Increasingly punitive attempts to curb prescription drug misuse constitute an expansion of the “War on Drugs” into mainstream medicine, leaving frontline health care providers caught between competing institutional logics of treatment and punishment. This study brings an institutional approach to frontline work by empirically examining how pharmacists manage discrepant logics while deciding whether to provide abusable medications and devices. Analyses of semistructured interviews with seventy-one retail pharmacists in the United States reveal that pharmacists manage discrepant logics by engaging in two gatekeeping processes—medical and legal—that lend themselves to different identities, epistemologies, field foci, patterns of action, and interpersonal orientations. Pharmacists' decisions have implications for patients' access to care and exposure to the criminal justice system. Findings advance theories of frontline work by systematically examining the interplay between elements of institutional environments and decision making and yield policy considerations as states increasingly monitor patients and providers through prescription monitoring programs.