Dreamland: The True Tale of America's Opiate Epidemic

Dreamland: The True Tale of America's Opiate Epidemic. By Sam Quinones. New York, NY: Bloomsbury Press, 2016, 384 pages, $12.23 on Amazon

Dreamland, by Sam Quinones, tells the intricate tale of the origins of the opioid crisis. The story begins in 1980, when Dr. Herschel Jick reviewed the Boston University drug database and found that of almost 12,000 patients prescribed opioids in the hospital only 4 had become addicted. He described his findings with no information about doses, specific opioids, or type of pain being treated. A graduate student named Jane Porter assisted with some calculations and sent a letter to the editor entitled Addiction Rare in Patients Treated with Narcotics. The letter was published in the New England Journal of Medicine on January 10, 1980. This article, which later became known simply as “Porter and Jick,” was cited countless times. Later that year, the World Health Organization stated that freedom from pain was a “universal human right.”

Although the tide was turning, the pain revolution did not really begin until the mid-1980s. During this time, leaders in the field of pain medicine became speakers for companies such as Purdue Pharmaceuticals, the makers of OxyContin. These clinicians traveled around the country promoting opioids such as OxyContin and teaching countless physicians that opioids were less dangerous than what was once thought. Meanwhile, pharmaceutical sales representatives were trained to say that the pills were “virtually nonaddicting” and they caused addiction in “less than 1%” of patients. OxyContin became a household brand name. Purdue offered coupons to physicians so their patients could get free prescriptions. Doctors received OxyContin-branded hats, stuffed toys, and pens. By 1996, the President of the American Pain Society posited that pain should be the “fifth vital sign,” and in 1998, the Joint Commission agreed and began evaluating hospitals on their management of pain, the newest “vital sign.”

Perhaps the most shocking part of Dreamland is Quinones' account of the concurrent rise of the “Xalisco boys,” a heroin network that continues to operate in cells across the United States. The Xalisco boys found wealthy suburban opioid users in cities such as Portland, Denver, Minneapolis, Columbus, and Charlotte. They established a foothold by scoping out local methadone clinics and giving addicted patients business cards with free samples of heroin. Quinones' story emphasizes how pervasive the Xalisco network has become in the United States. Many readers may be surprised to learn that they likely live within a brief drive of a thriving heroin market.

A major revelatory point of the book is Quinones' observation that the opioid crisis is, in many ways, a cautionary tale of the convergence of medicine, addiction, and capitalism. OxyContin became a brand in a brand-driven culture. An economy grew up around OxyContin itself; in Portsmouth, Ohio, pills could reliably be sold for $1 per milligram. Pills became a currency and could be used to purchase anything, including cable TV, dentist visits, and diapers. Doctors profited via “pill mills.” One of the most famous pill mill operators, a family physician named Dr. David Procter, charged patients $200 for a three-minute appointment. He then prescribed the patient OxyContin and Valium in the same amounts for every visit, regardless of the condition being treated. In one year, he prescribed over 2.7 million pills. Heroin dealers found a huge population of pill users who could no longer afford their habit and were ready to save money by switching to heroin. The Xalisco boys used common business strategies such as just-in-time supply, customer satisfaction phone calls, and giving faithful customers discounted prices to build brand loyalty. As OxyContin became a recognizable brand to U.S. consumers, so did Xalisco black tar heroin, often with tragic consequences.

The more emotionally engaging sections of the book highlight Quinones' ability to tell the human story of the opioid crisis. Matt Schoonover of Columbus, Ohio was a gentle giant standing six feet six whose last birthday card to his mother said “I love you, mommy” just a few months before he died of a heroin overdose following a three-week stay in a rehab. Matt died at the age of 21 while his brother Myles was away at Yale earning a master's degree. Enrique, the son of a poor farmer from Xalisco, Nayarit, Mexico, grew up with no paved streets or electricity. He traveled to California with a dream of working for his uncles and making enough money to get married. At the age of 15, Enrique sold over $5,000 of heroin per day. He returned home to Xalisco with a brand-new pair of Levi's 501 jeans, a Beretta 9 mm gun, and 2,000 U.S. dollars. He married a wealthy girl in town, and just like that, heroin changed Enrique's life forever.

Quinones concludes the book with a political message, which is both thought-provoking and bitingly insightful. He says that the opioid story is really a story about the breakdown of U.S. social structure and values: “Heroin is, I believe, the final expression of values we have fostered for thirty-five years. It turns every addict into narcissistic, self-absorbed, solitary hyper-consumers. A life that finds opiates turns away from family and community and devotes itself entirely to self-gratification by buying and consuming one product—the drug that makes being alone not just all right, but preferable.” He concludes that if we hope to reverse the opioid crisis, we need to focus on our local communities, families, and faith-based groups. In many ways, Quinones is right. There is no one person or idea that will help us end the opioid crisis, but perhaps we can improve things together by speaking up when we worry about our friends and families, taking mindful care of our patients, and bearing witness to their stories.