Sam Quinones's Blog, page 6

Can We Treat Our Way Out of This?

I was reading the obituary of a young woman named Isabella Sammartano from suburban St. Louis, Missouri, who died from a heroin overdose suddenly after being clean from opiates for 16 months.

Her obituary doesn’t provide a lot of detail, but it does provide some. It sounded as if she spent a lot of time in rehab, then relapsed each time. Finally, when she looked to be putting the worst behind her, she relapsed again and overdosed and died.[image error]

It’s an extraordinarily sad story – and it must have been very difficult for her parents to write the obituary.

It made me think of what her death can tell us. First, all addiction seems to involve relapse. I quit smoking (and started again) nine times before I finally quit for good – at 37.

But I lived through my cigarette relapses. With opiates, particularly given the amount of supply of dope on the street, getting out of treatment is like Russian Roulette. People go in, detox, get clean. Their tolerance to narcotics drops. They leave rehab and do well, then they relapse. With these drugs, and their prevalence and potency on the street, relapse too often means death.

It feels good to say, `We can’t arrest our way out of this.’ I agree. We do need expanded treatment. But, frankly, that also feels too easy.

My feeling is, when it comes to opiates, we have to arrest our way out of this before we can treat our way out of it. That’s a bit discombobulated, I know. What I mean is that we need to address supply on the street. That comes only with arrests. It seems to me dangerous to assume that in modern America people can get out of rehab and go home to areas awash in dope and be expected to stay alive, given the likelihood of relapse and the potency and controlling nature of opiates. It’s not cigarettes people are relapsing on. It’s pain pills and, especially now, heroin and fentanyl.

This is a supply story and has been from the beginning. Huge amounts of very potent opiates were unleashed on the country – first in the form of prescription opiate painkillers. When millions of people grew addicted to these pills, a lot of them looked for cheaper alternatives. Heroin traffickers, mostly from Mexico, slowly realized that these folks were a growing market and expanded their offering.

But it all has to do with supply. No treatment has much chance against a cheap and plentiful supply of potent dope.

It’s why doctors and the medical establishment need to continue reassessing how they prescribe opiate painkillers.

It’s also why we need to make Mexico a sustained priority. I’ve written elsewhere that I don’t think building a wall — or rather, more walls — at the U.S.-Mexico border is likely to do much to slow heroin trafficking. That doesn’t mean we shouldn’t seriously address Mexico’s continued production and exporting of this drug. Ninety percent of our heroin comes from Mexico, according to the U.S. State Department. It’s unconscionable that one country should export so much of this junk. China fought a war with England in the 1800s, twice, over this issue. We don’t need wars with Mexico, but it does seem to me that we need to make this the priority it deserves to be – and walls are a distraction from the real work that needs doing.

This young woman’s death also shows why we probably need to make much greater use of what’s known as medically assisted treatment – the use of drugs as replacements, as shields. These include methadone, Vivitrol and Suboxone – they either take away the craving for heroin or block overdoses.

It’s unreasonable, I think, to assume that addicts can go back to these same neighborhoods, where opiate supply is plentiful, without some sort of protection, some kind of shield.

The last couple years have shown how dangerous that is.

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House Republicans & Heroin

Governing is the opposite of dope.

It’s real world. It’s working the program. Accepting blame and accountability, breaking with fantasy. It’s hanging out with people who don’t think like you. It’s reminding yourself that life is full of constraints and you can’t just do whatever occurs to you. It’s realizing that you are not perfect and there are others whose opinions matter in this world.[image error]

That said, the recent health-care fiasco displayed House Republicans behaving like heroin addicts.

It’s easy to go on Fox News for years, blame someone else for everything when you don’t have to be accountable for finding solutions. It’s easy to rant about the endless failures of those people who do. Ranting is a narcotic; so is outrage; so is complaining and destroying. It gives us a big blast of dopamine to the brain. As does spending a lot of time insisting on all the nifty ways you’d do things better when you are king of the world. Feels so luxurious. Feels a lot like heroin, I suspect.

Being an opposition party means never having to put an idea to a constituent smell test. You get used to it – your tolerance for fantasy rises like an addict’s tolerance for a narcotic. Like addicts, you hang out with folks who think like you, talk like you, and never force you to face anything resembling reality, or the necessity of compromise.

Living without compromise is a nice idea in theory, but it’s possible only when you’re high on, and surrounded by, ideology — or dope.

A heroin addict brooks no compromise. He wants a world his way only. No messy complications, no one telling him no. Ask any parent of an addict.

What I think we saw was people addicted to a warm, euphoric ideological fantasy world in which they’ve lived for the last several years. Addicted to the idea that they could do it alone, didn’t need anybody, didn’t need to compromise. This Freedom Caucus seemed dead-set on depriving anyone but the wealthiest of what most would deem civilized health care: maternity care, ER visits, not to mention addiction-treatment coverage.

It was bizarre to watch them line up to take away benefits needed by so many who had just elected them and their president, and give them to our aristocracy.

Harold Pollack noted in this article in Politico that Democrats working to forge Obamacare held hearings over months and accepted more than 150 Republican amendments to the bill they passed. House Republicans this time took 18 days and “the payout to the top 400 families [in America] alone was estimated to exceed total ACA subsidies in 20 states and the District of Columbia.”

How do you come to the conclusion that thinking like the upper classes of pre-revolution France is okay?

Well, perhaps because House Republicans lived in a bubble for seven years, voting to repeatedly repeal Obamacare knowing it would be vetoed. Then the fantasy ended and they finally had the power to do it. They had nothing to replace it with. (John Boehner is, I’m sure, happy to be away from all that.) What they came up with would have savaged the very people who put them in office.

The word `compromise’ gets a bad rap these days, but it’s actually another way of saying something else. It’s saying, we’re behaving like adults. We’re not going to act like petulant children who want a world run according to their whims alone, which is, in turn, another way of describing how a heroin addict thinks.

Something like this, I suspect, is what Ryan was referring to when he spoke of House Republican “growing pains.” Getting off the dope of viewing compromise as a dirty word.

A big part of addiction recovery is relating to others again, accepting that your views are not the only ones that matter, that you have to modify your behavior, answer to others who may not think like you.

It’s like governing.

It’s messy and ragged; it’s hard and far from perfect. It’s adult, in other words, and it’s the opposite of dope.

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Saints and Sinners: Growing up in Portsmouth

A letter from a reader of Dreamland:

I was living in South Shore when Dr. David Proctor arrived in 1978.  I had just come back from college and was working at the local brickyard.  For a few years I was still apart of the local drug crowd but slowly moved away from it because I found it scary and upsetting.  I did not like buying from biker dudes I did not know and I did not like the small dealers that sold drugs to kids.[image error]

In small rural towns there are the “saints” and “sinners” and the doctors in any town normally are in the “saint” category.  One of my local small dealer friends went to Proctor while he was still apart of Dr. Riddle’s office. Proctor told him he would write him a script for any drug he wanted.  When my friend told me this I will never forget the stunned and serious look on his face, even though he got a prescription for Black Beauties.  My friend knew in the back of his sinner brain that something was very wrong.

Once my extended Pentecostal rumspringa was over, I returned to church.  I got married and left the area.  However, my husband was an abusive man and I returned to my mother’s home in South Shore with a small child.  It did not take me long even in my state of mind to see that Dr. Proctor along with another doctor had done major damage to my small town.  Even in my mother’s church there were five people that I knew about that were addicted to prescription drugs.

 Your book focused on the opiates but there was a doctor who ran a “diet” clinic who was free with the amphetamines. I would walk around the corner to see his lot filled with cars from Hamilton, Franklin, Pike and other counties in Ohio plus cars from counties in Kentucky and West Virginia.  The people I saw were lean not obese.  So South Shore was a one-stop on the small time dealer network for both opiates and amphetamines.

 There is one thing I would like to say about kids raised in fundamentalist churches. This is about the saint and sinner perspective.  They will be zealously saint or zealously a sinner and there seems to be no middle ground. This especially applies to rural areas.  If you are trained to live your life a religious zealot then when you turn away from your religious upbringing you live your worldly life just as fervently and passionately in the negative. However, when these same people turn back to their religious roots from the addictive life they are not ashamed to help others to do the same.

I left South Shore in the middle nineties with my middle school aged daughter.  I went back to Morehead State and cleaned up my mess from the 70’s and graduated with honors just in time for my daughter to start college. My daughter went on to get her masters at UK.  After reading your book I am glad we left the area for I can see decades of destruction manifest in South Shore when I go back to visit.

A positive note:  I loved your description of Chillicothe Street especially during the holidays.  I was not part of the middle class but was raise by a single mom with three children and no welfare. We would take a taxi to Portsmouth to shop on Christmas Eve.  I can remember the Salvation Army Santa ringing his bell in front of Kresges’ and my mom singing “Silver Bells.”  We would go to Kresges, Greens Five and Dime, Kobacher’s and to Martings to see their window display and buy hot peanuts from their candy area and play on the escalators.

All of this is etched into my childhood mind as well as all the great times swimming at Dreamland with my brothers and the neighbor kids who took us with them.  I thought all city pools were like Dreamland.

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Saints & Sinners: Growing up in Portsmouth

A letter from a reader of Dreamland:

I was living in South Shore when Dr. David Proctor arrived in 1978.  I had just come back from college and was working at the local brickyard.  For a few years I was still apart of the local drug crowd but slowly moved away from it because I found it scary and upsetting.  I did not like buying from biker dudes I did not know and I did not like the small dealers that sold drugs to kids.[image error]

In small rural towns there are the “saints” and “sinners” and the doctors in any town normally are in the “saint” category.  One of my local small dealer friends went to Proctor while he was still apart of Dr. Riddle’s office. Proctor told him he would write him a script for any drug he wanted.  When my friend told me this I will never forget the stunned and serious look on his face, even though he got a prescription for Black Beauties.  My friend knew in the back of his sinner brain that something was very wrong.

Once my extended Pentecostal rumspringa was over, I returned to church.  I got married and left the area.  However, my husband was an abusive man and I returned to my mother’s home in South Shore with a small child.  It did not take me long even in my state of mind to see that Dr. Proctor along with another doctor had done major damage to my small town.  Even in my mother’s church there were five people that I knew about that were addicted to prescription drugs.

 Your book focused on the opiates but there was a doctor who ran a “diet” clinic who was free with the amphetamines. I would walk around the corner to see his lot filled with cars from Hamilton, Franklin, Pike and other counties in Ohio plus cars from counties in Kentucky and West Virginia.  The people I saw were lean not obese.  So South Shore was a one-stop on the small time dealer network for both opiates and amphetamines.

 There is one thing I would like to say about kids raised in fundamentalist churches. This is about the saint and sinner perspective.  They will be zealously saint or zealously a sinner and there seems to be no middle ground. This especially applies to rural areas.  If you are trained to live your life a religious zealot then when you turn away from your religious upbringing you live your worldly life just as fervently and passionately in the negative. However, when these same people turn back to their religious roots from the addictive life they are not ashamed to help others to do the same.

I left South Shore in the middle nineties with my middle school aged daughter.  I went back to Morehead State and cleaned up my mess from the 70’s and graduated with honors just in time for my daughter to start college. My daughter went on to get her masters at UK.  After reading your book I am glad we left the area for I can see decades of destruction manifest in South Shore when I go back to visit.

A positive note:  I loved your description of Chillicothe Street especially during the holidays.  I was not part of the middle class but was raise by a single mom with three children and no welfare. We would take a taxi to Portsmouth to shop on Christmas Eve.  I can remember the Salvation Army Santa ringing his bell in front of Kresges’ and my mom singing “Silver Bells.”  We would go to Kresges, Greens Five and Dime, Kobacher’s and to Martings to see their window display and buy hot peanuts from their candy area and play on the escalators.

All of this is etched into my childhood mind as well as all the great times swimming at Dreamland with my brothers and the neighbor kids who took us with them.  I thought all city pools were like Dreamland.

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Our Heroin: From Afghanistan or Mexico?

While speaking on the topic of heroin in America, I’m often asked how much of our supply comes from Afghanistan, as we’ve been in a war over there for many years.

My answer, from interviews with traffickers, cops and DEA agents, is that most of our heroin comes from Mexico.

That view was confirmed this morning by William Brownfield, the U.S. State Department’s assistant secretary for International Narcotics and Law Enforcement Affairs.

In a conference call with reporters, Brownfield estimated that 90 to 94 percent of the heroin consumed in the United States originates in Mexico, with another 2 percent or so coming from Colombia and the remainder from other countries around the globe.

That represents a massive shift in our heroin supply since roughly 1980, when a lot of our heroin came from the Far East, and had for decades.

Interestingly, Brownfield said, a lot of Afghan heroin does make it to Canada, but not to the United States, where Mexican trafficking organizations, too close by, enjoy a more advanced and efficient distribution network, and offer therefore cheaper prices.

 

Brownfield was talking about the just-issued International Narcotics Control Strategy Report (INCSR), which talks a lot about the heroin/opioid problem in America. Brownfield’s message was a positive one about cooperation between Mexico and the United states on issues of drug enforcement.

A wall of law enforcement cooperation is in place, without constructing an actual wall, he said. Serious problems existed, he said, “but we have a far better architecture to address them today than we did in years past.”

Nevertheless, his answer on heroin’s origin stunned even me. I would not have guessed the estimate would be that high.

I’ve written elsewhere about my belief that it’s unlikely that more border walls between the two countries will do much to staunch the flow of heroin into the United States. What’s really necessary is even deeper cooperation, frank discussion with Mexico that a wall and the emotion it provokes would do much to corrode.

Yet Brownfield’s response highlights two things worth mentioning.

One is that Mexico must truly step up to this challenge. Its unconscionable that such a high percentage of illegal highly addictive dope come from one country to another. China had a similar issue in the 1800s, when the British forced opium into that country, resulting in the massive addiction of Chinese people for decades after.

If border walls are insulting to Mexico, it must understand that they are proposed because of Mexico’s own failings – both with regard to law enforcement and criminal justice, and in channeling the desires of its most hardworking citizens, who then feel the need to migrate illegally to the United States.

Second is that U.S. demand for heroin grows organically out of doctors’ massive prescribing over the last 20 years of pharmaceutical narcotic painkillers – the subject of my book DREAMLAND — something that no border wall will stop, of course. Also, if we get into discussions with Mexico about this topic, soon that discussion will also turn to our very accessible market for guns, many of which then go south through a variety of channels and end up being weapons in that country’s bloody drugs wars. So if we ask a neighbor to behave with maturity, we better be willing to do the same.

We have almost 700 miles of walls along the border that separate the two countries. Drugs aren’t much trafficked through those areas that have no walls, most of which are in forbidding terrain. Our drugs, instead, are trafficked through ports of entry where walls already exist. They are trafficked in cars, trucks, and by pedestrians. With heroin, the problem is exacerbated, as I’ve written elsewhere, by the fact that is the most condensable drug, thus the most easily and profitably trafficked,and one that we now have a huge demand for.

All in all, the issue begs a binational, cooperative solution, seems to me.

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Keith Dannemiller: A Podcast

Keith Dannemiller, a native of Ohio, has been one of the premier photographers out of Latin America for two decades now. His black and white street shots from Mexico City are strange and dazzling.

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Keith and I worked together in Mexico for many years, both of us freelancers. We recorded this conversation a while back when Keith’s first book of photography — Callegrafia – was coming out. It’s sold out, but the chat is interesting – about finding what to shoot, and why, and what got him started on street photography, and how a man devoted to his craft does his job.

Keith’s new exposition of his photography is called Luz Translation, opening in the town of San Miguel De Allende, Guanajuato, on February 2. Check it out if you’re down there. It’s at Centro Cultural El Nigromante Bellas Artes, #75 Hernandez Macias and running until April 23.

Find out more about him at his website, www.keithdannemiller.com, including the photo tours he leads of Mexico City.

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Photos by Keith Dannemiller

 

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The Last Velvet Painter in Tijuana

For many years, Alfredo Rodriguez Ortiz – Argo – was among the throngs of velvet painters making a living in Tijuana painting Elvis, Marilyn, John Lennon and John Wayne.

Those were velvet’s glory days of the 1970s. Now interest in the art has fallen off considerably. He keeps at it. Painting Bob Marley and Tupak more than any others.

He’s now among the last velvet painters, and the only one, from what I can determine, who still knows how to paint Elvis Presley on velvet.

I hope you like the video.

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Juan’s Story – The high cost of cheap prices

We came upon this taxi driver who started telling us of how, in order to build his family a house, he went to Texas to cut rock for housing facades, using a legal visa provided by his employer. Did this for three years, six days a week, 12 hours a day minimum.

Hope you like this video, which I did last week in Mexico.

Let me know what you think, either here on in the Youtube comment box. Please share it if you like it.

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A Doctor’s View of Pain Pills

Here’s a letter from doctor with a long exposure to the problem of addiction and pain pills. I get lots of email letters about Dreamland. I’ve put a few up on this blog – always with names and identifying details removed.

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 I have recognized for many years, at least since the late 1980s, that the chronic use of opioid medications was typically a barrier to recovery. I am a physiatrist, a physician specializing in physical medicine and rehabilitation, since 1986.  We manage patients who have catastrophic injuries: spinal cord injury, traumatic brain injury, amputations and those with multiple and severe trauma. I also treated many patients who had less severe injuries including strains, sprains and other soft tissue trauma. We often manage patients over many years. When the use of opioids became more frequent, in the late 1980s, I was perplexed. I did my best to manage pain, if at all possible, without the use of chronic opioid therapy. I was perplexed even more so in the mid to late 1990s when Oxycontin came on the scene. Physicians no longer were afraid to prescribe opioids for non-cancer pain and did so seemingly without caution. They were duped. Drug companies and their physician spokesmen duped them.

I grew up and later practiced medicine for many years in New Mexico. New Mexico, as you may know, has always had one of the highest drug overdose rates in the nation.  Heroin had been the drug of choice, at least until opioid medications came on the scene. I worked as a house painter’s apprentice in the late 1960s while in college. I worked on one crew that every journeyman painter was an ex-con related to heroin use.  I had plenty of opportunity to use heroin but it scared me. My co-workers told me how great it was. One guy, much older than me, made it sound so appealing. “Come over and we will shoot up and listen to jazz.”  I never tried it though I had lots of opportunity.

I knew quite well how dangerous heroin was and never believed that opioid medications were any less dangerous. When I started practicing in the late 1980s many of the patients I saw were on opioid medications when I assumed their care. Most of the more seriously injured patients I saw were successfully weaned off opioids. Many of the less seriously injured, especially those with work related injuries, were much more difficult to wean. Some patients of both categories ended up on long term opioids but were closely monitored to determine if they were benefitting from opioids and whether they were abusing them. Escalating doses were typically not allowed.

The work related injury group of patients who generally had much less severe injuries, were routinely on opioid medications when I took over their care. My job as a rehabilitation physician was to get them back to their usual activities including return to work. I found that opioid medications were a barrier to their recovery. Some of my referring physicians believed the standard of care was to treat pain with opioids as long as patients complained of pain. Some patients were never going to stop complaining of pain and the reasons were frequently psychosocial in nature. I never believed the hype from drug companies regarding the safety of opioids. I saw from up close as a young man and as a doctor that they were dangerous and in general not appropriate for long term use in non-cancer pain.

I knew little about Dr. Russell Portenoy at the time of the opioid prescription explosion but I knew plenty about what drug companies were saying about the safety of opioid medications and the unlikelihood for addiction. I now understand Dr. Portenoy’s role in this public health catastrophe.  I don’t believe Dr. Portenoy and other drug company marketer’s claims that they are now surprised about the addiction potential and danger of opioids. Intuitively it did not make sense. Oxycodone and hydrocodone are so similar to morphine and heroin both chemically and by their mechanism of action. Why would you believe they are so much safer? Those guys were either just plain dumb and so drunk with drug company money and self promotion that they refused to pay attention to what was happening to patients. I am sure they are not dumb. Dr. Portenoy is a brilliant and charming guy. Just view his video presentations and interviews. He is also a successful academic physician. That is what made him so dangerous.  I am just an average doc who has never had a higher academic position than a clinical assistant professor.  I have never authored a paper that made it to a medical journal. How could I know more than them and have been so right about the proper role of opioid medications?  Why didn’t they? Certainly not because I am smarter.

I think your book was very even handed, maybe a little too much, with Portenoy and the other opioid selling/promoting physicians. I’m telling you they knew better. Their response of “If I knew then what I know now….” just doesn’t cut it. They are responsible for the hundreds of thousands of deaths and ruined lives. They should not get off the hook. I suspect their narcissism will prevent even one sleepless night for the damage they have done. But they and their benefactors, the drug companies, have created a horrible health crisis that was largely preventable in the United States. It is almost strictly a U.S. problem caused by U.S. physician “thought leaders”, drug companies and misguided bureaucrats.

I applaud your book. Bringing the black tar heroin story into your narrative was great. You connected the dots. I wasn’t aware of that part of the story. Thanks again for your book. It may just impact our legislators and government officials even more so, to focus on rehabilitation not punishment for those young kids who got caught up in a drug problem often caused by misguided or crooked doctors.

The punishment of “pill mill” docs and drug company marketers including their corrupt physician lackeys could never be equal to the suffering they have created. Glad you spotlighted the problem and did it in such a well-researched, entertaining and cogent way. Thank you.

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An Ohio Farmer: Trump, Dope, Jobs & PC

A DREAMLAND PODCAST – John Russell is 26 and an organic farmer, raising melons in rural Ohio, not far from Columbus. This year he ran for the Ohio state legislature as a Democrat – and lost badly.

I had the chance to talk with Russell today.

We had a wide-ranging  conversation, about his decision to go into farming, about his campaign, about Donald Trump, as well as job loss and opiate addiction in America’s Heartland, PC culture, the challenges Democrats face in rural areas.

He’s one of the few, it seems, to go away to college then return to a rural community. So many towns have lost young people to the cities where the jobs are.

We talked about that as well, and about what happened to guys on his high school football team.

This is the first interview I did like this, via Skype, so I’m still working out the kinks, and there are a few buzzes and etc. So please bear with me.

Meanwhile, contact him at www.johnrussell.info, and follow him on Twitter: @JCruss

 

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