The House of Pain How the opioid epidemic threatens the United States.

Dreamland: The True Tale of America’s Opiate Epidemic

By Sam Quinones (2015, Bloomsbury Press) 369 pages including map, timeline, source notes and index

The heroin dealers of Dreamland, “the Xalisco Boys,” are unlike the legendary drug-pushing predators we have seen in the news, on TV, in the movies. They take orders by phone and deliver to the customer’s neighborhood, avoiding areas rung by gangs and rife with violence. They sell very pure, uncut product, give out free samples, offer discounts if you bring in new business. The Boys are marketers. 

A woman living 25 miles outside Columbus, Ohio, “hadn’t called to buy for three days.” A Xalisco Boy called her:

 

‘Señorita, why haven’t you been buying recently?’

‘I don’t have any money,’ she said.

He drove out to deliver fifty dollars’ worth of heroin to her, for which he required no payment. No, it’s free, he said.

‘He wanted me to keep using, and buying from him,’ she said. She did both.”

 

The story of this new breed of drug dealer, their origins in poverty-stricken Mexican ranchos, the economic and cultural motivations, their entry into the U.S. drug market and gradual honing of their successful strategy, and its devastating impact on cites and small towns in the American heartland is compelling enough. But Sam Quinones interweaves this narrative with multiple others: pharmaceutical drug marketing, chronic pain treatment, and prescription drug abuse. The result is a complex, fascinating and ultimately haunting book about a society betrayed by its fundamental trust in science and capitalism.

These narratives compel the reader’s interest, although the structure of the book sometimes makes them difficult to follow. Chapters about the development of pharmaceutical marketing practices and the problems of chronic pain patients alternate with Quinones’s vivid depictions of life in a group of small towns, ranchos, in the Mexican province of Nayarit. Quinones also narrates the careers of two dealers he talked with extensively, whom he names “Enrique” and “The Man,” and of several addicts who served as their guides and publicists. Also, although he tells the pain/opioid story well, he does not know the pain patients as intimately as he does the addicts and the drug-dealing Boys and he can not tell their stories as fully. But in tying together these many disparate events and bringing a clear light to bear on their interconnections, Dreamland represents a remarkable achievement.

Other treatment options, involving multidisciplinary or psychosocial care, took time, required patient investment, and were too often not covered by insurance. “[P]eople want simple solutions,” one pain specialist commented. “The commercial interests didn’t want to hear that” more complex treatment worked better for chronic pain patients. Beleaguered physicians began to use opioids more liberally; “nothing cuts short a patient visit like a prescription pad.”

Chronic pain affects some 100 million Americans and is estimated to cost $635 billion each year in medical treatment and lost productivity. Opioids–morphine, Vicodin, Percocet–are often effective treatment but until the 1980s, the fear of addiction limited their use except for acute pain of short duration and palliative care at the end of life. A decades-long effort at the National Institutes of Health to find “the Holy Grail,” a non-addictive analgesic for chronic pain, was unsuccessful. Researchers and physicians in the new pain management field, founded in the 1970s, began to champion the idea that opioids could be used safely for the chronic pain blighting the lives of so many patients.

This well-intentioned advocacy was based on very slender evidence. In 1980, Hershel Jick and Jane Porter wrote a one-paragraph letter to the New England Journal of Medicine, reporting only 4 cases of addiction among some 12,000 inpatients treated in Boston hospitals. Details about the patients’ diagnoses and dosages were unreported. This brief note was cited as “gospel,” as a “landmark study,” by champions of opioid therapy. The few studies done on outpatients were done without control groups, had few patients and were of limited duration. Yet this less-than-conclusive evidence was used to support the contention that chronic pain patients could be prescribed opioids without risk of addiction, abuse or overdose, that pain specialists today were “so much smarter than the doctors of many years ago.” Other treatment options, involving multidisciplinary or psychosocial care, took time, required patient investment, and were too often not covered by insurance. “[P]eople want simple solutions,” one pain specialist commented. “The commercial interests didn’t want to hear that” more complex treatment worked better for chronic pain patients. Beleaguered physicians began to use opioids more liberally; “nothing cuts short a patient visit like a prescription pad.”

Quinones’s counterpoint to this story traces the evolution of the “pill mill,” as unscrupulous or careless doctors began handing out scrips almost wholesale with little or no consultation, enabling patients who needed extra income to divert some of their supply to friends, family, or anyone with cash to pay for it. Unemployed workers in Rust Belt towns which had lost the factories that had supported families for generations and were now surviving on disability, and low-income seniors struggling to make ends meet on inadequate pensions or Social Security were ready customers for the pill mills. They sold or traded the meds to others to get the things they needed. “[Prescription medications] were an economic coping strategy for a lot of folks.”

At the same time, Purdue Pharma was preparing to launch its new slow-release oxycodone analgesic, Oxycontin. Quinones details the marketing strategies–educational conferences in resort locations, endless gifts and freebies to doctors, scientific handouts extolling the company’s drugs–developed by Purdue’s owner, Arthur Sackler; these practices have been described by Barry Meier in Pain Killer: A “Wonder” Drug’s Trail of Addiction and Death (2003) and Marcia Angell in The Truth About the Drug Companies: How They Deceive us and What To Do About it (2004), but not before creatively juxtaposed with the different, yet oddly resonant, tactics of street drug dealers. Purdue’s theme with Oxycontin, as reported by one of its sales managers, was that “it is ‘virtually’ non-addicting … It’s not right, but that’s what they told us to say.” Since Oxycontin released the active component over 12 hours, Purdue’s detail men explained, it was impossible for the patient to get high, to abuse the drug.

When Oxycontin came on the market in 1995, physicians already prepared to prescribe opioids for chronic pain saw the new pill as the long-sought holy grail.  And the prescription pill markets, the “junkie kingdoms” of the Midwest, had a new bestseller. Crush a few Oxys and concentrate the dose, and you could get a first-class high.

As Quinones recounts these events in medicine and pharmacology, in alternating chapters we read about the small-time Mexican dealers arriving from Najarit to sell their local black-tar heroin, first in Los Angeles, then expanding to other cities, moving East, avoiding the major metropolitan areas where drug traffic is controlled by violent gangs. The Xalisco Boys are polite, well-groomed, helpful, non-violent young men. They rarely carry more drugs than they can sell quickly. If they are arrested, they are usually just deported back to Mexico, and other young men quickly take their places. They learn to find potential customers outside methadone clinics, then use those addicts to lead them to other buyers. And when they reach Ohio, the eponymous “Dreamland,” they meet pill users who lead them to other pill users. Their heroin is cheaper than Oxy and much easier to get. “It was a good time to be a heroin dealer.”

The true horror of this epidemic only becomes clear when a few enterprising statisticians see the rising trends in overdoses and deaths. In Ohio alone, drug overdoses “surpass[ed] fatal auto crashes as [the] top cause of injury death” in 2007.  From 2003 to 2008, the number of people who died from overdoses in the state “was 50 percent higher than the number of U.S. soldiers who died in the entire Iraq war.”

Dreamland is a story of the American dream betraying itself. The Purdue salesmen, the pill mill doctors, the Xalisco Boys, the pain specialists, the insurance companies that cover medications but not multidisciplinary treatment, the addicts themselves, are all exemplars of our belief that American know-how and free enterprise will deliver quick solutions to any problem at an affordable price; it is all a matter of marketing the product at the right price.

Quinones offers some reasons for muted optimism at the end. State government and law enforcement become aware of the problem and begin taking action. Purdue executives wind up in court and the company is hit with a whopping fine. A few doctors develop better treatment approaches for young addicts. Rust Belt towns try to rebuild their economy and help their young people. Parents of young heroin victims spread the word and build networks to help the children of others. One of them feels that the antidote to heroin was not so much naloxone; it was community … ’Nobody can do it on their own.’”

But ultimately Dreamland is a story of the American dream betraying itself. The Purdue salesmen, the pill mill doctors, the Xalisco Boys, the pain specialists, the insurance companies that cover medications but not multidisciplinary treatment, the addicts themselves, are all exemplars of our belief that American know-how and free enterprise will deliver quick solutions to any problem at an affordable price; it is all a matter of marketing the product at the right price. But without a deeper consideration of costs and values, the price may turn out to be too high.

Read this book. You will see 21st-century America in a different light.