The Brief

Elizabeth Amirault had never heard of a Narx Score. But she said she learned last year the tool had been used to track her medication use.

During an August 2022 visit to a hospital in Fort Wayne, Indiana, Amirault told a nurse practitioner she was in severe pain, she said. She received a puzzling response.

“Your Narx Score is so high, I can’t give you any narcotics,” she recalled the man saying, as she waited for an MRI before a hip replacement.

Tools like Narx Scores are used to help medical providers review controlled substance prescriptions. They influence, and can limit, the prescribing of painkillers, similar to a credit score influencing the terms of a loan. Narx Scores and an algorithm-generated overdose risk rating are produced by health care technology company Bamboo Health (formerly Appriss Health) in its NarxCare platform.

Such systems are designed to fight the nation’s opioid epidemic, which has led to an alarming number of overdose deaths. The platforms draw on data about prescriptions for controlled substances that states collect to identify patterns of potential problems involving patients and physicians. State and federal health agencies, law enforcement officials, and health care providers have enlisted these tools, but the mechanics behind the formulas used are generally not shared with the public.

Artificial intelligence is working its way into more parts of American life. As AI spreads within the health care landscape, it brings familiar concerns of bias and accuracy and whether government regulation can keep up with rapidly advancing technology.

The use of systems to analyze opioid-prescribing data has sparked questions over whether they have undergone enough independent testing outside of the companies that developed them, making it hard to know how they work.

Lacking the ability to see inside these systems leaves only clues to their potential impact. Some patients say they have been cut off from needed care. Some doctors say their ability to practice medicine has been unfairly threatened. Researchers warn that such technology — despite its benefits — can have unforeseen consequences if it improperly flags patients or doctors.

“We need to see what’s going on to make sure we’re not doing more harm than good,” said Jason Gibbons, a health economist at the Colorado School of Public Health at the University of Colorado’s Anschutz Medical Campus. “We’re concerned that it’s not working as intended, and it’s harming patients.”

Amirault, 34, said she has dealt for years with chronic pain from health conditions such as sciatica, degenerative disc disease, and avascular necrosis, which results from restricted blood supply to the bones.

The opioid Percocet offers her some relief. She’d been denied the medication before, but never had been told anything about a Narx Score, she said.

In a chronic pain support group on Facebook, she found others posting about NarxCare, which scores patients based on their supposed risk of prescription drug misuse. She’s convinced her ratings negatively influenced her care.

“Apparently being sick and having a bunch of surgeries and different doctors, all of that goes against me,” Amirault said.

Database-driven tracking has been linked to a decline in opioid prescriptions, but evidence is mixed on its impact on curbing the epidemic. Overdose deaths continue to plague the country, and patients like Amirault have said the monitoring systems leave them feeling stigmatized as well as cut off from pain relief.

The Centers for Disease Control and Prevention estimated that in 2021 about 52 million American adults suffered from chronic pain, and about 17 million people lived with pain so severe it limited their daily activities. To manage the pain, many use prescription opioids, which are tracked in nearly every state through electronic databases known as prescription drug monitoring programs (PDMPs).

The last state to adopt a program, Missouri, is still getting it up and running.

More than 40 states and territories use the technology from Bamboo Health to run PDMPs. That data can be fed into NarxCare, a separate suite of tools to help medical professionals make decisions. Hundreds of health care facilities and five of the top six major pharmacy retailers also use NarxCare, the company said.

The platform generates three Narx Scores based on a patient’s prescription activity involving narcotics, sedatives, and stimulants. A peer-reviewed study showed the “Narx Score metric could serve as a useful initial universal prescription opioid-risk screener.”

NarxCare’s algorithm-generated “Overdose Risk Score” draws on a patient’s medication information from PDMPs — such as the number of doctors writing prescriptions, the number of pharmacies used, and drug dosage — to help medical providers assess a patient’s risk of opioid overdose.

Bamboo Health did not share the specific formula behind the algorithm or address questions about the accuracy of its Overdose Risk Score but said it continues to review and validate the algorithm behind it, based on current overdose trends.

Guidance from the CDC advised clinicians to consult PDMP data before prescribing pain medications. But the agency warned that “special attention should be paid to ensure that PDMP information is not used in a way that is harmful to patients.”

This prescription-drug data has led patients to be dismissed from clinician practices, the CDC said, which could leave patients at risk of being untreated or undertreated for pain. The agency further warned that risk scores may be generated by “proprietary algorithms that are not publicly available” and could lead to biased results.

Bamboo Health said that NarxCare can show providers all of a patient’s scores on one screen, but that these tools should never replace decisions made by physicians.

Some patients say the tools have had an outsize impact on their treatment.

Bev Schechtman, 47, who lives in North Carolina, said she has occasionally used opioids to manage pain flare-ups from Crohn’s disease. As vice president of the Doctor Patient Forum, a chronic pain patient advocacy group, she said she has heard from others reporting medication access problems, many of which she worries are caused by red flags from databases.

“There’s a lot of patients cut off without medication,” according to Schechtman, who said some have turned to illicit sources when they can’t get their prescriptions. “Some patients say to us, ‘It’s either suicide or the streets.’”

Elizabeth Amirault of Indiana has dealt with chronic pain for years. She believes a tool that tracks her prescription drug use negatively influenced her ability to get the medication she needs.

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Nicholas Amirault

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The stakes are high for pain patients. Research shows rapid dose changes can increase the risk of withdrawal, depression, anxiety, and even suicide.

Some doctors who treat chronic pain patients say they, too, have been flagged by data systems and then lost their license to practice and were prosecuted.

Lesly Pompy, a pain medicine and addiction specialist in Monroe, Michigan, believes such systems were involved in a legal case against him.

His medical office was raided by a mix of local and federal law enforcement agencies in 2016 because of his patterns in prescribing pain medicine. A year after the raid, Pompy’s medical license was suspended. In 2018, he was indicted on charges of illegally distributing opioid pain medication and health care fraud.

“I knew I was taking care of patients in good faith,” he said. A federal jury in January acquitted him of all charges. He said he’s working to have his license restored.

One firm, Qlarant, a Maryland-based technology company, said it has developed algorithms “to identify questionable behavior patterns and interactions for controlled substances, and for opioids in particular,” involving medical providers.

The company, in an online brochure, said its “extensive government work” includes partnerships with state and federal enforcement entities such as the Department of Health and Human Services’ Office of Inspector General, the FBI, and the Drug Enforcement Administration.

In a promotional video, the company said its algorithms can “analyze a wide variety of data sources,” including court records, insurance claims, drug monitoring data, property records, and incarceration data to flag providers.

William Mapp, the company’s chief technology officer, stressed the final decision about what to do with that information is left up to people — not the algorithms.

Mapp said that “Qlarant’s algorithms are considered proprietary and our intellectual property” and that they have not been independently peer-reviewed.

“We do know that there’s going to be some percentage of error, and we try to let our customers know,” Mapp said. “It sucks when we get it wrong. But we’re constantly trying to get to that point where there are fewer things that are wrong.”

Prosecutions against doctors through the use of prescribing data have attracted the attention of the American Medical Association.

“These unknown and unreviewed algorithms have resulted in physicians having their prescribing privileges immediately suspended without due process or review by a state licensing board — often harming patients in pain because of delays and denials of care,” said Bobby Mukkamala, chair of the AMA’s Substance Use and Pain Care Task Force.

Even critics of drug-tracking systems and algorithms say there is a place for data and artificial intelligence systems in reducing the harms of the opioid crisis.

“It’s just a matter of making sure that the technology is working as intended,” said health economist Gibbons.

Voters on Saturday rejected a measure that would have weakened California’s landmark environmental law by fast-tracking reviews for some projects.

With about 76% of votes counted, voters rejected Prop. 45 by 55.7% to 44.3%.

The vote maintains the status quo under the state’s Environmental Quality Act, which since 1970 has required public agencies to review project developments that could have harmful environmental impacts, and mitigate those harms.

“Californians have sent a clear message to corporate developers, utilities and data center builders that they will not stand for a broad assault at the ballot box on state law protecting our air, water and natural resources,” No on 45’s Woody Little said. “We were outspent but not outgunned.”

Supporters had said the changes would reduce building costs. The California Chamber of Commerce sponsored Proposition 45, the Building an Affordable California Act, which would limit the length of environmental reviews for projects deemed “essential” to 365 business days and require courts to resolve litigation in 270 calendar days. Those projects include housing, water, broadband and transit developments.

Proponents said the savings from building more quickly would pass to consumers and spent $41 million campaigning for the measure. The Building a Better California political action committee was the largest donor, giving $10 million to the campaign. The organization is funded partly by current and former Google executives Sergey Brin and Eric Schmidt. Two of the largest investor-owned utilities, Pacific Gas & Electric Company and Southern California Edison, together donated $4.4 million.

Environmental groups argued the measure would go too far in weakening a law meant to protect people from environmental harms. Opponents, including a coalition of environmental, health and union organizations, spent $30 million trying to stop it. Wendy Schmidt, a Democratic philanthropist, was the largest donor, giving $10 million to the campaign. The political action committee Clean and Healthy California Sponsored by Environmental Organizations contributed $7 million.

The California Democratic Party opposed the measure. The California Republican Party supported it, while county Republican groups were split.

Deborah Sivas, an environmental law professor at Stanford University, said Prop. 45 would radically change current law. It would shift power “away from local governments and to developers by giving them some new tools … and limiting what courts can do in terms of reviewing decisions that agencies and local governments make,” she said.

CEQA and housing

California’s environmental review law, signed in 1970, requires agencies to assess the environmental impacts of developments and help mitigate them.

Over decades, developers have raised concerns about the process, arguing litigation and bureaucracy slow down construction.

State legislators have tried to fix the problem by passing laws that exempt or streamline certain projects from environmental review. In 2025, Gov. Gavin Newsom signed laws that exempt many urban housing projects from the full review process.

But some supporters of Prop. 45, including the California Building Industry Association and the California Council for Affordable Housing, say those changes don’t go far enough.

“It’s an important piece of the puzzle, but (that type of housing) does not produce quickly or at scale,” said Jennifer Hernandez, an attorney who helped write the measure. “We need quicker, at scale, affordable housing.”

Supporters say Prop. 45 would help California redevelop large, unused sites like malls and parking lots into housing and make it easier to build away from urban areas.

Pro-housing groups, public agencies divided 

Pro-housing and local government groups usually support CEQA reform, but Prop. 45 has divided many of them.

Housing advocates in the Bay Area, including East Bay for Everyone and the Greenbelt Alliance, oppose the measure. Other Yes in My Backyard groups are neutral, including Abundant Housing Los Angeles and both California YIMBY and YIMBY Action — the movement’s two flagship advocacy groups.

The split between pro-housing groups lies in whether California should keep building outward onto undeveloped land or promote construction in urban centers. Some supporters, including Oakland Democratic Assemblymember Buffy Wicks, have said the state needs all types of housing.

Others say building away from urban centers would make it harder to address climate change.

“We believe we can (and must) solve the housing and climate crises simultaneously. That means building communities with denser housing and alternatives to automobile dependence,” wrote Max Dubler of California YIMBY in a blog post explaining the group’s neutral stance on Prop. 45.

Public agencies and local governments that could benefit from the building rules were also divided.

The California Municipal Utilities Association opposes the measure. But most other groups representing local governments, including the League of California Cities and California State Association of Counties, remained neutral.

Financial impacts for Prop. 45

Prop. 45 supporters argued that streamlining development would make life more affordable for Californians, but the long-term financial benefits are unclear.

An analysis by Blue Sky Consulting Group, commissioned by the California Chamber of Commerce, estimated the measure would produce $1.5 billion in savings and additional revenues for public agencies over 10 years that would reduce overall housing costs.

But the measure would initially cost local governments and public agencies more as they adjust to the measure’s rules, according to the Legislative Analyst’s Office, a nonpartisan adviser to the Legislature.

Democrats have done well in recent elections when they win young voters by a margin of at least 20 points. On Tuesday, they carried Gen Z — those under 30 — by nearly 50 points, according to exit polling.

It's a stunning shift from 2024, when the party lost critical ground with young people. Long seen as a part of the Democratic base, voters under 30 shifted right towards Donald Trump, motivated by his pledge to better their economic prospects.

But this week, the youngest generation of voters issued a strong rebuke of Republicans, taking another chance on Democrats and their change-focused message at a moment when many of them feel as though the American Dream is out of reach.

How young voters powered Democrats to victory 

Americans ages 18-29 have a history of turning out at lower rates than older voters, and this year was no exception. Gen Z made up 11% of the total vote on Tuesday.

However, where young Americans may have made the greatest difference is on the margins in House and Senate races where Democrats flipped seats.

The Texas Senate race is a key example. Democrat James Talarico won the state by 12 percentage points; however, when looking at just Gen Z, he won it by 60 points.

Explaining the massive shift from 2024

When assessing gains more broadly, Democrats argue the party's strong slate of candidates helped drum up increased enthusiasm.

But another motivating factor remains strong opposition to Trump. Throughout his second term, Gen Z increasingly soured on the president, with some arguing he failed to make good on a number of core campaign promises — from pledging to lower prices and repeatedly vowing "no new wars," to calling for a crackdown on federal corruption and the release of the Epstein files.

Much of that disappointment was reflected in exit polling. Economic issues were the top concern for a plurality of 18- to 29-year-olds, at 43%, and these voters expressed broad frustrations with Trump's handling of the issue. More than eight in 10 said that Trump's policies have worsened economic conditions, with similar shares opposing his tariff strategy and the decision to go to war with Iran.

The young voters Trump lost

Early analysis from CIRCLE indicates that 15% of young people who backed Trump in 2024 voted for a Democratic House candidate in this year's midterms.

Democrats made gains with some young voters who backed Trump two years ago, including white men and Latino men, two blocs that narrowly voted Republican in 2024 and then voted blue on Tuesday by double digits. Democratic candidates also narrowed the margins with young rural voters and people without college degrees.  

Some of those gains may have been helped by young Trump voters who chose to sit this election out, but it's unclear how many of them there were.

How the election results broke down by age

The midterm results underscore how neither of the two major parties owns Gen Z, according to John Della Volpe, a left-leaning pollster who's extensively studied the politics of young Americans.

"The cohort of younger people in this cycle had a different set of experiences than the cohort of people two years ago, or four years before that," he said. "Every candidate, every party has to earn their votes."

Della Volpe, who runs the Harvard Youth Poll, notes that in the latest survey, released in October, there was a sizable enthusiasm gap between young Democrat and young Republican respondents. While half of Democrats said they definitely planned to vote, just a third of Republicans and less than a quarter of Independents said the same.

"I also think we shouldn't overread what's happened," he added. "Clearly a significant historic rebuke on the party in office — that's obvious — however, I think we need to more fully, kind of understand, the contour of the electorate, who showed up and who didn't show up."

By 2028, Gen Z and millennial voters will make up more than half of the electorate, a demographic shift with huge implications for Democrats and the GOP.

"Young adults can make a difference," said Elizabeth Matto, who serves as the director of the Center for Youth Political Participation at Rutgers University.

"They do care about politics. They can sway the outcome of elections. And they're a voting bloc worth paying attention to."
Copyright 2026 NPR

The morning after Tuesday's midterms was gloomy and rainy in Minneapolis, but people still gathered at the place where Border Patrol agents shot and killed Alex Pretti, a VA nurse and U.S. citizen, last January. All week, community members have come here to place their "I Voted" stickers at the memorial.

Nicki Adams, who dated Pretti and was his close friend for nearly 17 years, watched quietly as a woman added her sticker to a street lamp completely covered in the red decals.

"I wanted to see all the stickers. I just wanted to be here," she says. "It just means a lot to me. I think it would mean a lot to Alex, too."

A few blocks away, people left their stickers where an ICE officer killed Renee Good, a mom of three and a U.S. citizen, just a few weeks before Pretti's death. In Houston, they left them where an ICE officer killed Lorenzo Salgado Araujo, a father of three and a Mexican immigrant, in July.

Adams says these stickers, and the election results this week, send a clear message to Congress: "You work for us, and please carry on these values that we care about … We want to be seen and heard and taken care of and have our neighbors taken care of."

The deaths of Pretti and Good during the ICE surge in Minneapolis marked a pivotal moment for the country, sparking intense public backlash to President Trump's aggressive deportation efforts. But federal law enforcement officials have given little indication they're progressing in investigating their deaths, or the deaths of at least seven other people killed by federal immigration agents since Trump took office again last year. DHS did not respond to an NPR request for the status of those investigations.

Now, after Democrats' sweeping wins this week, their deaths at the hands of immigration agents will likely be the targets of renewed investigations. With a majority in Congress, Democrats can issue subpoenas to the major players in Trump's mass deportation plan, compelling them to testify under oath before the legislature.

That could include White House Border Czar Tom Homan, former Homeland Security Secretary Kristi Noem, former Border Patrol Commander Gregory Bovino, and White House Chief of Staff Stephen Miller, among others.

Congress can also demand internal documents, like use-of-force reports.

"They can dissect these individual shootings, and really unravel the story of what happened," says Naureen Shah, who leads the ACLU's immigration policy work.

Democrats have already held shadow hearings on the ICE shootings, during which they've called in family members and witnesses to testify.

But Shah says now Congress can ask key questions of top decision makers: What orders were given to immigration officers in the field? What was training like for these officers?

Who made the decision to paint Good and Pretti as threats, including calling Pretti a "would-be assassin" and a domestic terrorist, when video showed otherwise?

"It's like we can turn the faucet on and actually find out so much more," Shah says. "There's an aspect of this that is really about a kind of reckoning with how it's possible that things that seemed unthinkable could happen on American streets. How do you have that reckoning if you don't actually have the ability to force people to explain themselves?"

Democratic leaders have already said that's the plan.

Maryland Democratic Rep. Jamie Raskin, who is expected to lead the House Judiciary Committee, told NPR in a statement that Congress will use "every tool" at its disposal to investigate ICE and that it is time for the agency to "start answering to the American people."

California Democratic Rep. Robert Garcia, expected to lead the House Committee on Oversight and Government Reform, vowed to take on DHS and ICE abuses in a two-word statement: "Lawyer Up."

Mississippi Democratic Rep. Bennie Thompson, expected to lead the House Committee on Homeland Security, sent a letter on Wednesday to Homeland Security Secretary Markwayne Mullin, demanding the agency "comply with all document preservation requirements."

Illinois Democratic Rep. Delia Ramirez wrote on social media that Noem, Miller, Homan, Bovino and Mullin should "clear" their schedules.

In response to that, DHS general counsel James Percival said Democrats are "more interested in political shenanigans than in governing" but said the agency is prepared to "deal with this nonsense."

There are key limitations to what Democrats in Congress can do with their majority when it comes to ICE accountability, says Rachel Moran, a professor at the University of St. Thomas School of Law.

Major changes, like clawing back funding for the agency, would require a veto-proof majority, something the Democrats don't have.

"You still have a president who has shown a complete lack of interest in accountability for federal agents and in fact, a great deal of knee jerk defensiveness about their conduct," Moran says.

In a statement, a White House spokesperson told NPR "if Democrats choose to pursue sham investigations and radical left policies, they are choosing to work against the American people."

Democrats, the statement added, "should be reminded that we still control the federal government and all of its powers."

But that's not true. Congress has its own powers, one of them being the ability to compel testimony. Moran says a deeper probe into the shootings could still serve important purposes, like making evidence available for states to use in their own criminal investigations.

Minnesota officials, for instance, have been fighting with the federal government to get evidence related to the Pretti and Good killings.

Brent Ganger, Renee Good's brother, says learning more information about his sister's death will be hard to hear, "but I think it's also super important for us to understand what happened that day. I don't want history to keep repeating itself."

It was painful, he says, to watch immigration agents kill more people after his sister. He thought her death would be a turning point. In a way, it might have been the start of one. After the surge in Minneapolis, most Americans said ICE had gone too far.

Ganger, who considers himself a moderate, was happy to see the Blue Wave this week. On election night, he was scrolling Instagram when he saw a photo of his sister's memorial site, with all the "I Voted" stickers.

"I was very grateful to see the repudiation of this administration from the country. It felt very supportive of my entire family," he says.

The next morning, in his home in Colorado, he got up and made biscuits and gravy, his sister's favorite breakfast.
Copyright 2026 NPR

Abraham Zavala was born at Adventist White Memorial. So were his kids. So late Friday, when he heard federal immigration agents were at the Boyle Heights hospital, and that local youth were out blowing whistles to warn neighbors, he went. 

“To me that’s sacred ground,” said Zavala, an organizer with Unión del Barrio.

“I’m a dad,” he said. “I wanted to be there to support the youth.”

He was among the Boyle Heights residents who converged on the hospital and stayed in a standoff with federal immigration agents into the early hours of Saturday. Agents detained at least two people, according to rapid response groups.

Neighbors alerted each other with noisemakers and fireworks. A woman pounded her pots and pans. Teenagers ran across Mariachi Plaza, shouting that ICE was in the area and urging residents to lock their doors. 

“Even though we’re afraid, you know we’re still showing up,” said Myra Vasquez, a Boyle Heights resident who rushed to White Memorial after hearing reports of ICE in the area. “We’re not going to allow them to just come into our communities and terrorize us because they’re the real terrorists causing harm.”

Myra Vasquez, a Boyle Heights resident and co-owner of Espacio 1839 rushed to White Memorial after hearing reports of ICE.

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Alejandra Molina

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Boyle Heights Beat

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The confrontation peaked around 11:30 p.m. Video shared with Boyle Heights Beat shows agents pushing back protesters who had moved toward them, and the two sides begin shoving. Agents appear to pepper-spray people on the sidewalk. One agent then tackles a man and pins him to the ground, while a second person is pulled from the crowd. Both were detained.

The standoff continued past midnight. Zavala said agents got out of their vehicles and formed a line in front of the parking lot where paramedics enter, blocking an emergency exit. “They literally became White Memorial’s private security detail,” he said. Zavala said he and another person were sprayed with Mace.

Adventist Health White Memorial Hospital in Boyle Heights.

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Steve Saldivar

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The LA Local

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The Dept. of Homeland Security declined to comment about the incident in Boyle Heights, and, in a statement, the agency said they would “not disclose or discuss law enforcement operations.”

The spokesperson instead said that obstructing law enforcement is a federal crime.

“ICE does not target hospitals, schools, or churches,” the statement said, despite the large turnout of protesters who encountered the masked agents at the hospital.

Father Brendan Busse, who pastors nearby Dolores Mission Church in Boyle Heights, rushed to White Memorial after seeing reports from the Boyle Heights Immigrant Rights Network of ICE at the hospital.

Busse, a Jesuit priest, said he witnessed people caring for each other and tending to those suffering from pepper spray. People there advocated for them to find treatment at White Memorial, Busse said. Community members, he said, “were obviously doing their best, not just to communicate their feelings, but to push, to instigate the dispersal of this ICE presence.”

As clergy, Busse said their presence can help combat a narrative of those advocating for immigrants as “somehow dangerous, or violent, or vulgar.” 

“Just to be there is a sign that that’s not the only version of what this looks like,” he said.

Initially, Busse showed up wearing a hoodie, but he decided to change into his green stole he had in his car as things appeared to get tense. “Just try to do what I could to bring a presence of maybe a little moral authority,” he said.

“It’s bad enough that people have to lift up their voices to say something so obvious, that their lives matter, that our communities are sacred, that families belong together,” Busse said. “It’s bad enough that they have to be out at 3 a.m. in the morning to tell anybody that.”

“It’s even worse if they would have to suffer the consequences of retribution and violence that comes from speaking out in that way,” Busse added.

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