I could dispute, and a great deal that resonated with my lived experience. It is a work of thorough, balanced, but impassioned advocacy. However, short of the large‐scale systemic changes suggested in the conclusion—however appropriate those recommendations may be—I found myself wishing for more immediate, direct actions that might offer short‐term progress. If other readers find themselves galvanized to action as well, I appreciated Smirnova's final concluding recommendation: to amplify the voices of affected persons and to foster empathy and connection with impacted communities. It is a place to start.