In fascinating detail, Sam Quinones chronicles how, over the past 15 years, enterprising sugar cane farmers in a small county on the west coast of Mexico created a unique distribution system that brought black tar heroin—the cheapest, most addictive form of the opiate, 2 to 3 times purer than its white powder cousin—to the veins of people across the United States. Communities where heroin had never been seen before—from Charlotte, NC and Huntington, WVA, to Salt Lake City and Portland, OR—were overrun with it. Local police and residents were stunned. How could heroin, long considered a drug found only in the dense, urban environments along the East Coast, and trafficked into the United States by enormous Colombian drug cartels, be so incredibly ubiquitous in the American heartland? Who was bringing it here, and perhaps more importantly, why were so many townspeople suddenly eager for the comparatively cheap high it offered?
With the same dramatic drive of El Narco and Methland, Sam Quinones weaves together two classic tales of American capitalism: The stories of young men in Mexico, independent of the drug cartels, in search of their own American Dream via the fast and enormous profits of trafficking cheap black-tar heroin to America’s rural and suburban addicts; and that of Purdue Pharma in Stamford, Connecticut, determined to corner the market on pain with its new and expensive miracle drug, Oxycontin; extremely addictive in its own right. Quinones illuminates just how these two stories fit together as cause and effect: hooked on costly Oxycontin, American addicts were lured to much cheaper black tar heroin and its powerful and dangerous long-lasting high. Embroiled alongside the suppliers and buyers are DEA agents, local, small-town sheriffs, and the US attorney from eastern Virginia whose case against Purdue Pharma and Oxycontin made him an enemy of the Bush-era Justice Department, ultimately stalling and destroying his career in public service.
Dreamland is a scathing and incendiary account of drug culture and addiction spreading to every part of the American landscape.
Sam Quinones is a long-time journalist and author of 3 books of narrative nonfiction.
He worked for the LA Times for 10 years. He spent 10 years before that as a freelance journalist in Mexico.
His first book is True Tales from Another Mexico: The Lynch Mob, the Popsicle Kings, Chalino and the Bronx, published in 2001, a collection of nonfiction stories about drag queens, popsicle-makers, Oaxacan basketball players, telenovela stars, gunmen, migrants, and slain narco-balladeer, Chalino Sanchez.
In 2007, he published Antonio's Gun and Delfino's Dream: True Tales of Mexican Migration. In this volume he tells stories of the Henry Ford of velvet painting, opera singers in Tijuana, the Tomato King of Jerez, Zacatecas, the stories of a young construction worker heading north, and Quinones' own encounter with the narco-Mennonites of Chihuahua.
His third book was released in 2015. Dreamland: the True Tale of America's Opiate Epidemic recounts twin tales of drug market in the 21st Century. A pharmaceutical company markets its new painkiller as "virtually nonaddictive" just as heroin traffickers from a small town in Mexico devise a system of selling heroin retail, like pizza. The result is the beginning of America's latest drug scourge, and the resurgence of heroin across the country.
The book has received rave reviews in Salon.com, Christian Science Monitor, Wall Street Journal, American Conservative, Kirkus Review, and National Public Radio.
Amazon readers gave Dreamland 4.7 stars and called it "a masterpiece" and "a thriller."
"I couldn't put it down," said one. Said another: "This book tells one of the most important stories of our time."
Following Antonio's Gun, the San Francisco Chronicle called Quinones "the most original American writer on Mexico and the border out there."
He has done numerous Skype sessions with book groups that have chosen his books to read.
For several years, he has given writing workshops called Tell Your True Tale. Most recently the workshops have taken place at East Los Angeles Public Library, from which have emerged three volumes of true stories by new authors from the community.
There are not enough stars in the rating system to accurately explain how important this book is. There isn't a home that should not have a copy. Dreamland by Sam Quinones is the single most well researched, well written, and heartbreaking account on the plague of opiate addiction. I can tell you this confidently because I am an oppiate addict, who has been clean for five years. Dreamland will take you not only through the history of opiates but to living rooms of white suburban American who has fell victim to this epidemic. I started highlighting passages throughout the book but had to stop because my entire kindle copy was yellow. Every word is important and every story heartbreaking. Every fact astonishing but true. I thank Sam for keeping this conversation going and for bringing research and heart to the table.
I will never forget the day I could actually announce I was free from pain pills for a year. During the height of my addiction I went to more funerals than weddings. Being in my early thirties, this is a horrible truth. When I was able to announce that I seemed to be winning my fight on opiates I did so on Facebook. The next day my message in box was full from friends and family asking me for help because they to had a problem or a loved one with a problem. I was shocked. I am a 38 year old white women from the burbs. I owned a home, have an amazing husband and child. Opiates gave me a sense of happiness I had never been able to acheive on my own. Then it slowly and systematically dismantled my life. We lost our home, our cars, my 80k a year job, but I am one of the lucky ones. I did not lose my family or my life.
Addicts are no longer the stereotypical image you have or have had and I believe this book does an amazing educating people who may judge. Addiction is a disease and does not discriminate. Please read Dreamland and let it open your eyes or if your struggling, know you are not alone.
This book does not read like a medical journal, it is not boring. It is so well written that it felt more like a conversation. It will educate you as to how it's brought to our country and put a face to both the dealers and the addicts. It's simply the best book on our opiate epidemic that I have ever read.
Thank you Netgalley and publisher for the advanced copy in exchange for an honest review.
Adam Smith said it first: ‘Greed is good.’ According to him and his intellectual and political descendants, the desires of individuals form a self-regulating economic system which is advantageous to everyone. The rich do get richer, but so do the poor. It’s called capitalism: having and meeting needs through honest competition without interference from bureaucrats, politicians, or government agencies.
And capitalism works. It does exactly what it says on the packet. Dreamland is a testament to the power of Adam Smith’s theory. The Sackler family and Purdue Pharma spotted a need - unrelieved pain - and they met that need with a ‘killer app’ known as OxyContin. They lobbied for the easing of government restrictions on its use, and employed their formidable marketing skills to sell it to every MD and health care institution in the country. A capitalist win/win success story: less misery, more wealth.
Except there is what economists call an ‘externality.’ Like so many other pharmaceutical breakthroughs in the last half century (Valium was another of the Sackler family marketing successes) OxyContin is really, really addictive. Great for the company who can count on continued rising sales; not so great for the individuals who are dependent on the stuff and have to pay for it, or for the public health and social services that have to deal with the consequences.
But once again the capitalist system demonstrated its ability to respond creatively to issues it might encounter. OxyContin is costly. Its market price has to recover some huge R&D expenses as well as equally huge corporate overheads. Global marketing, for example, doesn’t come cheap. The situation is a Harvard Business School case study in competitive opportunity. Product innovation and a radically new low cost delivery system comes to the rescue of the monopolistic market.
The product is black tar heroin, a low tech high yield pain-killer that costs peanuts to make. Conceivably anyone could have entered the OxyContin market developed over years by the Sacklers; but it was an entrepreneurial group of rancheros on the Pacific coast of Mexico who grabbed the brass ring first. Clever enough as well to avoid the established marketing channels for white heroin (a specialité de la maison of the large, and consequently dangerous, illegal cartels in the big cities), these Mexicans became the WalMart of the drugs world, spreading widely and rapidly across rural America.
Like WalMart, the Mexicans piled it high and sold it cheap. Also like WalMart, they had a fantastic logistics system to supply their nationwide network, using low wage, easily replaceable drivers from the Mexican homestead. Interruptions like police arrests and confiscations were therefore about as serious as an occasional flat tire or speeding ticket. A simple telephone call and the operation was back on the road. Writing off an occasional lost load was trivial given the minimal cost of goods sold. And even this risk was mitigated by the standard financial business tactic of ‘portfolio diversification’ through franchising - too many eggs were never in any one basket.
But unlike WalMart, customer service was a priority in the black tar heroin trade. With another phone call, the Mexicans delivered to your door, or the toilet of your nearest McDonald’s, with the speed of Amazon. Special introductory and volume discounts, periodic sales to promote turnover, local mouth to mouth advertising, incentive compensation, and other standard commercial techniques completed the value-proposition. Absence of fixed assets meant that resources could be re-allocated as required for maximum return. The market boomed and so did the business.
Of course quality control often might not be what it should have been. Product strength and purity wasn’t quite as uniform as OxyContin. But no doubt these hiccups would be ironed out over time. The casualties (mostly infections from muscular injection), deaths (dosage is hard to judge) and costs of emergency services (notably medical rather than police) for the most unfortunate customers were merely part of a business learning curve. In any case an entire sub-culture emerged across America that became increasingly savvy to the new product. Caveat emptor was never a more serious command.
America isn’t unfamiliar with illicit drug use. What makes the black tar heroin market political however is that: 1) it is dominantly white people who are its customers; 2) these people are mainly middle class from the towns and regional centers of the ‘heartland’; 3) it is a market created by pillars of the existing capitalist society - the pharmaceutical industry and the medical profession; and 4) it is organized and run not by international mobsters and terrorists but by a bunch of Mexican sugar cane farmers with a real can-do attitude and entrepreneurial spirit.
That’s the story told in Dreamland. The bulk of the book is journalistic detail, largely anecdotal, about representative ‘players,’ their victims and their families in the legal and illegal drugs game. In good journalistic style, Dreamworld is long on description of people, places and things but short on analysis and productive opinion. So the content of the book doesn’t go much beyond a television documentary. As an introduction to the issue, the book is worthwhile. But serious students of the problem will probably want to look elsewhere for actionable inspiration.
3,5/5 Uważam, że autor bardzo rzetelnie zebrał wywiady i w mądry sposób je uszeregował przeplatając wizje lekarzy i doświadczenia uzależnionych. Byłam pod ogromnym wrażeniem rozdziału z historiami rodziców uzależnionych dzieci, których przygoda często kończyła się śmiercią. Jednak nie mogę przejść obojętnie obok braku konsekwencji w nomenklaturze medycznej np. kręcimy się wokół nazw handlowych leków tj. Oxycontin lub Oxycodone, ale już mówiąc o dodatku paracetamolu, zastosowana jest jego skrócona nazwa chemiczna tj. acetaminofen (zamiennie stosowana z paracetamolem, ale moim zdaniem mało kto wie, że to o nim mowa). Nie popieram również braku rozdzielenia opiatów i opioidów (co jest zaznaczone na początku), bo to dwie definicje, które nie wprowadziłyby zamętu, a to ważne aby rozumieć różnicę. W szczególności, że inne pojęcia medyczne są szybko tłumaczone w fabule, a później namiętnie używane tj. generyk.
It only took me a month, but I'm finally done! Whew.
But it was the United States...that now consumed 83 percent of the world's oxycodone and fully 99 percent of the world's hydrocodone...people in the United States consume more narcotic medication than any other nation worldwide.
Dreamland is the story of the surge of opiate addiction in the mid 90s / early 2000s in the United States. Facilitated by the massive prescribing of new "miracle dug" Oxycontin, new changes in the attitudes around managing pain, and the surge of black tar heroin coming up from Mexico, all colluded to form a sort of perfect storm that sprouted pill mills and rampant addiction.
For those who don't know, I have worked in pharmacy for roundabouts four years. I LOVE my job. I get to play with drugs all day, help patients, and work with some pretty awesome people. I also have a pretty good idea of what Dreamland talks about when it discusses Oxycontin, overprescribing, addiction, and how it affects those with legitimate pain.
Approx street value:
So despite the fact that so much of this relates to my work life, I was less than impressed. Number one, this was VERY repetitive. I mean, I understand if you tell me about a concept in chapter two, go ahead and give a quick refresher in chapter twenty-three. That's cool. But this was almost like every single chapter was written without reference to each other.
I started skimming towards the end. You could cut out a good 30 or 40% of the book without losing anything of importance.
I can't really recommend Dreamland. The subject matter is absolutely interesting, but the presentation is extremely repetitive.
If you can manage to get through this without skimming or falling asleep, you deserve a damn trophy.["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>["br"]>
Quinones weaves together two themes to help explain today’s opiate and opioid epidemic. He uses the term opiate throughout to refer to both so I will too. Theme one is the story of the dramatic spike in the use of painkillers, particularly oxycodone. This culminated in pill mills that devastated many communities. Theme two is the spread of black tar heroin taking advantage of those already addicted to prescription painkillers. The heroin comes from a Mexican sourcing and distribution network dubbed the Xalisco Boys. Quinones, a journalist, builds his narrative through many short vignettes alternating between his main themes. These profile addicts, parents, dealers, doctors and law enforcement.
The ascendance of painkiller addiction begins with a change in accepted medical practice in the late 1980s. In response to an institutional reluctance to prescribe opiates even when clearly indicated, doctors swung to the opposite extreme. The drug companies, particularly Purdue Pharma, played a major role in this movement. Arthur Sackler, whose name graces many museums and medical facilities, founded modern drug marketing in the 1950s using extensive advertising and direct sales force calls on physicians. His first campaign for Pfizer, then a small chemical company, catapulted terramycin into widespread use. In the 1960s and 70s Sackler made valium the first billion dollar drug.
Then along came Purdue in 1996 with its continuous release oxycodone called OxyContin. This powerful opiate came just as prescribing opiates for all types of chronic pain, not just surgery and cancer, became accepted practice. Purdue marketed OxyContin as non-addictive and it backed up this claim with slick presentations given by a well-trained sales force. With a huge potential market of people suffering from everything from bad backs, fibromyalgia, toothaches, minor injuries, etc., Purdue spared no effort or expense in getting its message to doctors. The message was that continuous delivery blunted the highs and lows that fostered addiction.
Even the FDA chimed in approving a label stating OxyContin’s delay feature meant less risk of abuse. Accepted for many years, we now know these claims are wrong. Taken as prescribed OxyContin does deliver a hefty high and for those in a hurry it was easy to dissolve the outer coating in water or suck it off to remove the continuous release feature. Then to get the entire dose at once simply smash it and snort it or mix with liquid and inject – voilà. In 2001 OxyContin sales exceeded a billion dollars. Sales weren’t broken down between recreational and medical users. “Hillbilly heroin” took over Appalachia. Rehab clinics filled with OxyContin users whose addiction was indistinguishable from heroin users.
At first addiction increased through well-meaning doctors following Purdue’s advice and prescribing OxyContin for a wide variety of pain. But quickly the pain clinics turned up and most were pill mills with doctors who wrote prescriptions for cash. In some states they could also operate pharmacies and fill the prescriptions themselves. With all the pills floating around, recreational users got into the action, particularly high school and college kids. Appalachia became an epicenter of the pill mills. Contributing to this were all the people who had sought disability income as a replacement for their lost jobs.
Quinones illustrates with the southern Ohio town of Portsmouth and the pain clinic run by David Proctor. Everyday outside Proctor’s clinic were long lines of disheveled people stretching out through the parking lot and into the street. Proctor was full service. He would file workman’s comp claims and had his own pharmacy. Just have the cash and everything’s taken care of. It takes very little time to become addicted so repeat business is good and every time patients return they need even more pills.
Eventually Proctor lost his medical license. Having sex with patients in his office in trade for prescriptions didn’t help his case. But even though he could no longer work at the clinic, he still owned it. He hired 14 doctors who were desperate for jobs and grew his business. As clinics spread, a number of them were owned by people with no medical background who hired willing doctors often with spotty records. Eventually the law caught up with Procter and he served eleven years in prison.
Other ways to make money off the pills proliferated. Those with a little cash in their pockets could pay for the visits of others taking half the pills in return. They could either sell or use their share. One enterprising individual named Mary Ann repeatedly reproduced an MRI of an injured person changing the name on each copy to give to those she drove to the clinics. To reduce the cost of the drugs she sought out individuals with Medicaid cards. As the pill mills grew so did those applying for Social Security Disability. With these credentials non-addicts could make good money selling pills. Someone making $500 a month could sell their pills for thousands each month.
Those who built businesses paying for addicts visits could support a very comfortable lifestyle making thousands on each trip. In places like Portsmouth and other parts of Appalachia OxyContin pills became currency at one dollar per milligram. OxyContin came in 40 and 80 milligram doses. Junkies stole to support their habit trading merchandise for pills. Half the store tag price was the accepted value in trade for pills. Entrepreneurs like Mary Ann would place orders with junkies for what she wanted and pay in pills. She even bought a car and paid her dentist with pills. The most successful pill entrepreneurs were not addicts.
The U. S. became the world leader in per capita narcotic medication consumption. And much of it was for recreational use with 25 million non-medical users of prescription narcotics in the first decade of the 21st century. The average age was Twenty-two. In 2011 there were 488,000 emergency room visits in the U. S. for from prescription painkiller abuse. In 2012 one person died every half hour from opiate overdose.
In 2006 the U.S. attorney for the western district of Virginia, Republican John Brownlee, brought a case against Purdue for criminal misbranding taking on Purdue’s claim that OxyContin was not addictive. But first he was contacted at home by a Department of Justice official. This was during the Bush presidency. The official told Brownlee to slow down his case against Purdue. Brownlee refused and immediately found his name on a list of U.S. attorneys to be fired. Brownlee kept his job but believed he was listed for not caving to political pressure. Purdue agreed to a plea deal paying $635 million and a felony count of misbranding. Some executives were placed on probation. As one witness who lost a son to OxyContin said at the sentencing, “You are nothing more than a large corporate drug cartel.” This makes a good segue to the second theme.
The Xalisco Boys, as Quinones calls them, came from rural villages around the town of Xalisco in the Mexican state of Nayarit. This was a very poor area where young people faced a bleak future. Everyone was related in networks of interwoven clans. In the nearby mountains Cora Indians grew poppies. Some enterprising Nayriot residents learned to cook the poppy goo into black tar heroin. It was pure, potent and consistent. The black tar was taken to the U.S. and distributed in a unique and brilliant operation that could be called corporate except there was no hierarchy only individual cells with individual bosses. Since everyone involved knew each other or had relatives in common, there was no violence within and between cells and their methods were consistent.
In the 1980’s, the Xalisco Boys began drug trafficking in the San Fernando Valley. In the 1990’s they spread across the country to handpicked cities, choosing ones without established drug gangs and with Mexican communities to blend in with. They established cells in Reno, Portland, Salt Lake City, Boise, Denver, Santa Fe, Columbus, Nashville, Charlotte and many other similar sized cities. They never went to New York, Baltimore, Philadelphia or the like where they would have faced violent drug gangs.
The cell boss hired drivers, usually 17 to 30 year old relatives from the same village. The boss paid to get them across the border. He provided them with “company” cars, “company” apartments and food. They were provided beepers or cell phones when they became available. Each driver would carry small balloons filled with a single dose of black tar heroin. He kept these in his mouth and swallowed them if approached by police. If swallowed they would pass through his system. After a few months’ work the boss replaced them sending them home with the salary they earned, clothes they bought and gifts for their family and friends. The bosses would switch out too and go home with their money and fancy gifts, live it up and spend to impress, and then return to the same or new cell in the U.S. They were not moving to the U.S. They were building big homes back in Xalisco.
The cells would start up by giving out free samples in front of the local methadone clinic or other addict hangout. Included with the sample was a phone number to call for more. The price was reasonable, the product potent and uncut, and delivery to your street corner free. Because the drivers were salaried they had no incentive to mess with the price or the drug. They marketed like a corporation, giving free doses to addicts who brought them new customers. They gave away free heroin to get addicts to take them to new areas, even new cities, and introduce them around.
Prior to the Xalisco Boys the heroin available in the U.S. was powder cut down many times from source to addict. It was unreliable, expensive and available typically in dangerous places run by gangs and watched by police. The Xalisco system was much safer for the addicts. Drivers were never armed and avoided violence. The Xalisco model avoided trouble with police. Even if a driver was caught the small amounts were considered petty and below the radar of the DEA. The driver who was related to the boss would remain loyal and would be deported. It was many years before police and federal agents finally put the pieces together and realized how these cells worked and how far they had spread. One thing that ensured their success was the explosion of OxyContin. Black tar heroin was even better, cheaper and more convenient to get. Why pay $40 or $80 for an OxyContin pill when a $10 balloon of black tar heroin would do the job?
Besides avoiding cities with drug gangs, the Xalisco Boys avoided African Americans, who they believed would rob them. They sold exclusively to whites who were already rapidly becoming addicted to prescription pills providing them with a dependable source of supply. Reliability and low cost helped the black tar spread through schools making new addicts. The explosion of white addicts, many from good homes in the suburbs, had a political impact. Legislators who had never cared all of sudden called for criminal justice reform. The sharp change in attitude was particularly notable among Republicans in Appalachia and other areas hit by the opiate epidemic. All of a sudden “their people” were getting the stiff sentences.
In Portland Oregon in 1990 there were 10 heroin overdose deaths. In 1999 there were 111. In 2000 in Washington State 600 addicts were under treatment. In 2010 there were 8600. In Ohio in 2007 for the first time deaths from drug overdoses exceeded those from car accidents. In 2008 for the first time overdose deaths exceeded those from car accidents for the entire U.S. Current statistics from the National Institute on Drug Abuse show 64,000 Americans died from drug overdoses in 2016, far exceeding the deaths from auto accidents. The National Highway Traffic Administration reports 37,461 deaths from auto accidents in 2016.
Quinones also details law enforcement initiatives, arrests and crackdowns but the Xalisco Boys network is resilient. Quinones points out that a major DEA bust in Santa Fe called Operation Tar Pit disrupted the heroin network for exactly one day. New cells immediately are formed to replace those taken down. Quinones shows how the one two punch of readily available prescription drugs followed by cheaper illicit drugs has created an epidemic with no end in sight.
Left out in this review are the many individual stories Quinones tells. These make this a book of personal tragedy as well as crime and national emergency. The book is well researched and convincing. It is filled with first hand interviews of dealers, addicts, police and doctors. Sam Quinones, an American, lived in Mexico for ten years and speaks fluent Spanish. His knowledge of Mexico and ability to converse with traffickers and Xalisco residents adds credibility. His repeats himself a bit much and he abruptly skips from one topic to the next but in spite of shortcomings in style his message is well delivered and important. Highly recommended.
I have been an American cardiologist for many years. I've had little awareness of the many thousands of deaths caused by the narcotic epidemic described so well in this book. The strangling web of causes, you will learn, includes misinterpreted medical research leading to deadly malpractice, shady doctors, the rusty economic meltdown, the easy penetration of Mexican heroin into the U.S., the economic desperation of Mexican small town culture, highly effective just-in -time drug marketing techniques and even low pay at Walmart. This is insightful sociology told in the form of brief biographies. While sometimes repetitive, the overall effect of the book is devastating. This should be required reading for health professionals, law enforcement officials and legislators. The problem is far from over. This book will shock many awake. The author has done brave work -- the Waltons, Pharmacy execs, and the cartels will not be happy readers.
The spectacular public service reporting Sam Quinones does in this nonfiction is so detailed and many-faceted that it left me feeling a little voyeuristic, not having been visited by the scourge of opioid addiction myself. Good lord, I kept thinking, so this is what we are dealing with. I knew something was different, I just didn’t have any conception of the size, scope, method, and means of this problem.
Quinones starts his story in the early 1980s when the first rancho Xalisco marketers came up from Mexico with an innovative method for just-in-time drive-by selling of drugs to rich white kids in the suburbs. They explicitly avoided cities and black people because they admitted they were afraid of them, their violence and their gang activity. Besides, the thinking went, blacks never had any money. They’d just as soon steal from a dealer as pay him. The white kids had money and wanted convenience above all.
At almost the same time, and a cultural habitat away from small-time drug dealers of black tar heroin from Mexico, a drug company owned by the Sackler medical empire released an opiate derivative in pill form meant to alleviate pain. Early on, it is possible that creators, marketers, and prescribers of this plague did not know what they had unleashed. But within a couple of years, it is difficult to avoid the conclusion that great numbers of people within and without the company sold the product in full knowledge of its wicked potency and addictive properties.
Quinones has been researching and reporting on this topic for a couple of decades, and lived in Mexico for ten years, observing the supply-side. Before having a comprehensive understanding of the subject, Quinones thought the heroin problem began with U.S. demand for drugs. After researching the situation in the heartland United States, he has decided that our problem now with heroin and fentanyl overdoses was caused paradoxically by a huge supply of opioid pills, prescribed by doctors in legal clinics, and condoned at every level of society and government in our country.
The story Quinones shares is un-put-down-able and truly remarkable, particularly his discussion of the marketing techniques for black tar heroin used by the small farmer-seller systems first set up by residents of Xalisco. Their method of growing-packaging-selling expansion into the heartland of America should make us sit up and pay attention. Ground zero for the meltdown of middle America is identified by Quinones as Portsmouth, Ohio, a middle class town at the center of a web of major cities like Cincinnati, Cleveland, Louisville, Indianapolis, Pittsburgh. The first known vector of the opioid infection was an unscrupulous doctor who overprescribed pills, knowing they were addicting his patients. Aided by ordinary well-meaning doctors who listened to marketing spiels by the drug makers, and who believed the pills to be non-addictive, the infection spread rapidly. Quinones tells the tale as it unfolded, involving Medicaid scams and cross-state purchases and sales.
What Quinones tells us gives us lessons for many other supply-side problems (marijuana? guns?) we may face in our society, now or in the future. When asked in an interview why restrictions on Class A prescription pills or opiates of any sort would produce the better outcomes, Quinones points out that when prohibited liquor was once again allowed to be sold openly, it was classified as to strength and sold differently. He warns that we are rushing to sales of marijuana with potency levels unknown fifty years ago and may wish we’d instituted some restrictions or controls before it becomes socially acceptable.
This nonfiction is dispassionate enough to allow us time to adjust our thinking around the problem of young people—entire families, really—losing their place in a productive society, with almost no way out. Now, with the recognition of the problem being forced upon our politicians, teachers, medical personnel, and law-enforcement officers, some changes are being instituted which may help after the fact of addiction, never a good time to try and solve a problem. With discussion and buy-in by ordinary citizens it may be possible to attack this problem before it begins.
There are at least seven interviews with Quinones available free on Soundcloud, ranging in length from 15 minutes or so to an hour and a half. You have to hear some of these stories. It's mind-blowing. I listened to audio version, very ably read by Neil Hellegers, and produced by Bloomsbury. It is a must-read, must-listen.
Really important to get this information out, and the book is very well researched. From a writing perspective, though, I agree with the reviewer who said the structure doesn't build a narrative and feels very repetitive. The piece Quinones published in the NY Times a few weeks back covered most of the key points quite well in a more compact format.
The last 20% or so brings in some of the solutions to the problem and covers more topics.
In the acknowledgements section the author seemed to say that his editors each had worked on sections of the book, which definitely would explain why it felt like a lot of magazine pieces stuck together.
Overall a good and important book, but lacking a cohesive voice or narrative.
Frightful Look at the Catch-22 'twixt Controlled Opioids & Outlawed Black Tar Heroine
This is an ominous, but illuminating, exploration of the scourge in the U.S. of controlled opioids (overprescribed or sold on the streets) and the outlaw opioid heroine, and what has led us here, i.e., the interplay between controlled opioids (lortab, norco, oxycontin, etc.) and the cheaper outlaw substitute that opioid addicts turn to when they cannot afford the opioids' high street price: black tar heroine, which is sold mostly by a loose-knit Mexican marketers' mafia.
If you enjoy documentaries touching on human nature, you should find this book intriguing for its review of how regular people get hooked on pain pills and exploration of the pain pill cycle (from manufacturers, pushers, pain med mills/docs who prescribe for kickbacks, and the blowback when the poorer addicts, who can no longer afford the opioids at street value (after the gov't targeted these drugs), turn to a killer of a substitute in the cheaper black-tar heroin. This black-tar heroin flows in mainly from El Chapo's Sinaloa cartel in the mountainous Sinaloa region of Mexico. While I was aware of the opioids dilemma, I wasn't of black tar heroine.
I recommend this book if anyone in your circle of family and close friends is or has been addicted to pain pills, or you're fascinated by documentaries on human nature, addiction or the war on drugs.
I've seen the needle and the damage done, A little part of it in everyone, But every junkie's like a settin' sun Neil Young, "Needle and the Damage Done," 1971
Read this book. I'm going to say that again: READ. THIS. BOOK. If you live anywhere in middle America, but especially if you live in Southern Ohio, you have to read this book to see where the scourge of narcotics has come from. The origins of the opiate epidemic are laid out as clearly as possible for all to see. One of the most significant problems in our society over the last 20 years, and the perfect storm that led to it called out in black and white. But probably most significant is how clearly you can see that the issue is not one of moral failings on the part of drug addicts. It is the result of our society's delusional pursuit of wealth at all costs, and the desire to live some absurd dream life that is not only unrealistic, but isn't even life. Not only in the desire to eliminate pain with a magical pill, but also to make huge amounts of money selling those pills no matter the human cost. How clearly you can see that it's not just the "junkies" pursuing that delusion, it's the heroin pushers, the drug reps, pharmaceutical companies, Walmart, and the unrealistic expectations placed on middle class America.
But not only can you see exactly how we got here, you can also see how we're beginning to wake up and get out. The first step to recovery is admitting you have a problem, and that applies not just to the "junkies" but to all of us as well. This isn't a problem just for criminal lowlifes who are hooked on drugs. This is a problem for all of us. When you look at that "junkie" you have to see a brother or a sister, not some morally corrupt non-being. We have to stand up and say "no more." We have to accept that alleviating pain is hard work, and there is no short cut. We have to recognize that our salvation is not in a pill or a doctor or a corporation or a bigger house or a better car. It's in ourselves and in our connection to other human beings. I swear I got choked up at the end of the book because in Portsmouth's recovery I saw the recovery of Chillicothe and Columbus and so much more of middle America. A recovery that I've witnessed again and again as individuals stand up and say I'm going to make a difference in my community. A recovery that is based in reaching out to each other, speaking the truth to each other, pulling each other up, and saying to anything or anybody who would put us down that we're better than that, and we'll prove it.
A powerful exposé. Mr. Quinones has written an intensive work piecing together the progression of oxycodone and black tar heroin use in America. He unearthed the perfect storm when his research showed the medical community interpreted false opiate addiction data and ignored the resulting addictions and deaths. The scene was ripe for the black tar heroin producers of Narayit, Mexico to step in and fill addiction gaps with cheaper and better opioids. A deadly epidemic was created.
Mr. Quinones discusses the modern business model for selling heroin to small town, white America. He describes an American society that allowed the opioid grip to take hold (recession, lack of community, the search for pleasure, greed). He shows how steps are being taken to change legislation regarding pain clinics and opiate prescribing. And he recognizes the need to stop the stigma around heroin deaths in middle America and admit and talk about how the staggering number of opioid deaths are caused.
This is an amazing piece of work. Highly recommended.
Side note - in the early 2000’s, our fiery prosecuting attorney became so enraged with the upswing in OxyContin crimes that he stormed over to the hospital’s medical chief of staff and insisted he control his doctors’ rampant prescribing of the drug. My staff strongly protested that our prosecutor was blaming the wrong people. Turns out he wasn’t so wrong.
This is an intense, chilling account of how the parallel forces of Purdue Pharma (with the support and ignorance of the medical community) and entrepreneurs in the town of Xalisco, Mexico pushed millions of Americans into becoming addicts of oxycontin and black tar heroin. I was familiar with the outlines of the "opioid crisis" but there was so much I didn't know until reading this book. I really appreciate how Quinones laid out his research in an engaging and riveting manner. Like many non-fiction books, there is too much repetition - some of his chapters seemed almost duplicates of other chapters - just set in another town with different players. Overall, a very important book.
This is a remarkable book explaining the forever changing and evolving drug trade in the United States (which also influences Canada). There are two aspects that the author analyzes in detail and how they became tied to each other.
He reveals how the drug companies have always searched for an elusive elixir that could remove pain. The trouble was that in many people in caused addiction. But with production of OxyContin this was advertised as being non-addictive, but based on very little research. The author points out that pain (or pain control) became a significant part of the medical process starting in the 1980’s and that a pill could successfully resolve this. However this removed other aspects of healing from the curative health process – like changing your lifestyle, doing more exercise, eating better foods and taking into account psychological and social issues (like stress). Pain relieving pills became the “be all and end all”.
And this hit hard in the heartland of the U.S. where there was high unemployment. Pill mill clinics started to proliferate as addiction grew. And the “high’ spread to teenagers. For example it became popular with school athletes to control or subdue their pain from injuries – one can easily imagine how these pills (OxyContin) were spread around to friends. Addiction became rampant.
Into this entered black tar heroin which was grown and distributed in an impoverished region of Mexico from the town of Xalisco in the province of Nayarit. This was a “non-violent cartel” who marketed their product brilliantly. It was cheaper than OxyContin and it was delivered to your door (think pizza delivery with no delivery charge!). The “Xalisco boys”, as they were called, focused on new markets of white middle class kids who were fast becoming junkies. The “Xalisco boys” would work only a few months in towns like Columbus and Portsmouth, Ohio and Boise, Idaho, and then return to Xalisco with their American dollars. There were always many willing recruits to go to El Norte – and they sometimes would set-up their own delivery system competing with other Xalisco boys. They would use junkies to locate and establish a new market.
The author delineates the growth of both of these – the pharmaceutical and the Xalisco boys. There has now been more legislative controls set-up for pain killers and prescriptions. OxyContin has been confirmed as being highly addictive. Rehabilitation is back in vogue, as opposed to prison sentences. This is a little hypocritical because now it is white kids becoming addicted and it is not seen as proper to send them to jail. On the other hand far more have died from OxyContin overdoses than during the worst days of the crack-cocaine epidemic.
This book is most enlightening on the spread of pharmaceutical drugs and its relationship to heroin.
there's more at my online journal nonfiction page, so feel free to click here to go there if you'd like.
If you are someone who pays attention, it is no secret that there is a massive heroin epidemic in this country. Dreamland takes its readers into examining the burgeoning heroin problem. Mr. Quinones charts how the "realities of American medicine and medical marketing of the 1980s and 1990s" came to be "connected to why, years later, men from a small town in Mexico could sell so much heroin in parts of the country that had never seen it before." Several things come together here: 1) the clever methodologies of these small-town dealers, 2) a huge unprecedented push by a leading pharmaceutical company trying to market and sell their opioid wares, most importantly for this book, OxyContin, 3) economic decline in formerly industrial areas, and 4) the changes in how doctors treated pain among their patients (along with changes brought by managed health care).
For anyone at all interested in this topic, Dreamland is a work of investigative journalism that explores the roots and the spread of our modern heroin epidemic, with Quinones taking a very wide-ranging approach to his examination. Whether or not you agree with his conclusions, it is a fascinating book and I for one, couldn't put it down. Looking at what other readers had to say about it, a lot of people zone in on the repetition that is found throughout and I can understand their complaints -- the number of times he uses the phrase "delivering heroin like pizza" is frankly annoying. But this is a very minor complaint that seems pretty irrelevant in comparison to what a reader will come away with after finishing this book.
I highly, highly recommend this very eye-opening book.
This book was incredible. I had only vaguely heard about it and needed something new to audiobook, and wound up having my mind blown.
It's a story of the opioid epidemic told through fascinating characters and a history of capitalism over the past few decades--everything from the disappearance of factory jobs to the retailing of heroin sales to the birth of pharma advertising to the role of Walmart in small towns and so much more.
It occasionally slides into some sort of weird bootstrappy ish when talking about alternatives to opioid prescriptions for chronic pain, but it's such an amazing work of journalism that I'll forgive the author not being a commie like me. Because it turns out, when you do in-depth journalism of this magnitude, you do wind up at the conclusion that it's the "free market" at fault.
DREAMLAND: The True Tale of America's Opiate Epidemic by Sam Quinones, 2015 @bloomsburypublishing
Even after reading many articles and another book on the opioid crisis in the US, this book provided the most expansive view of HOW things occurred - the scale, the interconnectedness - more of the macro approach. Beyond Purdue Pharma and the Sacklers, beyond pill mills and hack doctors...
Quinones' investigative work shows the rise of 'black tar heroin' from the small rural area of Xalisco, Nayarit, Mexico and the way it was commoditized and retailed in small-town US, at the same time that Oxycontin was being overprescribed, first by well-meaning doctors who wanted to provide relief to chronic patients, but simply didn't do their due diligence and research, and also by any person with a prescription pad. Highly addictive substances and virtually identical in makeup, but different manufacturing and distribution streams.
The "Xalisco Boys" were unlike any other narcotraffickers - not a cartel, they shunned violence, did not carry guns - but parking outside of methadone clinics and offering up "samples" and a free delivery service, and being friendly. They even had customer service surveys and referral discounts. Many never even tried the drugs they were peddling, caring more about getting new clothing and cars to show off back in their Mexican hometown. This was the most eye-opening portion of the book for me - the character "Enrique" and "The Man", and the interviews with the people from Xalisco.
There's a lot more to this book and what Quinones puts together. We don't get the same focus on individuals as other books (Beth Macy's DOPESICK and Hari's CHASING THE SCREAM come to mind), but more the wide-angle lens. My copy of the book has an additional afterword by the author, written about changes in the Rust Belt towns since his original investigations. Five years after publication & some states seeing an increase in overdose deaths in 2019, but also general public awareness and education in prevention and life-saving measures.
My first job as a nurse was on a surgical floor. I routinely gave people narcotics, both intravenously and as pills. I had patients who had undergone radical surgeries that required high doses of course, but as any healthcare provider can attest, there were also plenty of patients demanding narcotics for even minor procedures. I remember one patient, in her early twenties, who refused to be discharged unless her doctor gave her a prescription for fifty percocets! He did, of course, so she would finally leave. I assumed that over prescribing and elevating pain as the 5th vital sign were the major factors contributing to opiate addiction. I could never imagine however, how the epidemic is really a confluence of so many societal factors - the economic downturn of heartland America, the entrepreneurial ingenuity of Mexicans in the small state of Xalisco, false advertising and zealous marketing by pharmaceutical companies, pill mills, and the structure of Medicaid, among other things. This book very thoroughly discusses all of these factors, interspersed with personal stories, on how opiates and eventually heroin came to quickly dominate regions of the country where street drugs were previously unknown. It also discusses how prosecutors, DEA agents, public health officials, and social workers are working to try and get a handle on the epidemic. I gave the book three stars because I thought the book repeated itself a lot and was too long. I also almost didn't finish it because part of it was just too depressing. It ends on a positive note, even as it acknowledges that society has a long way to go before we approach a large scale resolution.
המחבר סם קווינונס (או משהו כזה תסלחו לי אם עיוותתי את השם) יוצא במסע מחקרי אל לב המאפליה של ההתמכרות האמריקאים להירואין ואופיאטים. במסע מבוסס על ראיונות עם מכורים, בני משפחתם, אנשי חוק וסוחרים קטנים הוא מתחכה אחר מקורות המגפה שתקפה את אמריקה בשני העשורים האחרונים.
הספר די מזעזע והוא מתאר שלב אחרי שלב את התפשטות מגפת ההתמכרות לאוקסיקונדין שהיא תרופת שיכוך לכאבים מקבוצת האופיאטים ולהתפשטות מגפת ההירואין בארה"ב. החל מהשלב החרדתי של מערכת הבריאות שהיתה מוטרדת מהתמכרות לתרופה ועד שחרור כל הבלמים בדהירה אל קטסטרופה לאומית וכלכלית.
מזעזע בשל הבורות המופגנת והבוטה של הממסד הרפואי לגבי השפעות הממכרות של התרופה. מזעזע בשל המניפולציות השיווקיות של חברות התרופות. ומזעזע בשל הנזק העצום והבלתי נתפס למליוני אנשים שפשוט חיפשו מזור לכאבים הכרוניים מהם סובלים ומצאו עצמם מכורים לתרופות.
הבעיה המטרידה ביותר היא הנורמטיביות לכ��ורה של האוקסיקונטין כתרופה לגיטימית שמתקבלת במרשם רופא אבל למעשה היא דומה בפעילות שלה להירואין. התעשיה של תרופות המרשם של אופיאטים גילגלה ואני מניחה שעדין מגלגלת מילארדים בזכות אמירות חסרות אחריות וטענות מופרכות שהתייחסו לכאב כסממן החמישי למדדי בריאות הגוף ולפסקה במאמר משנות ה 80 בו נטען כביכול שרק 1% מהמשתמשים יתמכרו לתרופה. טענה מופרכת והזויה שהוצאה מפיסקה שבעצמה הוצאה מההקשר הרחב שלה שהתייחס לאפשרות התמכרות בטיפול מבוקר ובהשגחה צמודה.
עשור לאחר המצאת האוקסיקונדין, והחדרתו לשוק באמצעים שיווקיים אגרסיביים כגון חופשות, מתנות קטנות וימי השתלמות ממומנים לרופאים, 6.1 מליון אמריקאים השתמשו לרעה בתרופה בין אם עי צריכה שלה ישירות והתמכרות לכדור ובין אם עי פירוקה ושימוש בחומר שבה בצורות לא מושהות. גם מתדון, שנחשב בטוח לשימוש הפך לגורם משפיע בחילחול התופעה, הוא לא טיפל בכאבים הכרוניים. יותר ויותר אמריקאים מתו משימוש במנת יתר של תרופות אופיטיות וגיל השימוש היה בירידה תלולה.
הספר עוסק בתחלואי מערכת הרווחה והבריאות האמריקאית כאשר מערכת הרווחה סיפקה ביטוח רפואי שאפשר קבלת כדורי אוקסיקונדין בעלות מגוחכת. סביב כדורים אלה התפתחה תעשיית סחר חליפין שאיפשרה לנתמכי רווחה להשיג מוצרי צריכה ונוחות בתמורה לכדורים. תעשית סחר החליפין בדרך עקיפה עודדה גניבות בסדר גודל קולוסאלי מוולמארט שהחזיקו את כלל מוצרי הצריכה והרווחה והמוכרנים שלהם לא היו לויאלים לחנות בגלל השכר הנמוך ואיפשרו את הגניבות הללו. הסופר נותן את הדוגמא של השפעת ההתמכרות ההמונית הזו על הכלכלה של פורט'סמית. ילדים מתו משימוש יתר ותושבי העיר המתועשת הלכו והתדרדרו ממעמד הביניים הכלכלי לאשפתות. מזעזע כבר כתבתי?
בד בבד מקבל הקורא סקירה על התפשטות מגיפת ההרואין ממקסיקו ודרכי החילחול שלו לתוך אוכלוסיות נורמטיביות גם בעקבות התפשטות מגפת האופיאטים כסם משלים. מגפה שלא זוהתה נכון בגלל מודל ההפעלה היחידני והבלתי אלים שלה. ההרואין שהיה נדבך משלים לכדורים חילחל בכמויות עצומות ומחירו בשוק ירד לסכומים מגוחכים. רשויות החוק לא הצליחו לשים ידם על מחוללי הפשיעה כי הסחר נעשה עי יחידנים שלא נשאו עימם כמויות סם משמעותיות. כך רק מבצע פדרלי חוצה מדינות הצליח לטרפד את מחוללי העבירה אבל הדבר היה מאוחר מידי ומעט מידי. לאחר אמצע שנות ה 2000 כאשר נוסחת האוקסיקונדין עברה שינוי עי חברת פרדו ולא היה ניתן לפרק את הכדור ולהשתמש בו בצורות לא מושהות, מגיפת ההירואין קיבלה מימדים מפחידים. ספורטאים, שחקנים ואנשי שם מהשורה מתו כתוצאה משימוש יתר גם אחרי שעברו גמילה. בעקבות מכת המוות של אנשים מפורסמים המודעות של האמריקאים התעוררה והחלה תנועת התנגדות כולל של מינהל התרופות, סידרת תביעות משפטיות כנגד החברות, פעולות אגרסיביות כנגד היחידנים שפעלו למכירת הירואין ומודעות גוברת של הרופאים לתוצאות ההרסניות של השימוש באופיטים.
מדובר באחד הספרים המרתקים שיצא לי לקרוא. עריכה קצת יותר הדוקה היתה מצמצת את החזרות בספר ומביאה יותר סיפורים אישיים. ארץ החלומות בפורת'סמית אוהיו, הפכה ברבות השנים לארץ חרבה כתוצאה מהתעלמות הרשויות האמריקאיות ונצלנות חברות התרופות לגריפת עושר אגדי. כיום, מה שנותר הוא ללמוד את הלקחים ולשקם את ההריסות של חיי מליונים שנחרבו.
לגבי המגפה של האופיטים אפשר לקרוא בכלכליסט מאמר מרתק שיצא בעקבות ספר אחר על התופעה -
A fascinating and incredible work of journalism undermined by poor organization and excessive repetition.
The ideas behind the book itself are incredible. Essentially, small cities/towns across the Midwest have been devastated by two simultaneous trends: 1) the aggressive over prescribing of opiates for pain and 2) the importation of black tar heroin from essentially a small village in Mexico. The former essentially primed a lot of young people for the latter, leading to waves of overdoses and addiction. And making this even crazier, the people this is happening to are largely white and solidly middle-class.
Quionones has clearly done his homework. He's gone to Mexico to track down the heroin gang and profiled in depth how they operate in a non-violent fashion, sending a steady stream of people across the border to deliver heroin in what sounds a lot like Uber for drugs--you call a number, someone shows up pretty quickly and delivers it to you. There's little to no violence and the network is completely decentralized, meaning that just arresting a few people has no effect on the larger operation.
He pairs that story with a devastating critique of Perdue Pharma and its role in Oxycontin, which rests on a complete misinterpretation of the literature that makes opiates seem addictive than they are. Add that to many stories of overdoses of young adults and you've got the makings of an incredible and sad topic.
So why only 2 stars? Organization, organization, organization. The book is a bit of a structural mess. We get short chapters that jump across characters, which is fine, but it also comes with constant repetition. We are reminded again and again that the heroin dealers are non-violent, they all come from one place, how they operate, etc. Same deal with the pharmaceutical company. It just feels like either Quinones doesn't trust his reader enough to ensure that they'll remember these big picture details or his editors largely failed him.
Either way, the result of this is a book that is at times quite frustrating to read. There are whole chapters that feel like they aren't adding anything except repeating things you've already read. The book is divided into sections but not for any clear reason--resulting in basically one section for about 2/3 of the book and then three sections over the final 50-70 pages.
Lop about 100 pages off and fix the organization and you've got pretty one of the most intriguing books I've read in some time. But in its current form the information is great but reading it doesn't quite work.
As the mother of both a medical student and of a recovering (? Part of the pain - you can never be completely sure) addict, I found this impeccably researched book on the creation of opiate addiction (in large part by doctors who were fed and believed lies by the pharmaceutical companies pimping their wares) in the US compelling, fascinating, terrifying, heartbreaking, and scary af.
The book itself could stand a bit of editing; at times it feels like Quiñones spent so much time investigating he couldn't bare to leave any detail out. But his descriptions of how cheap black tar heroin infiltrated the suburbs and then more insidiously how prescription opiates took hold were chilling. My daughter in medical school assures me the stories of Big Pharma repeatedly citing a "study" proving opiates were not addicting and encouraging doctors to increase doses under the idea in the 1990s and early 2000s that pain was something no one should have to deal with; while the "study" was merely a half page letter to the editor and not a study at all - is completely true. I am relieved medical schools now are teaching their students about other ways to manage pain - like lifestyle changes. And realizing that some pain is just part of life. I would like to see more of this explored - what is it about this time period in the US where we believe life ought to be and can be sunshine and unicorns all day every day and completely pain free?!
Highly recommended reading - everyone should be aware of how this epidemic which currently takes more lives than auto accidents - came about. When the medical industry is consumer driven and people demand freedom from pain even well meaning doctors get worn down. And people believe what they want to believe. It seems asinine now to think anyone could ever have believed opiates weren't addicting... Makes you wonder what craziness we are currently believing because we want to believe...
This book is a fascinating and disturbing look at the connection between the use of prescription opiates and heroin addiction. The author blends facts with real life stories, pulling us into this world where pharmaceutical companies and pill mill doctors are knowingly creating addicts.
Much of the story centers around Portsmouth, Ohio, a blue-collar town where families once thrived. We follow its history, through an economic collapse, the burgeoning pain clinics and Oxycontin push, and the subsequent onslaught of heroin dealers and addicts.
But the problem is certainly not limited to this one area of Ohio. Quinones takes us through the country, where opiate and heroin addictions go hand-in-hand.
We also learn about the Xalisco Boys, a loosely formed group of Mexican immigrants who take advantage of the new opiate addiction by providing a cheaper alternative. Black tar heroin comes from Mexico, not Afghanistan, and it is a far worse problem than the white powder has ever been.
Throughout this book, we meet the addicts and their families, the dealers, the doctors, and the DEA agents who are trying to make sense of this fast-growing epidemic.
Oxycontin, Oxycodone, and heroin all come from the morphine molecule. One is not safer than the other. They are all highly addictive drugs. Quinones uncovers the lies told to doctors and to patients about the supposed safety of the Oxy product, with pharmaceutical representatives calling it nonaddictive and pushing doctors to prescribe in increasing dosages. The pharmaceutical company here is worse than the street dealer, as they purposely and knowingly create a nation of addicts all in the name of profit. Yet no one is locking them away for their crime.
This is a book that needs to be read by the masses. We have become a nation of drug addicts. Putting it in pill form and labeling it 'medication' only means our dealers are now pharmaceutical companies instead of drug cartels. That is, until the doctor cuts us off or we can't afford the pills anymore. Addiction doesn't go away because the doctor stops writing prescriptions or because the pills cost too much. When that happens, we just turn to the cheaper alternative. Whether we call them 'legal medications' or 'illegal drugs', it's all the same and it's all destructive.
*Neither I nor the author make the claim that pain meds should not be prescribed and used appropriately - only cautiously.*
**I was given a free copy of this book by Bloomsbury via NetGalley, in exchange for my honest review.**
This wide-ranging, insightful story of America's opiate crisis makes for painful and sad reading. The author keeps things moving while presenting the sobering facts. One thing that struck me is the mistaken belief some parents had that a 30-day therapy/detox would "fix" their kids' addictions. It's a lifetime struggle. I'm sure many families, including my own, have been touched by the scourge of heroin and opiate pills like OxyContin. Big pharma comes off looking really bad in their crass pursuit of the Almighty Dollar. The author has an engaging narrative style I found easy to follow. If you want to know more about what happened, this book might be the right one for you.
This book is rich with information and some interesting analysis. But the author does get repetitive with too many anecdotes, especially when revisiting the black tar heroin connection in Xalisco, Mexico, and the pill mills in Portsmouth, OH.
"In heroin addicts, I had seen the debasement that comes from the loss of free will and enslavement to what amounts to an idea: permanent pleasure, numbness, and the avoidance of pain. But man’s decay has always begun as soon as he has it all, and is free of friction, pain, and the deprivation that temper his behavior."
"Worldwide morphine consumption began to climb, rising thirtyfold between 1980 and 2011. But a strange thing happened. Use didn’t rise in the developing world, which might reasonably be viewed as the region in most acute pain. Instead, the wealthiest countries, with 20 percent of the world’s population, came to consume almost all— more than 90 percent— of the world’s morphine."
"while many Utahans, as Mormons, didn’t consume caffeine, nicotine, and other drugs, the clandestine use of prescription pills, primarily painkillers, had taken hold, giving clinicians ample opportunity to study addiction."
acting on false assumptions, without scientific proof.....
"An idea advanced that pain counteracted opiates’ euphoric effect and thus reduced the risk of addiction....There appeared to be no ceiling on the dose of opiate painkillers a pain patient might take. Pain acted against the tendency of opiates to stop the lungs from breathing."
I can speak for my Boomer generation that, like Alice, many of us have always been looking for the magic mushroom that will take away pain and depression. Our very own Soma or Murti-Bing (link in first comment). Prozac turned out to be a disaster. Right now it's CBD. And, if Michael Pollan is to be believed, a return to psychedelics.
Beginning with California, states passed laws exempting doctors from prosecution if they prescribed opiates for pain within the practice of responsible health care....but In some hospitals, doctors were told they could be sued if they did not treat pain aggressively, which meant with opiates.
Perhaps the most astonishing story in the book is the tale of Porter & Jick, two medical researchers at Boston University who did an accounting of opiate addiction under very limited circumstances. Their database consisted of hospitalized patients from years when opiates were strictly controlled in hospitals and given in tiny doses to those suffering the most acute pain, all overseen by doctors. The analysis concluded that less than 1 percent of patients treated with narcotics developed addictions to them. These were not chronic-pain patients going home with bottles of pain pills. These stats were contained in a letter to the editor on page 123 of the January 1980, New England Journal of Medicine.
That single paragraph letter, buried in the back pages of the New England Journal of Medicine, was mentioned, lectured on, and cited until it emerged transformed into, in the words of one textbook, a “landmark report” and "an extensive study" that did much to counteract fears of addiction in pain patients treated with opiates. The "study" was cited over and over in medical schools and by pharmacists and nurses. A pain specialist, a true believer named Russell Portenoy, became the chief evangelist through numerous information organs. In fact, it's a case study in misinformation and propaganda.
In the 2000's, Americans were enjoying an era of amped consumer spending based on massive debt and towering real estate values that appeared to rise endlessly. It was a time when the country seemed a dreamland where the old rules, constraints, and knowledge no longer applied. Americans consumed 83 percent of the world’s oxycodone and fully 99 percent of the world’s hydrocodone (the opiate in Vicodin and Lortab).
Overdose deaths involving opiates rose from ten a day in 1999 to one every half hour by 2012. Abuse of prescription painkillers was behind 488,000 emergency room visits in 2011, almost triple the number of seven years before.
Methadone prescriptions more than quadrupled— from under a million in 1999 to 4.4 million in 2009 nationwide— mostly for headaches and bodily pain. Many doctors, however, didn’t understand that methadone, while it was long-lasting and therefore effective as a maintenance drug, was not a long-lasting painkiller. It relieved pain for only a few hours. So patients took more and more of it through the day to get pain relief. The drug built up in their bodies, causing overdoses. As methadone prescriptions rose, so did overdose deaths involving methadone— from 623 in 1999 to 4,706 in 2007.
This is a shocking indictment of how lax drug laws, misinformation about opiates, and big bucks propaganda campaigns created an epidemic that is the worst human-generated health crisis in a generation.
It is also a symptom of the greed and lack of ethics that dominates our country. It seems to be in numerous sectors right now, including the government and big tech, especially Facebook
The Sacklers are only touched on briefly in this book. They are supposed philanthropists who essentially became a legal cartel pushing OxyContin through the notorious family-owned Purdue Pharmaceuticals.
Highly recommended story about them in the New Yorker....
Fascinating and infuriating account of the work of the Xalisco Boys (a network of Mexican drug dealers selling cheap heroin) and Purdue Pharmaceuticals selling the pain medication oxycontin (which Purdue insisted was non-addictive even though it's essentially heroin) converged to create an opiate-addiction epidemic across the country, but particularly in the Ohio River Valley. Some people genuinely needed pain medication; others were people leading hopeless lives in the Rust Belt and were looking for a high; but they all got addicted. And if they were short of cash or couldn't get legit prescriptions, the Xalisco Boys were there to sell them black tar heroin, which was cheaper than oxycontin. The epidemic was a result of good intentions, greed and hopelessness. The Xalisco Boys were poor kids from Narayit, Mexico, many of them from families so poor they sometimes didn't have enough to eat, who wanted to give their families a future. Conscientious doctors wanted to do something for patients suffering from chronic pain and wanted to believe Purdue sales reps who told them oxycontin was not addictive. Purdue wanted to make more money. Unscrupulous doctors saw writing oxycontin prescriptions for anyone who asked as a way to make a lot of money fast. People in towns where all the industries had left and were often second-generation unemployed saw heroin or oxycontin highs as a temporary escape from their bleak lives. Still others in those same towns saw selling bootleg oxycontin as their easiest route to making a decent income.
A horrifying, utterly fascinating, underreported story.
A brilliant, fascinating account of the rise of opiate addiction in America. This is a masterwork of research and writing that traces the factors — from pharmaceutical marketing to the invasion of black tar heroin — that created a perfect storm and ruined the lives of millions. More frightening than anything I could ever write.
I read this book to learn more about the history of the opiate epidemic and believe me, I learned a lot. That said, it took me awhile to plow through the many redundancies. Some aggressive editing would have made this book more palatable. However, I'm giving it 4 stars for the author's meticulous research and ability to make that information accessible to me. It simultaneously tells the stories of the Xalisco boys, who introduced Mexican black tar heroin to many communities, Purdue Pharma Company, and the docs trying to manage their patients' pain. I didn't understand how widespread the opiate economy is. People travel many hours to pill mills where "docs" write scripts for OxyContin. If they can't get there on their own, dealers take them in exchange for half of their prescribed pills. As one example, Broward County had 4 pain clinics in 2007 and 115 by 2009. It's an extremely profitable business.
Widespread shoplifting (mostly at Walmart, sometimes Lowes) provides capital. Dealers and users scour Walmart parking lots for discarded receipts. They buy the items on the receipt then return them for cash. Without the receipts, they can get gift cards for their shoplifted items. Those gift cards are used as currency. Some set up stores in their apartments to sell shoplifted items.
If you are drawing $500 a month "have a Medicare card that allows you to get a monthly supply of pills worth thousands of dollars, you're going to sell your pills." Many people used this income for their necessities, others for luxuries.
It was widely believed in the 1990's that opiates would not cause addiction problems for people who used them for pain. Once that was disproven and many were addicted, heroin became a cheaper and longer lasting substitute---especially that Mexican black tar. When you use drugs, your brain development, particularly the frontal lobe, is stalled. So, we have many older users acting like 15 year olds. For sure.
Sadly the fields of pain management and addiction almost never work together. After kicking opiates it takes two years for your dopamine receptors to start working naturally. Our American medical system seems to be "good at fighting disease but awful at leading people to wellness".
In 2008 drug overdoses passed car accidents for the leading cause of death. We all need to pay attention.
Sprawly, vivid, fascinating, horrifying journalism. How can you tell if a business that calls itself a pain clinic is an actual pain clinic or a pill mill? Check out the parking lot. If the lot is full of people standing around, wearing pajamas, getting into fistfights, and having pizza delivered, then you are looking at a pill mill.
One of the doctors that Quinones interviews has a theory: America has about the same percentage of addictive personalities that it has always had, but that OxyContin and similar drugs--because they are so addictive and often fatal themselves, and because they are such an effective gateway drug to heroin--are crippling and killing addicts much faster than alcohol does. The doctor said that he sees people break down from alcoholism after about 20 years of problem drinking. With Oxy it's more like five years.
I had no idea that there is a vast network of drug dealers who deliver heroin like pizza, who are paid a flat rate so they never dilute the product, who deal in small quantities and drive beater cars to avoid police attention, and who fear and avoid black people.
I admire Quinones's dogged reporting and his compassion for the parents, grandparents, and children of addicts.
It wasn't the cartels. It wasn't a big city criminal class. It wasn't apathetic law enforcement or inept parenting. This is the story of how a rural sugar cane growing village in the Pacific coastal state of Nayarit and Purdue Pharma, the aggressive marketer of OxyContin, a time-released opioid pain-killer, formed an unwitting symbiotic relationship. OxyContin was approved for sale in 1996. In just over a decade it had outpaced automobiles as the leading cause of accidental deaths nationwide.
“...OxyContin had already tenderized the terrain, sold not to tapped-out old junkies but to younger kids, many from the suburbs, most of whom had money and all of whom were white. Their transition from Oxy to heroin...was a natural and easy one. Oxy addicts began by sucking on and dissolving the pills' timed-releast coating. They were left with 40 or 80 mg of pure oxycodone. At first, addicts crushed the pills and snorted the powder. As their tolerance built, they used more. To get a bigger bang from the pills, they liquified and injected it. But their tolerance never stopped climbing....As they reached their financial limits, many switched to heroin, since they were already shooting up Oxy and had lost any fear of the needle....[E]very Oxy addict was a tar junkie in waiting.” (p.165-166) That was the addictive power of a legalized prescription drug.
“The terrain” was middle-sized and small town America – places like Huntington, West Virginia, South Shore, Kentucky, Portsmouth, Ohio. Later Columbus, Nashville and Charlotte became new hubs for distribution. These are the places Quinones visits. He interviews still grief stricken families about their frantic efforts to rescue their addicted children.
He also introduces us to the isolated investigators who early on identified fragments of the rapidly growing problem: 1995-Denver Police Officer Dennis Chavez; 1997-Director of the Counseling Center in Portsmouth, Ohio, Ed Hughes; 1999-Multnomah County Health Department official Dr. Gary Oxman, Portland, Oregon Recovery Association Project (RAP) activist Ed Blackburn and Albuquerque based DEA agent Jim Kuykendall.; 2003-Columbus Children's Hospital pediatrician Dr. Peter Rogers; 2005-Epidemiologist for the state of Washington Jennifer Sabel; 2007-Supervisor of the Violenc and Injury Unit of the Ohio Dept. of Health Christy Beeghly. These were people who heard rumors, combed through statistics, tried to make sense of what they learned and tried to warn the public.
Quinones has done ample research, but this is not a book about timelines and numbers. It is a book about stories. A pill mill in Portsmouth, Ohio set up by David Procter became a template for selling prescriptions across the region. A suspicious rise in Medicaid recipients became a screen for a secondary market of opioid pill sales. Toxic consumerism destroyed local businesses in the wake of Walmart mega-stores, which in turn became shoplifting paradises. High school and college sports churned out injured athletes who, in their quest for success, became hooked on pain-killers. Florida became a drug mecca because until 2009 it had no prescription monitoring system. And throughout the period, Xalisco Boys with hustle became part of a decentralized network that relied on market expansion and excellent customer service. It was capitalism in action. After a 6 month stint they would return to Xalisco only to feed a village culture of parasitic relatives and outsized conspicuous consumption. They would return to the states to continue the cycle.
Dr. Phillip Prior, specialist in addiction medicine at the VA Hospital in Chillicothe, Ohio sums up the tragedy: “'I've yet to find one [addict] who didn't start with OxyContin....They wouldn't be selling this quantity of heroin on the street right now if they hadn't made these decisions in the boardroom.'” (p.269)
This is thorough to progress for this horrific opiate epidemic that has lead to numerous "black tar" heroin overdose deaths. At times in places within the USA that never had a single heroin related problem before this progression of the last fifteen years. This quite beyond the huge number of addictions to opiate pills which ignite the need for more of the same class.
It details the Mexican group/ groups primarily expanding to a huge business within the USA.
It holds 100's of anecdotal stories, but beyond that it has startling stats. I was horrified to see how long that this particular cause of death had risen above accidental car collision death in several different states. Despicable!
The poor families, the money spent on every level. Gotten/ bought with money from crimes (numbers of other criminal behaviors beyond stealing/robbery) to the spending of the entire family's equity. And also $$$$ for rehab by government and by individuals' families/communities. But the suffering!
This is a terrible problem and I don't feel you could impart it without all these repetitions or the numerous personal records in the print. So many people avoiding pain! And finding far more where that came from.