How Opiates Devastated the Heartland

Dreamland:  The True Tale of America’s Opiate Epidemic

by Sam Quinones

ISBN 978-1-62040-250-4  (Bloomsbury Press:  2015)

350 pages plus index

Many of us are puzzled, confused and stunned by the rapid expansion of addiction to pain-killing medicines that has swept across America in the 21st century. In a recent year, over 16,000 people died from overdoses of prescription pain-killing drugs – more than from all illegal drugs combined. We always thought that drug addiction was limited to big-city ghettos and Hollywood celebrities; heroin was virtually unknown across the heartland of America.  And yet, the reality today is that many small and mid-sized towns in America contain substantial populations who came to their addiction through entirely legal pain-killing medicines.  How could that have happened?

Sam Quinones answers that question with this gripping presentation of the intertwined pathways of prescription drugs and Mexican heroin. The subheading “true tale” indicates that the narrative is accurate, even if names and other details were changed. To assemble the information underlying this book, during 2009-2014 Quinones conducted many interviews across different segments of the population, including prisoners.

A cascade of short chapters skips from a Mexican mountain village to medical conferences to certain American cities, each bringing together one more piece of the puzzle. “Dreamland” is a fascinating page-turner, where at the end of each chapter the reader is anxious to find out what happened next.

On the medical side, we learn that in 1980, a one-paragraph letter in the New England Journal of Medicine reported that under close supervision, patients in hospitals found pain relief from oxycodone, without becoming addicted. Meanwhile, doctors had been searching for a non-addictive painkiller for a very long time, and desperately wanted to believe the R&D reports about such a drug. Subsequently, many doctors were easily convinced of the inflated claims by an unscrupulous pharmaceutical company.

At roughly the same time, a Mexican farming village became the source of Black Tar heroin; their remarkably simple retail operation, involving pellets of heroin inside small balloons, made heroin easy to obtain. If caught by the police, the couriers seemed to be in possession of very little heroin, hardly worth bothering with in circumstances where a big bust of the kingpins was the goal of the police. The story of those young Mexican entrepreneurs comprises a fair fraction of “Dreamland”; the story of law enforcement trying to understand and contain their spread is presented in parallel.

It is the confluence of those two advancing trends that brought about today’s epidemic. People who couldn’t imagine themselves as addicts became hooked on opioids (notably OxyContin) and were desperate for ever-greater amounts. Opioids became the “gateway” drug into using heroin.

All this is brought out with exceptional clarity in the pages of “Dreamland.” The title derives from a grand swimming pool in Portsmouth Ohio at mid-20th century. Recurring throughout the book are chapters displaying the progressive disintegration of Portsmouth as opiates became ever more commonplace. While the example of Portsmouth presents an egregious prototype, we learn that the same progression from prescription drugs to heroin was going on in countless other American towns.

Oxycodone is one of many opioids; hydrocodone is another. By coating oxycodone with a time-delaying shell, Purdue Pharma invented a continuous-release version of it, and gave it the brand name OxyContin. Then Purdue began a very aggressive marketing campaign, bringing doctors to conferences at fancy resorts to tell them how great OxyContin was. Extrapolating from very scant medical studies in the 1980s, they claimed that because of the slow time-release feature, OxyContin prevented the “high” associated with addictive drugs.

Since all doctors were wishing and hoping for a non-addictive pain reliever, it was fairly easy to make their case. When Purdue Pharma applied for approval to the US Food & Drug Administration (FDA), the assertion of only a 1% addiction rate was very persuasive. They didn’t mention that the favorable initial data was for patients in a hospital under supervision.

Believing Purdue’s claims, the FDA licensed Oxycontin in late 1995, and soon many doctors were routinely prescribing it for pain relief. “Dreamland” describes how it took a decade of adverse experience for the medical community to realize how addictive are the opioid medicines.

Once OxyContin was approved, countless millions of the pills were prescribed in the years that followed. Patients were given OxyContin for knee replacements, high school sports injuries, and other routine conditions. All sorts of abuses followed. Pill Mills were opened, where patients perfunctorily told a doctor they had pain, and in 3 minutes left with a prescription for Oxycontin – minus a several-hundred-dollar fee for the doctor visit, of course. Some of those doctors eventually went to jail. Senior citizens who had OxyContin they didn’t need could sell the pills for a dollar per milligram (a huge profit) to desperate addicts. In the deteriorating town of Portsmouth Ohio, OxyContin pills became a form of local currency, where a 30-milligram pill was equivalent to a $30 bill.

As thoroughly explained in “Dreamland,” a lot of people who got addicted to OxyContin switched to using Mexican black-tar heroin, which was plentiful and comparatively cheap. You could get it as easily as having a pizza delivered. The epidemic spread to suburbia and heartland America, far beyond the big urban centers where heroin had long been taken for granted.

There is plenty of blame to go around. Purdue Pharma succeeded in ballooning up unsubstantiated claims because too few people understand the way numbers and test results can be manipulated. For the deceitful way that Purdue Pharma had promoted OxyContin, they reached a plea-bargaining agreement to avoid jail time and paid a $634 million fine, circa 2013.

The porous nature of the US-Mexican border was taken for granted, barely even mentioned. The Mexican farmers and heroin couriers in American cities were operating under the radar of both law enforcement and the big-city drug cartels.

But most of all, it was the doctors who wanted to believe in a non-addictive pain killer that blinded them to the dangers of opioids. Not just the marginal sleazy doctors, but fully reputable doctors believed that opioids were safe. “Dreamland” recounts one incident where a young woman confronted a prominent doctor at a conference, saying “You killed my brother.”  Some years later, he recalled “My instructors told me that when you take opioids for pain you can’t become addicted because pain absorbs the euphoria. That was at Harvard Medical School. It was all rubbish, we all know now. Why do we listen to those messages? Because we wanted them to be true.”

Russell Portenoy, the doctor whose skimpy study of 38 patients in the 1980s became the scientific basis for believing that opioids were safe, was interviewed decades later by the Wall Street Journal and said "Did I teach about pain management, specifically about opioid therapy, in a way that reflects misinformation? Well, against the standards of 2012, I guess I did," Portenoy said. "We didn't know then what we know now."

Anyone who read the original medical-journal paper might easily have seen its inadequacy; regrettably, too many people didn’t check up, because they wanted to believe the result.

It’s sobering to realize how history repeats itself. A century ago, the synthetic pain killer heroin was sold over-the-counter; a Sherlock Holmes novel featured it. About 25 years elapsed until heroin was taken off the market. “Dreamland” describes events of recent decades, which led to an epidemic that is still with us today.

On one level, Sam Quinones chronicles the events of this debacle.  More important, on another level his strategy of having consecutive chapters take place in one or another location weaves together the total story into one coherent picture. That is what makes this book such a great read. The reader arrives at the final pages with an understanding of how it all fit together to bring about America’s worst drug epidemic.

While “Dreamland” is well documented and has an excellent index, Quinones avoids the pitfall of writing a scientific tome that few will read. Everyone who reads it will realize “this could happen right next door.” That shocking reality conveys urgency, and is what makes this book a page-turner, a “must read.”

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