The Prescription-to-Prison Pipeline: The Medicalization and Criminalization of Pain

Book Title: The Prescription-to-Prison Pipeline: The Medicalization and Criminalization of Pain

Author: Michelle Smirnova

Publication Details: Duke University Press, 2023, 158 pp., $24.95, paperback

In The Prescription-to-Prison Pipeline, Michelle Smirnova describes how nonmedical prescription drug use arises out of: (1) societal inequities in pain and access to health care, and (2) the medicalization of pain. She addresses the ramifications of this by considering the inequities in the legal system. Health equity has been defined as everyone having “a fair and just opportunity to be as healthy as possible.”² Professor Smirnova argues that the system has been neither fair nor just for many who have been caught at the intersection of the pharmaceuticalization of societal problems and criminalization of substance use behaviors.

By definition, health equity must remove obstacles to health (eg, poverty, discrimination, insufficient pay, inferior education, substandard housing, unsafe environments, and lack of access to health care).² Professor Smirnova disputes reframing such social problems as biological problems. She focuses on the complex issue of substance dependence as a societal, not an individual, failure. She describes the pipeline for individuals moving from prescribed use of medication, to nonmedical use of prescription drugs, and finally, to involvement in the justice system.

Michelle Smirnova is Associate Professor of Sociology and Affiliate Faculty of Race, Ethnicity, and Gender Studies at the University of Missouri-Kansas City. She bases the book on 40-minute interviews of 40 men and 40 women incarcerated in Missouri. She tells some of their stories to supplement her points.

After the author’s introduction of the topic, Chapter 1 describes the downside of medicalizing the problems of pain and addiction and the need to address these issues at the societal level rather than with the criminal justice system. Chapter 2 (“Prescription”) presents stories of those who were prescribed medication for problems rooted in the environment and who ultimately became involved in the justice system due to substance dependence. Chapter 3 (“Pipeline”) explores the inequities in the regulation of substances that impact who comes to the attention of the law for substance use problems. Chapter 4 (“Prison”) delineates the ways in which those who become incarcerated find their situations made much worse. In her concluding chapter, the author asserts the need to recognize the potential and real harms resulting from the medicalization process. She calls for reform of our health care and legal systems, which currently protect those in power while punishing those without power.

The strength of this book is in drawing attention to issues of inequity and how the medical and legal systems contribute to harming individuals rather than helping them. The author uses a wide angle to cover entrenched beliefs and policies at the heart of these problems. However, the book is repetitive in its arguments, the interview data are limited, and the author does not discuss the issues with a nuanced acknowledgment of the trade-offs in making policy changes. In contrast, the Appendix explores the ethical dilemma of whether her research harmed her subjects or gave voice to those who typically have none. This wrestling with benefit versus injury is precisely what physicians have to do with patients throughout each day. No matter what system is in place, clinicians and those working in the legal system must continually grapple with how best to help the person in front of them. Professor Smirnova takes a macro view of the issues but does not comment on the inherent compromises needing to occur given limited societal resources.

While the author’s call for more equitable structures, policies, and approaches should be taken seriously, there are details missing from her analysis of the problems and solutions are missing. How do we sort those who will benefit from medication from those who won’t? What do we do with those dependent on harmful substances when treatment and incarceration don’t work? How do we go about shifting American values from an individualistic culture to a more collectivist culture? Professor Smirnova’s goals are laudable, though, specific steps towards the goals are scant.

The Prescription-to-Prison Pipeline highlights ways in which inequity in medical and legal systems manifests in patients who develop substance use issues following being prescribed medicine. Knowledge of these forces and how they intersect fosters one’s commitment to changing them. The need is great and requires efforts in multiple sectors.³ Dismantling inequity is an enormous task. Both Michelle Smirnova and Don Berwick have assigned that job to all of us.