I probably wouldn’t have read Dreamlandif my daughter and son-in-law hadn’t given it to me when we had Easter dinner. After all, there has been nonstop coverage of the overdose deaths plaguing white America for several years, and I pretty much thought I knew it well enough—well enough to be disgusted that the attitude of official America had softened dramatically from the “get tough on drugs” approach that had locked up millions of urban African Americans to the “we need understanding and medical treatment” that had prevailed when the addict ghetto suddenly became white and suburban. But they did and I did, and now I think everyone else should—read the prizewinning 2015 book by Sam Quinones titled Dreamland, that is. It really is a gripping and infuriating tale of malfeasance, first by a medical community that adopted prescription opiates for pain with missionary-like blinders; then by the health care establishment that refused to pay for the full treatment for pain (psychologists, social workers etc.) that pain clinics recommended but only for pills; then by the pill-pushing pharmaceutical companies that cashed in on the bonanza without a care for the horror they were perpetrating but only for their profit; and finally by an American public whom success had schooled to expect quick technological fixes, especially for pain, any pain at all which, they thought, every American had a right to not ever suffer. All this, and more, is part of the true tale that Sam Quinones tells. It is essentially a tale with two major strands: in one, unscrupulous doctors operating “pill mills” write thousands of opioid prescriptions for people with nothing but a claim of pain (back pain, knee pain, any kind of pain), thus creating millions of addicts in suburban towns where none had existed before; and in the other, young men from a small area in western Mexico called Nayarit discover that the black tar heroin they can make from poppies nearby can be peddled in an entirely new, safe, and convenient way in small cities and suburbs in America.
Quinones begins his tale with the story from which his title comes, Dreamland. It was the name of a community pool in Portsmouth, an idyllic center of safety and pleasure for a suburban town in southern Ohio that used to be a main U.S. manufacturing center for shoes and shoelaces. Like other small Midwest factory towns, though, outsourcing to foreign countries with cheap labor killed the manufacturing, and killed Dreamland along with it. And it was in Portsmouth Ohio, along with nearby towns in Kentucky and West Virginia, that the opiate epidemic found a dispirited and dead-end population eager to be seduced out of its existential pain.
To understand how this could happen, Quinones takes us through the growth of the American pain revolution. He starts with the discovery of heroin in Germany in 1898 (the drug was actually first synthesized in London in 1874 as diacetylmorphine, but the Bayer chemist named Dreser who duplicated it in Germany called it heroin—from heroisch, German for “heroic.”) Though heroin was first believed to be non-addictive, regulators soon learned better, and its use in the United States was strictly controlled starting in 1914. Still, there continued to be people, particularly in big cities, who got hooked, and one of the treatments for such addicts was a substitute drug called methadone—with methadone clinics maintaining addicts in cities all across the country. The problem with these clinics was that they tried to limit addicts to doses of methadone that were too small, so addicts had to find their dope fix elsewhere. Now shift to the Nayarit-based (the municipality was Xalisco) dealers of black tar heroin, a form that is much less purified than regular street heroin, but also far more powerful—delivering 80 percent heroin compared to the usual street version at 10 or 15 percent. As Quinones puts it, the Xalisco Boys “discovered that methadone clinics were, in effect, game preserves” which provided one of their first footholds in American cities.
But then the pain revolution happened. It started in the 80s with well-meaning doctors seeking to provide mostly terminal cancer patients with pain relief. They called it ‘palliative care,’ essentially figuring that risking addiction ranked low on the ladder for someone who was dying soon anyway. This work was ‘helped’ when, in 1984, Purdue Frederick Pharmaceuticals came out with MS Contin, a timed-release morphine pill that would soon become OxyContin. Fitting perfectly with pain-management, the new pills “seemed far less addictive because through their timed-release formulas they eased relief out to the patient over many hours” (85); that is, addicts couldn’t get the big “rush” from a normal morphine hit. At about the same time, pain management organizations promoted the idea that “America was undertreating pain,” all kinds of pain, any kind of pain. State lawmakers followed suit, passing laws “exempting doctors from prosecution if they prescribed opiates for pain.” Things then grew like Topsy, with patients soon getting used to demanding drugs for pain (my own doctor in Pt Reyes, CA told me that to this day, even with all that is known about the opioid epidemic, his clinic sees patients literally demandingpain drugs from doctors); and, more important, doctors becoming convinced that these morphine-based painkillers were virtually non-addictivewhen used to treat pain. This latter idea stemmed from an alleged “report” in the New England Journal of Medicine by a doctor named Hershel Jick, which claimed that “less than one percent of patients treated with narcotics developed addictions to them.” Drug companies like Purdue producing timed-release opiates seized on this alleged “landmark report,” turned it into a “scientific study,” and promoted their pills as non-addictive, with most doctors quick to believe them. In truth, of course, the Porter & Jick “study” was merely a “one-paragraph letter to the editor” that commented specifically on the use of opiates with cancer patients under strict hospital supervisionwhere the danger of over-use was almost non-existent. But no one bothered to look up the research (there was none), and Purdue Pharma aggressively promoted the use of OxyContin for all kinds of pain relief, at the same time ridiculing the fear of patient addiction as “basically unwarranted.”
Now what you had in places like Portsmouth, OH were hordes of people looking for relief from their pain (from back pain to sports pain to post-operative pain to existential pain), and just as suddenly, scores of unscrupulous doctors setting themselves up in pain clinics to dispense prescriptions for OxyContin to anyone claiming to be in pain. Any kind of pain. All pain. The result was long lines outside these pain clinics, and beyond that, many now-unemployed people throughout Appalachia signing up for SSI (Supplemental Security Income), because with it they could get a Medicaid card that paid for their pain prescriptions. This Medicaid scam actually became a business for many; they would get their prescriptions filled for a $3 copay and sell the pills to those who had run out for up to $10,000 on the street. Some bright entrepreneurs actually took to driving carloads of pill seekers long distances to cheaper pill mills in Florida and elsewhere—anywhere that pills could be procured more cheaply—for a nice profit. By 2002, according to Quinones, OxyContin prescriptions for pain rose from 670,000 in 1997 to 6.2 million five years later. And of course, contrary to the claims by Purdue Pharma that the pills couldn’t be misused, addicts soon learned to crush the Oxy pill and snort it, or even liquefy it and inject it, thus “obtaining all twelve hours’ worth of oxycodone at once” (138).
The stage was now set for the Xalisco boys to expand their range to those towns outside the major urban centers, especially in the middle of the country, that had a growing supply of opiate users. And they did, moving operators to Portland, Cincinnnati, Las Vegas, Portsmouth, Charlotte, Nashville, and everywhere in between. Their appeal was, first, that their prices for their black tar heroin were so much cheaper than prescription pills (which could cost as much as $30 a pill). As Quinones puts it,
by 2011, you could buy fifteen balloons of potent Xalisco black tar heroin for a hundred dollars— $6.50 a dose, about the price of a pack of Marlboros—in Charlotte, NC, a town that barely knew the drug a few years before (229).
The second appeal was the delivery system. The Xalisco boys had early discovered that it was easy, in the suburbs, to set up personal delivery to addicts. All an addict had to do was call a cell phone number; the driver would deliver it in minutes to an agreed-upon place like a mall parking lot. And since the Mexican drivers were trained not to carry either weapons or excess dope but only five or six balloons with pellets of heroin inside that they carried in their mouths, they were almost never caught carrying heroin. If police came, they would simply swallow the balloons. Even when caught, their punishment was usually simple deportation, and another driver would soon replace them. The third appeal, of course, was the potency of their product. As noted above, black tar heroin was up to 80% pure. This was a boon at first, but then it had its negative effect: overdoses by addicts who were used to a far-less-potent hit.
It was the overdose deaths that began to alarm officials throughout the nation. Two government workers in Olympia WA, Jamie Mai and Dr. Gary Franklin, began to investigate the overdose deaths in their state and found they were increasing by alarming rates, and in tandem with the amount of opiates being prescribed, or rather “overprescribed.” When they published their results recommending strict prescribing limits for opiates, though, they were not greeted as heroes; rather Mai and Franklin were sued by a doctor named Merle Janes alleging that their opiate guidelines exhibited “an extreme anti-opioid discriminatory animus or zealotry known as Opiophobia” (234) that would corrupt the management of public health policy. Fortunately, Dr. Janes’s lawsuit was thrown out of court in 2011, and Washington state issued its guidelines, soon followed by several other states. But it had taken a long time, perhaps too long. In 2005, for example, an epidemiologist in the Ohio Department of Health noticed that not only were poisoning deaths in Ohio increasing alarmingly, but that most of them were drug overdoses. By 2007, further analysis revealed that drug overdose deaths in Ohio were about to, and did in 2008, “surpass fatal auto crashes as Ohio’s top cause of injury death” (249). This, again, corresponded with the amount of Oxycodone dispensed, which rose by almost 1,000 percent in Ohio between 1999 and 2008. Put another way, “the number of Ohioans who died from overdoses between 2003 and 2008 was 50% higher than the number of U.S. soldiers who died in the entire Iraq War” (250).
There is much more detail in this astonishing and infuriating book, but to bring it up to date, here are some facts about the state of the opioid crisis in the United States as of 2018. The U.S. is still, by far, “the leading prescriber of opioids in the world” (this and all subsequent quotes from Vox.com, 3.6.18, Ella Nielsen, “America’s opioid crisis has become an ‘epidemic of epidemics’”). Driven by the drugs named above, plus the powerful heroin synthetic, fentanyl, “drug overdoses claimed 64,000 lives in 2016 alone, more than the entire death toll during the Vietnam War.” And finally, because of intravenous drug use, “there are 40,000 to 50,000 new cases of bacterial endocarditis (infection from re-using unclean needles) in the U.S. each year” which cost “more than $120,000” apiece to treat. When added to the new cases of Hepatitis C from the same source, this amounts to what researchers now call a “syndemic,” or “multiple diseases feeding off one another.” The two Washington State researchers, Jaymie Mai and Gary Franklin put this another way, calling the opioid crisis “the worst man-made epidemic in history, made by organized medicine” (Quinones, 310).
One has to agree with this, and with Quinones, when he underscores Martin Adler’s (professor of pharmacology at Temple U) take on morphine as “a great metaphor for life.” Here’s how Adler puts it, referring to the perversion that prevailed for a time in the idea that pain was somehow to be exiled from human experience:
“The bad effects of morphine act to minimize the use of the drug, which is a good thing. There are people born without pain receptors. [Living without pain] is a horrible thing. They die young because pain is the greatest signaling mechanism we have” (313).
To attempt to take away that signaling mechanism, as American medicine tried to do, was more than a terrible blunder; it was a fundamental misunderstanding of life and the human organism— how it works and how it is designed to work.
Lawrence DiStasi
