Posts Tagged ‘Dreamland’

Book Review: “Dreamland: The True Tale of America’s Opiate Epidemic,” by Sam Quinones

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I’m happy to tell my readers of a great new book. Published in 2015, this book is about the pain pill epidemic in the U.S., and how black tar heroin from Mexico quietly filled the void when pain pills became less plentiful.

The story of how this nation found itself in the middle of an opioid addiction epidemic isn’t a new tale, but the scope of the story has rarely been told with the completeness found in this book. The author talked to, or attempted to talk to, key people in all the realms affected by addiction: pain management experts, drug company leaders, addicts, parents whose children died from opioid addiction, doctors who prescribed OxyContin, everyday members of drug rings, prominent leaders of drug rings, law enforcement personnel, and addiction treatment personnel.

This book covered the pain management movement of the late 20th century, and how pain management experts grossly underestimated the risks of prescribing opioids long-term for chronic pain. Those experts taught other doctors that the risk of triggering addiction was almost zero, and that physicians had an obligation to relieve pain in their patients. Pain was described as the “fifth vital sign,” with the implication that a patient’s reported pain level was as objective as their pulse, blood pressure, body temperature, and heart rate.

All of these recommendations were based on thin evidence. Some of the pain management experts were also employed by drug companies marketing powerful opioid pain relievers, creating at the least the appearance of a conflict of interest.

The author described the inappropriate marketing of pain medications in general, and then focused on Purdue Pharma’s criminally inaccurate promotion of OxyContin. Purdue taught its young and attractive drug representatives to say things about OxyContin that were not true. These drug reps pushed their product with fervor, using falsified material provided to them by their company (p. 265). Purdue wasn’t the only drug company to oversell its products, but they did the best job of it. Ultimately, their marketing strategy lead to a criminal case brought in Southwest Virginia, and resulted in Purdue Pharma, along with their three top executives, pleading guilty to a felony count of misbranding. They were ordered to pay a fine of $634.5 million…but the company’s profits have been estimate to exceed three billion dollars thus far.

For me, the most interesting part of the book described the Mexican drug dealers. In a relatively small, agricultural area of Mexico, sugar cane farmers switched to growing opium poppies. The crop was easier to harvest, and much more profitable. Then young men from the area were recruited to travel north to the U.S. to sell the semi-processed heroin known as black tar. This was not a centralized drug unit, but rather multiple small organizations of growers, transporters, and driver-salesmen. Many of these groups were from Xalisco, a city in the Mexico state of Nayarit.

Each group had a handful of drivers located in smaller U.S. cities, ready to deliver black tar heroin to young addicts who called them on the phone. By delivering the product, middle and upper class addicts didn’t have to travel to bad neighborhoods for their drug. The drivers carried only small amounts of black tar heroin with them, in balloons which they carried in their mouth. If stopped by the police, they could swallow the evidence. Even if they were caught, the amount of heroin was so small that they were only deported, not jailed.

The drivers-dealers didn’t use the product, so they weren’t tempted to dilute the product for personal use. Drivers were paid by the hour, so that also gave no financial incentive to dilute the product. These young Mexican men were polite, and taught to give the best possible customer service, to keep the business of the addicts. In fact, they frequently ran sales on their product, as an incentive for customer loyalty.

This heroin was cheap and potent. Opioid pain pill addicts who were desperate to avoid opioid withdrawal switched to heroin because they could get high with less money. Because the tar could be snorted, the stigma of IV use was avoided – at first. Ultimately as the addiction progressed, addicts who started using intranasally eventually switched to IV use.

Groups of heroin sellers competed with each other to sell the most heroin, but they didn’t engage in violence. Since they were all from the same relatively small area of Mexico, and violence in the U.S. would bring repercussions from relatives back home. The drivers delivering the product were cautioned to stay away from blacks, since the Mexicans believed blacks to be more violent.

Because these heroin-selling groups avoided all violence, they were able to concentrate of profits. They didn’t call attention to themselves, making it easier to pass under the radar of law enforcement.

Groups of heroin dealers from Nayarit settled in mid-sized cities. They avoided cities where established drug cartels controlled the sale of heroin, such as New York City, Los Angeles, Philadelphia, Baltimore, or Detroit, fearing there would be violence from the cartels. Instead, they settled into cities like Salt Lake City, Portland, Oregon; Columbus, Ohio; and Charlotte, NC. They needed cities where other Mexicans worked in order to blend in with the populace. The book tells of opioid addiction in Huntington, WVA; Denver, Colorado; Boise, Idaho; Santé Fe, New Mexico; Nashville, TN; and Myrtle Beach, South Carolina.

These Mexican farm boys returned home with money and spent ostentatiously in order to impress their neighbors and friends. They hired bands, threw parties, and built houses with the money they earned from selling heroin. In a relatively poor area, young men saw there was a way to make their fortunes, so recruiting new drivers wasn’t difficult. In fact, the supply appeared to be inexhaustible.

The author makes the point that all of this happened slowly and without much publicity, but I question this conclusion. He says that it was only when Phillip Seymour Hoffman died that the U.S. sat up and took notice.

Maybe I have a different view since I’ve been treating opioid addicts since 2001, and saw a rapid rise of opioid addiction in my state since then. At conferences we seem to talk little about anything else – but then, I go to Addiction Medicine conferences.

The book has its flaws. It was a little repetitive, and many chapters were short, giving the book a choppy feel, but this was because the author described events chronologically, and described what was happening in multiple areas to multiple people.

He described drug abuse in Portsmouth, Ohio, which he called the birthplace of the pill mill. I don’t agree with this. Ever since doctors could prescribe medications that caused euphoria, there have been pill mills. Sadly there are always a handful of unscrupulous doctors who prescribe freely to patients willing to pay. I don’t think Portsmouth was the location of the first pill mill, and sadly it won’t be the last.

The most distressing thing that I read was how the Mexican drug families would move into a new city and go to the methadone clinics to recruit its first customers. From there, word of mouth via the addict grapevine resulted in plentiful business for the Mexicans.

That’s appalling. I’m sure it seems like no big deal to people wanted to make money off of addicts, but to target people who are in treatment to get well, and then tempt them into a relapse…that is low down. The book also describes how drug rings would pay more attention to an addict if he said things about quitting heroin. The dealers would offer this person an exceptional deal to remain a customer.

I know this is good business. But this business breeds death and misery.

I struggle with how to provide security at opioid treatment programs. I don’t like it when an armed guard in the parking lot makes it feel like a police state, but then I want our facility to be safe, and free from interlopers such as these described in the book.

I was also disappointed about the lack of information about treatment. Granted, the title implies only coverage of how the opioid epidemic emerged and evolved, but it would have been nice to add even a small section to readers who are addicted themselves, or who have relatives who are addicted.

Aside from the few nit-picky flaws, this book is great – it’s well-written, informative, and entertaining. It’s one of the best books I’ve read about this country’s story of opioid addiction. It picks up where “Pain Killers,” by Barry Meier left off.

This book should be read by anyone interested in our pain pill epidemic. Addicts should read it so they can realize where their money goes. Families of addicts should read it to better understand the compulsion of addiction. Law enforcement personnel should read it to hear the stories of the addicts, and come to see them as people with a disease, not just as criminals. Every doctor should read it, to better understand risks to patients who are prescribed heavy opioids. Treatment center personnel should read it to get a better idea of the milieu of addiction in the U.S.

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