This. This book is one of the strong arguments for why I took on this crazy book project in the first place. I wanted to read things I’d never pick up otherwise…things I wouldn’t seek out on my own. Dreamland: The True Tale of America’s Opiate Epidemic by Sam Quinones, about the overlapping scourges of heroin and prescription-pill addiction, has been eye-opening.
Like everyone else, I’ve seen the headlines about America’s opiate troubles…but I’m sorry to say that I haven’t paid much attention. I don’t really have any skin in the game: To my knowledge, I don’t personally know anyone who has experienced opiate addiction. As heartbroken as I was when Prince died of an accidental opiate overdose in 2016, I guessed it was just another celebrity drug problem…not remotely understanding the myriad issues that play into it.
And God willing, I won’t ever experience opiate addiction, either for myself or for someone I care about. But this book, and the subsequent research it’s caused me to do, have convinced me to never say never. The truth is that many of us may be one bad car accident or slipped disc away from a very dangerous addiction to opiates…because information about who’s susceptible to opiate addiction and who’s not is sorely lacking, even now. An addiction epidemic is raging (just today there was an article in my local paper about how, for the first time ever, “drug abuse” has overtaken “neglect” as the number one reason why Minnesota children are being put into foster care); and opiates are still heavily prescribed…even though, to this day, according to Quinones, “…there is still no evidence of how many chronic-pain patients can be successfully treated with opiates without growing dependent, then addicted.” In other words, there’s little medical understanding of why some people can take opiates for pain and come off them with no trouble; and why others spiral into addiction.
What we do know is that opiates (illegal ones like morphine and heroin, and legal ones like oxycodone, and their derivatives) are, without a doubt, highly addictive. When taking them for routine pain, even some people who have never had any kind of addiction issues have reported the challenges of giving them up, due to their intense withdrawal effects and the extended withdrawal period they induce.
Dreamland describes the “perfect storm” that came together in the 1980s and 1990s to create the opiate crisis in America today. The chronology goes roughly like this:
- 1970s and ‘80s: A revolution in pain management develops, the thrust of which is that Americans have been suffering from a great deal of undiagnosed pain; and that human beings have the “right” to be pain-free.
- 1986: An influential paper is published in the journal Pain by two doctors advocating that opiates, previously used primarily to ease pain for cancer patients in the end stages of life, can and should now be used for a wider variety of chronic pain.
- 1980s and 1990s: A new kind of drug, black-tar heroin, emerges from Mexico, and spreads first to the San Fernando Valley. Throughout the ‘90s, it spreads across the American West and in 1998 jumps the Mississippi to land in Columbus, Ohio. This highly potent, inexpensive narcotic is marketed and distributed via a completely new trafficking system not unlike pizza delivery: efficient, inexpensive, and safe.
- 1996: Purdue Frederick, a pharmaceutical company in existence since the 1890s, releases OxyContin, considered the long-sought “Holy Grail” of medications: A pain reliever that wouldn’t cause addictions. Made of almost pure oxycodone (a semi-synthetic opioid derived from the opium poppy), OxyContin was marketed primarily for chronic-pain patients.
- 2008: Drug overdoses, mostly from opiates, surpass auto fatalities as the leading cause of accidental death in the United States.
The Xalisco Boys
Dreamland author Sam Quinones is a crime reporter by trade, and first stumbled upon this story through his research on the Xalisco Boys. This name makes them sound like a gang, but it wasn’t a name they gave themselves; merely the name a local Denver police officer coined to denote a nationwide, loosely-bound but highly organized conglomerate of young men exclusively from Xalisco, a small town in the very small and otherwise unknown and unremarkable Mexican state of Nayarit. Largely farm kids, the Xalisco Boys developed an ingenious drug-trafficking system in which marketing played the biggest role. Because this was an industry run almost entirely from one small town, the participants knew each other and (unlike previous American drug epidemics) didn’t see violence as an effective way to eliminate competition…so marketing became the tool by which individual operational cells made money.
Successful marketing techniques including recruiting new clients outside methadone clinics; giving free heroin to addicts just getting out of prison…Xalisco Boys even gave bonuses of free heroin to clients if they brought in additional customers. Most importantly, Xalisco Boys also prided themselves on being clean-cut, polite, and delivering excellent customer service. Where previously to obtain illegal drugs you might have to drive to a known crack house in a sketchy part of town, Xalisco Boys took calls and delivered drugs directly to you…on the closest street corner, to a hotel room, even to your home if need be. They were reliable, and because of the intense competition from other Xalisco drug cells, and the enormous supply, the heroin they supplied was extremely inexpensive.
Additionally and significantly, dispatchers and drivers were paid by salary–unheard-of in the world of narcotics trafficking. Since they got paid no matter how much they sold, unlike in other drug-trafficking systems, there was no need to “step on” the product (to increase the volume by diluting it). As a result, black-tar heroin from Mexico was significantly more potent than the powdered form of heroin police officers had been used to seeing. Street-level heroin had typically been about 12% pure. By the late ‘90s, cops all over the country were seeing heroin busts in which the heroin was as much as 80% pure.
Xalisco Boys had also figured out that large amounts of heroin and weapons were what most American cops were looking for. These were the things that constituted a “successful” drug bust by both police officers and U.S. narcotics agents. By ensuring, through their non-violent, individual-driver delivery system, that they would never be caught with either of those things, this vast drug network for many years ensured that their most serious consequence was typically deportation back to Mexico…and the organizational level of the system was such that they were replaced in a day, by other young, hungry men from Xalisco, with virtually no interruption of operations.
As fascinating as the story of the Xalisco Boys is, however, the even more fascinating story to me is the other side of opiate addiction that the story of Dreamland tells–the completely legal, medically-blessed side: the story of OxyContin.
All over the country, but especially in the heartland of Ohio, Indiana, Kentucky, and West Virginia–one of the areas of America hardest-hit by devastating recessions in the late ‘70s and early ‘80s–OxyContin hit like a tidal wave. It was marketed heavily, in the days when marketing drugs came with very few restrictions. Purdue Pharma sales staff sent doctors on vacations, treated docs to high-end steak dinners; made rah-rah videos not approved by the FDA before distribution (which was illegal). OxyContin was marketed as the “Holy Grail” of medications, one researchers had been searching for for decades: A pain reliever that was non-addictive. The FDA even approved a warning label for OxyContin allowing Purdue to claim that because of its time-release formula, OxyContin actually had a lower potential for abuse than other oxycodone products. It was believed that the drug’s time-release function would inhibit its ability to deliver the intense highs and lows normally associated with pure opiates. It was the only Schedule II narcotic ever allowed to make such a claim.
Ironically, OxyContin was actually the drug most able to encourage addiction because unlike previous pain relievers like Vicodin and Percocet, OxyContin (like black-tar heroin) was very pure. Vicodin, Percocet, and other drugs also contained acetaminophen or Tylenol, making it harder to extract the active ingredient. OxyContin, as pure oxycodone, could be crushed, liquefied, and injected with ease. Eventually, Purdue and three of its executives pleaded guilty to misdemeanor charges of false branding, and the company was fined $634 million.
The Pill Economy
In Portsmouth, Ohio–Ground Zero for the deadly combination of OxyContin prescriptions and black-tar heroin use–a number of different “pill mills” (cash-only pain clinics) opened and marketed OxyContin to addicts. A typical business model involved dealers who offered addicts a ride to a clinic (sometimes more than one in a day), and paid for their $250 visit. The addict would typically be prescribed 90 OxyContins and 120 generic oxycodone pills (considered a month’s supply), of which the dealer would take half in payment. The dealer then sold their 100 or so pills on the street for about $5,000. Needless to say, dealers, who usually weren’t users themselves, were at the top of this social caste system, and fed off the street rats who barely made it from month to month. (Sometimes, the relationship between street addicts and wealthy dealers grew to be something almost like sharecropping: Addicts might ask a dealer to front them pills to help them get through the month, and by the time their monthly appointment came around, they might owe almost everything they were to be prescribed.)
Eventually in Portsmouth, a kind of OxyContin “economy” developed. Dealers could (and did) buy cars with OxyContin pills. They bought refrigerators, DVD players, and kids’ school supplies. Many of these purchases happened via shoplifters, who stole things in high demand from the local Walmart, then sold them to dealers for pills in denominations of 15, 20, 30, and 80 mg. Prolific stealers could even take orders for certain in-demand items, say, for video-game consoles intended as Christmas presents.
In fact, Walmart helped make this drug economy possible. When Portsmouth’s main street had been booming with small businesses, it might have taken multiple visits to several different stores to shoplift all the things on your list…and you might have to contend with small-business owners who were a lot more invested in their business than your average Walmart manager. Walmart, with its poor wages (i.e. uninvested workforce), its lenient return policy (which let you “return” items you had stolen without needing to show a receipt, and get a giftcard in exchange), and its habit of employing elderly greeters who might not notice everything you’re leaving with, was the perfect enabler of this new economics.
The Xalisco Boys were a threat to middle America. OxyContin was a threat to middle America. But perhaps neither of these factors has mattered as much as the way Americans have evolved our understanding of how to manage pain. Would opiates have taken hold the way they have if it weren’t for our insistence on feeling no pain…?
REVOLUTION IN PAIN MANAGEMENT
How we treat pain in this country is a fascinating topic. According to Dreamland, the country’s first pain-management clinic had been started at the University of Washington in 1960. It took a multidisciplinary approach to pain: that pain was caused by many factors and thus needed to be treated in many different ways. A patient might see as many as 14 different specialists for their pain, who would put together a plan for therapy that could include occupational therapy, physical therapy, nutrition, exercise, even a social-work component. This approach was intensive and required the patient to do a lot of the work when they left, but it was effective.
According to Dr. John Loeser, a director of that first University of Washington pain-management center:
“We were trying to teach [patients] that they were the ones who controlled whether they were well or not well. The patient has to do the work. Chronic pain is more than something going wrong inside the person’s body. It always has social and psychological factors playing a role….there is a philosophy among many patients–’I’m entitled to be free of pain.’ People are entitled to health care. Health care should be a human right. Pain management must be a part of health care. But they are not entitled to pain relief. The physician may not be capable of providing them with pain relief. Some problems are not readily solvable. A patient is entitled to reasonable attempts to relieve the pain by reasonable means. You’re not entitled to pain relief any more than you’re entitled to happiness.
“But usually the patient says, ‘I come to you, the doctor. Fix me.’ They treat themselves like an automobile. People become believers in the philosophy that all I need is to go to my doctor and my doctor will tell me what the problem is. That attitude has been fostered by the medical community and Big Pharma. The population wants to be fixed overnight. This is the issue we addressed with chronic pain patients. They have to learn it’s their body, their pain, their health. The work is done by them.”
Over time, many such clinics followed this model…by 1998, there were over a thousand of them in the country. Remarkably, in the late ‘90s and early ‘00s this model crashed and burned in quite a spectacular fashion: Merely seven years later, only 85 such multidisciplinary pain clinics still existed nationwide. Why the abrupt change in how we thought about pain?
In the mid-1980s, a remarkable revolution began to take shape in American medicine. Pain came to be seen as something that people were entitled to be free from; something to avoid at all costs. Pain, in spite of being completely subjective and virtually impossible to accurately measure, began to be seen as “The Fifth Vital Sign,” and controlling it became a focus of many medical professionals. A perception rose of pain as a chronically undertreated condition of the American public.
At the same time that the field of pain management was growing and doctors began advocating “freedom from pain” as a universal human right, patients also were given much more control of their own medical treatment. On the surface, everyone would agree that more patient input to their own care is a good thing…but the results of that power may be concerning. Patients began to feel empowered to ask for doctors to “fix” their pain…and less desirous of putting the time and energy into lifestyle changes that required more work and discipline. It was in this environment that the search for the Holy Grail of medications intensified; OxyContin, the answer to that search, came out in 1996.
In addition, multidisciplinary pain clinics weren’t helped by the development of “managed care,” in the 1980s and ‘90s. Under managed care, insurance companies needed to cut costs, and started by reducing the kinds of services they’d pay for. They also negotiated lower fees with doctors. To make up the difference, primary-care doctors had to fit more patients into a day. When you combine this phenomenon with the fact that it actually took much more time with a patient to figure out if they were a good candidate for chronic-pain drugs, it’s not a recipe for success. These drugs were marketed primarily to primary-care physicians, who traditionally had little pain-management training. More than one study has shown that prescribing of all kinds rises as doctor visits shorten.
To add to the challenges, a common kind of patient survey during the 1990s became widely-used in hospitals that were anxious to gauge patient satisfaction with their doctors. As patient rights became paramount, the surveys took on greater significance, and doctors reluctant to write prescriptions for pain relief might score poorly, raising concerns for hospital administration. Medical professionals reported getting raises (or not) and keeping their jobs (or not) based on how happy their patients were…which might be very contingent on how much pain they had.
Unfortunately, many addiction specialists believe that the problem still hasn’t peaked. Drug overdoses have surpassed car accidents as America’s leading cause of fatalities–something unimaginable until a decade ago:
“This was a stunning moment in the history of U.S. public health. Since the rise of the automobile in America, vehicle accidents sat unassailed atop the list of causes of injury death in every state, and in the United States as whole. Now [the] numbers showed that would soon no longer be true in Ohio. And by the end of 2007, it wasn’t….Drug overdoses passed fatal vehicle accidents nationwide for the first time in 2008. But it happened first in Ohio, where two complementary opiate plagues met and gathered strength in the late 1990s: prescription painkillers, especially Purdue’s OxyContin, moving east to west; the Xalisco Boys’ black-tar heroin moving west to east.”
I realize that what I’ve basically been doing is summarizing this book for you…which in a way might be helpful, because this book does have some flaws, and one of them is unnecessary repetition. Maybe I’ve saved you some time here: “Katy Epler: She reads books so you don’t have to.”
And I know I’m going on and on (believe it or not, there’s so much more I could tell you, but I’m holding back). I guess I just found this book fascinating, and vitally important. For something I knew nothing about, and something that hasn’t affected me personally in any way, I find I’ve become kind of passionate about the subject of opiate abuse in America. In that way, maybe this book has been a little life-changing. Maybe there’s a bit of a “there but for the grace of God go I” feeling about it. With so little research into opiate addiction, who knows which of us might be susceptible if given the right conditions?
And more importantly, because this is an epidemic of young people who have largely gotten pills not through injuries or prescriptions but from friends and through casual social contacts…is there a way to change this pattern? What’s the antidote to addiction…or more precisely, maybe what I’m really asking is, What’s the preventative to addiction? I don’t see my kids becoming street-corner junkies, living out of cars…but none of these parents with dead kids did either. Dreamland inspired me to have a long, serious talk with my kids, currently ages 10 and 13, about the fact that drugs aren’t likely to find them through some stranger approaching them on the street. But drugs might find them–maybe not this year, but someday–through a friend at a party who says, “Hey, I heard these make you feel really good. You wanna try one with me?” It’s in the abstract for them now, but it’s a conversation we’ll keep having, regularly, throughout teenagerhood.
A quote from the father of a dead opiate addict interviewed in Dreamland haunts me. The young man, Matt Schoonover, had an upper middle-class upbringing; had jobs, friends. And he was a heroin addict. When he returned from rehab after three weeks, looking good, feeling well, ready to take on the world, his parents thought rehab had fixed their son. A day after returning from rehab, Matt was dead of a black-tar heroin overdose.
His parents, Paul and Ellen Schoonover, made it a mission to work on preventing this from happening to other people, and the research they undertook as part of that commitment helped them realize how very inadequately prepared most of us are for a loved one’s addiction problems: “[I]t takes two years for your dopamine receptors to start working naturally. Nobody told us that. We thought he was fixed because he was coming out of rehab. Kids aren’t fixed. It takes years of clean living to the point where they may–they may–have a chance. This is a lifelong battle. Had we known, we would never have let Matt alone those first few vulnerable days after rehab. We let him go alone that afternoon to Narcotics Anonymous, his first day out of rehab….He was going to play golf with his friend. Instead of making a right turn to go the meeting, he made a left turn and he’s buying drugs and dying. When you start into drugs, your emotional development gets stunted. Matt was 21, but he was at the maturity level of middle-teen years.”
And from Ellen, Matt’s mother: “There was so much evil in all of this. We will turn that into something good. We can embrace it and find meaning from Matt’s death.”
The author makes the argument that kids today are perhaps uniquely susceptible to drug use because of their high rate of isolation in car-dependent suburbs, and their low sense of self-esteem from having had their parents handle too many of their problems for them all their lives. Now, the phrase “low self-esteem” has become a kind of comical shorthand for an overprivileged, under-challenged whiner. BUT…there is truth to the fact that kids who aren’t confident in their decisions, in their abilities, are far more vulnerable to societal ills like drug and alcohol problems. Kids DO gain confidence from overcoming challenges and disappointments. Are too many parents shielding their kids from pain and difficulty, leaving kids vulnerable to feelings of inadequacy and incompetency?
The author compares this search for kids to have an emotionally pain-free life to that of adults trying to live physically pain-free. Much as those early pain clinics advocated taking personal responsibility for one’s own physical health and creating healthy physical habits, emotional health for kids can start with learning how to face age-appropriate challenges and overcoming them. Wanting to ensure that your kids don’t have to face emotional pain might start with parents arguing with a coach who told them their kid wasn’t good enough to make a sports team. If parents continue to “protect” their kids in this way–maybe challenging teachers over grades or achievements (something my own high-school teacher husband has experienced regularly), maybe paying for a parking ticket–this sheltering might eventually manifest itself in another trend we’re seeing more of: college students demanding “trigger warnings” for reading materials that might cause distress, or rioting against campus speakers they don’t agree with. Millennials get an unfair rap sometimes, but it’s possible that there is a worrisome fragility there–one, sadly, largely created and enabled by their parents.
In spite of the horrendous toll taken during the heroin epidemic of the last 20 or so years, the author had some positive points to make as well. Portsmouth, Ohio is rebounding from both the recession of the ‘80s and the drug scourge of the ‘90s. Recently, local citizens have rallied around one of the last remaining industries in the town to prevent it being moved to Honduras. New housing is being developed. And most importantly, Portsmouth is repositioning itself as a recovery center, helping addicts recover and build new lives. It makes sense: People in Portsmouth know more about drug abuse than almost any city in the country.
In addition to the slow successes coming to Portsmouth, there are signs of positive growth elsewhere:
- There is a remarkable shift happening for some politicians regarding prison and treatment of drug addicts. This is an especially surprising development in red states, and among Republican politicians…or maybe not. The author interviewed a drug-court judge in Tennessee who presides over the only drug court in American that is physically attached to a long-term residential drug treatment center. Judge Seth Norman spent most of the 1990s begging for support from the legislature, arguing that treatment is almost always cheaper, and more successful, than prison–an argument that fell on the deaf ears of state legislators who wanted to be perceived by red-state voters as “tough on crime.” Fifteen years later, however, lawmakers are quietly showing far more support for Norman’s ideas–when they’re not calling him to ask if he can intervene in the case of a nephew, a friend, a neighbor, who’s addicted to opiates. Since the opiate crisis is almost exclusively hitting rural and suburban white people, maybe their political leaders’ change of heart isn’t that surprising…and we’ll leave the question of where their compassion was for black, inner-city crack users and dealers in the late ‘80s and early ‘90s for another day.
- Many parents, previously terrified of revealing the shame of losing kids to drug addiction, are speaking up and shedding the stigma. Some who have opened up about the truth of their loss have found themselves hearing whispers of support, “my kid too,” and realizing that they’re not as alone as they thought. Organizations like “SOLACE” and “Tyler’s Light” in Ohio, and more recently Facebook pages like “Sharing Without Shame,” allow parents who have lost kids to work toward ensuring that those kids’ losses can be worth something. And parents with more recent losses can know they’re not alone.
- We are learning more about how addiction affects the brains and thought processes of its victims. Columbus, Ohio, addiction specialist Dr. Richard Whitney: “[Functional MRI scans] verified a lot of what we did intuitively. Once people get addicted they really lose the power of choice. It takes thirty to ninety days for the brain to heal enough to make decisions. Otherwise, it’s like putting a cast on a broken bone and expecting someone to run five miles. We have as good or better treatment results as they do for asthma or congestive heart failure–if we have the tools to work with. But people do not get enough treatment to get well. It’s as if we said you only get half the chemotherapy you need to treat your cancer. People wouldn’t stand for that.” Of course, Whitney also went on to say that insurance companies aren’t funding addiction treatment with enough duration and intensity because our society is not demanding it…so obviously, there’s still work to do.
- Little by little, attitudes toward addicts and addiction are slowly shifting. We are on our way to seeing it not as a failing, a personal weakness of some kind. We know now that addicts are not moral failures, deviants, and criminals, as we saw them for most of the 1900s. Instead, we are beginning to know addiction for the disease it is.
Interestingly, as I write this, just three days ago the family of singer Tom Petty received the results of his autopsy. They were gracious enough to share them with the public. In their words (in part):
“Our family sat together this morning with the Medical Examiner – Coroner’s office and we were informed of their final analysis that Tom Petty passed away due to an accidental drug overdose as a result of taking a variety of medications.
Unfortunately Tom’s body suffered from many serious ailments including emphysema, knee problems and most significantly a fractured hip.
Despite this painful injury he insisted on keeping his commitment to his fans and he toured for 53 dates with a fractured hip and, as he did, it worsened to a more serious injury.
On the day he died he was informed his hip had graduated to a full on break and it is our feeling that the pain was simply unbearable and was the cause for his over use of medication.
We knew before the report was shared with us that he was prescribed various pain medications for a multitude of issues including Fentanyl patches and we feel confident that this was, as the coroner found, an unfortunate accident.
As a family we recognize this report may spark a further discussion on the opioid crisis and we feel that it is a healthy and necessary discussion and we hope in some way this report can save lives. Many people who overdose begin with a legitimate injury or simply do not understand the potency and deadly nature of these medications.”
I so appreciate the candor and honesty with which Petty’s family is addressing this situation. Like the Schoonovers above, they are not ashamed or embarrassed about the true story of their loss. Indeed, they want it to be known, in the hope of helping others. It took Rock Hudson to help many Americans understand AIDS; now the stories of Prince and Tom Petty can help us understand the nature of painkiller addiction and how we think about and treat it.
Final words from Sam Quinones:
“Heroin is fearsome enough to force us to action. What it does to users, their families, and their neighborhoods is so harrowing that heroin reminds those who live through it of the ties that bind them to others–producing in some places the opposite of the isolation that that produces in users.
“So there are even times when I think I’m right–that perhaps heroin is the most important force for positive change in our country today.
“Anyway, after years of writing about it, that’s what I’d like to hope. And if it is, and for all it has taught us and forced us to recognize about ourselves and how we live, as one woman told me, ‘we may thank heroin some day.’”
Katy Epler is a writer, an historian, and a pop-culture enthusiast who is making her way through decades worth of Entertainment Weekly’s Best Books of the Year lists, and then representing them to us in a modern light. Contact her at firstname.lastname@example.org
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