Dreamland: The True Tale of America's Opiate Epidemic

by Sam Quinones

1853: The hypodermic syringe is invented. Inventor’s wife is first to die of injected drug overdose.

1898: Bayer chemist invents diacetylmorphine, names it heroin.

But across America, thousands of people like Matt Schoonover were dying. Drug overdoses were killing more people every year than car accidents. Auto fatalities had been the leading cause of accidental death for decades until this. Now most of the fatal overdoses were from opiates: prescription painkillers or heroin. If deaths were the measurement, this wave of opiate abuse was the worst drug scourge to ever hit the country.

Her name was Carol Wagner. Carol went on to tell me of her handsome, college-educated son, Chad, who was prescribed OxyContin for his carpal tunnel syndrome, grew addicted, and never got unstuck after that. He lost home and family and five years later lay dead of a heroin overdose in a Cincinnati halfway house. Carol’s daughter-in-law had a nephew who’d also died from heroin.

I met other parents whose children were still alive, but who had shape-shifted into lying, thieving slaves to an unseen molecule.

Railcars carried the coal the region mined to Huntington, where river barges shipped it to the rest of the country. The city is at the nexus of America’s North and South—much like West Virginia itself. Democrats ran the state like a Tammany Hall. They created a legal and political system supportive of coal and railroad interests. The name of the state’s best-known senator, Robert C. Byrd, is on a dozen public buildings in Huntington alone—including a bridge over the Ohio River. Yet West Virginia sent its raw materials elsewhere to be transformed into profitable, higher-value products. Parts of the South threw off this third world model of economic development. West Virginia did not. Resource extraction mechanized and jobs left. Railroads declined and economic turbulence set in. But the state’s political system prevented a robust response or new direction. Poverty intensified. Marijuana became the state’s number one crop. In 2005, the state produced more coal than ever, but with the fewest workers ever.

Finishing his medical studies, Sackler became a psychiatrist at Creedmoor, a New York mental hospital. There, he wrote more than 150 papers on psychiatry and experimental medicine, and identified some of the chemical causes in schizophrenia and manic depression. He was an antismoking crusader long before it was popular, and prohibited smoking at the companies he would later own. At Long Island University, he started Laboratories for Therapeutic Research, which he later directed and supported with large donations. Meanwhile, he established the first racially integrated blood bank in New York City.

His father was elected treasurer of the local sugarcane farmers’ cooperative. He oversaw the installation of the first village streetlights. It surprised Enrique to see his father so diligent about putting in village light poles while he brought so much darkness home.

Excess contaminated the best of America. Caltech churned out brilliant students, yet too many of them now went not to science but to Wall Street to create financial gimmicks that paid off handsomely and produced nothing. Exorbitant salaries, meanwhile, were paid to Wall Street and corporate executives, no matter how poorly they did. Banks packaged rolls of bad mortgages and we believed Standard & Poor’s when they called them AAA. Well-off parents no longer asked their children to work when they became teenagers.

What gave the morphine molecule its immense power, he said, was that it evolved somehow to fit, key in lock, into the receptors that all mammals, especially humans, have in their brains and spines. The so-called mu-opioid receptors—designed to create pleasure sensations when they receive endorphins the body naturally produces—were especially welcoming to the morphine molecule. The receptor combines with endorphins to give us those glowing feelings at, say, the sight of an infant or the feel of a furry puppy. The morphine molecule overwhelms the receptor, creating a far more intense euphoria than anything we come by internally. It also produces drowsiness, constipation, and an end to physical pain. Aspirin had a limit to the amount of pain it could calm. But the more morphine you took, Coop said, the more pain was dulled.

As the mature poppy’s petals fall away, a golf-ball-sized bulb emerges atop the stem. The bulb houses a goo that contains opium. From opium, humans have derived laudanum, codeine, thebaine, hydrocodone, oxymorphone, and heroin, as well as almost two hundred other drugs—all containing the morphine molecule, or variations of it. Etorphine, derived from thebaine, is used in dart guns to tranquilize rhinoceroses and elephants.

Most drugs are easily reduced to water-soluble glucose in the human body, which then expels them. Alone in nature, the morphine molecule rebelled. It resisted being turned into glucose and it stayed in the body. “We still can’t explain why this happens. It just doesn’t follow the rules. Every other drug in the world—thousands of them—follows this rule. Morphine doesn’t,” Coop said. “It really is almost like someone designed it that way—diabolically so.”

When, for example, someone discovered that cocaine cooked with water and baking soda became rock hard, the smokable cocaine known as crack was born. Crack was a more effective delivery mechanism for cocaine—sending it straight to the brain.

Most Mexican immigrants spent years in the United States not melting in but imagining instead the day when they would go home for good. This was their American Dream: to return to Mexico better off than they had left it and show everyone back home that that’s how it was. They called home and sent money constantly. They were usually far more involved in, say, the digging of a new well in the rancho than in the workings of the school their children attended in the United States. They returned home for the village’s annual fiesta and spent money they couldn’t afford on barbecues, weddings, and quinceañeras. To that end, as they worked the toughest jobs in America, they assiduously built houses in the rancho back home that stood as monuments to their desire to return for good one day. These houses took a decade to finish. Immigrants added to their houses each time they returned. They invariably extended rebar from the top of the houses’ first floors. Rebar was a promise that as soon as he got the money together, the owner was adding a second story. Rods of rebar, standing at attention, became part of the skyline of literally thousands of Mexican immigrant villages and ranchos.

Opium was likely our first drug as agricultural civilizations formed near rivers. Mesopotamians grew the poppy at the Tigris and Euphrates. The Assyrians invented the method, still widely used today, of slicing and draining the poppy’s pod of the goo containing opium. “The Sumerians, the world’s first civilization and agriculturists, used the ideograms hul and gil for the poppy, translating it as the ‘joy plant,’” wrote Martin Booth, in his classic Opium: A History. The ancient Egyptians first produced opium as a drug. Thebaine, an opium derivative, is named for Thebes, the Egyptian city that was the first great center of opium-poppy production. Indians also grew the poppy and used opium. So did the Greeks. Homer and Virgil mention opium, and potions derived from it. The expanding Arab empire and later the Venetians, both inveterate traders, helped spread the drug.

In 1853, meanwhile, an Edinburgh doctor named Alexander Wood invented the hypodermic needle, a delivery system superior to both eating the pills and the then-popular anal suppositories. Needles allowed more accurate dosing. Wood and other doctors also believed needles would literally remove the patient’s appetite for the drug, which no longer had to be eaten. This proved incorrect. Wood’s wife became the first recorded overdose death from an injected opiate.

In London in 1874, Dr. Alder Wright was attempting to find a nonaddictive form of morphine when he synthesized a drug that he called diacetylmorphine—a terrific painkiller. In 1898, a Bayer Laboratory chemist in Germany, Heinrich Dreser, reproduced Wright’s diacetylmorphine and called it heroin—for heroisch, German for “heroic,” the word that Bayer workers used to describe how it made them feel when Dreser tested it on them. Heroin was first believed to be nonaddictive. Heroin pills were marketed as a remedy for coughs and respiratory ailments. With tuberculosis a public health threat, this was no small point. As junkies ever since have discovered, heroin is an effective constipator and was thus marketed as an antidiarrheal. Women used it, on doctor’s orders, for menstrual cramps and respiratory problems. Doctors didn’t have much else to prescribe for pain or disease. Thus addiction exploded—to a drug that people believed was safe because doctors said so.

wrote historian David Courtwright in Dark Paradise, his history of opiate addiction in America.

But heroin was never about the romantic subversion of societal norms. It was instead about the squarest of American things: business—dull, cold commerce. Heroin lent itself to structured underworld businesses. Addicts had no free will to choose one day not to buy the product. They were slaves to a take-no-prisoners molecule. Dealers could thus organize heroin distribution almost according to principles taught in business schools, providing they didn’t use the product. And providing they marketed.

Directing the clan was its patriarch, Don Jaime Herrera-Nevarez, a former police officer, who never left Mexico. It’s said that he had something to do with the reason that a Mexican ounce of heroin—known as a pedazo, or piece—is actually twenty-five grams, and not twenty-eight, which is the normal measure of an ounce. (This difference has caused many disputes among buyers who, unaware of the difference, feel they’re getting ripped off.) Legend has it that Don Jaime had a large spoon holding twenty-five grams that he used to scoop heroin. That became a standard ounce in the Mexican heroin world. I never learned whether this legend, recounted by several older DEA agents who tracked the Herreras, was true.

Most important of all—and crucial to the expansion of the Xalisco Boys—was that junkies could navigate America’s methadone clinics.

The painkiller known as methadone was synthesized by German scientists in the effort to make Nazi Germany medicinally self-reliant as it prepared for war. The Allies took the patent after the war, and Eli Lilly Company introduced the drug in the United States in 1947. U.S. doctors identified it as a potential aide to heroin addicts.

Methadone, Dole found, was the only opiate whose addicts did not demand increasing doses every few hours. Instead, they were happy with the same dose once a day, which could carry them through the next twenty-four hours. Methadone addicts could actually discuss topics unrelated to dope. This was not true of heroin addicts, whom Dole found tediously single-minded in their focus on the drug. Dole believed addicts could be maintained on methadone indefinitely, and that with one dose a day they could function as normal human beings. In 1970 in New York City, he opened the first methadone clinic for heroin addicts.

President Richard Nixon permitted methadone as a treatment for heroin addiction, which plagued many soldiers returning from the Vietnam War. By the late 1970s, federally regulated methadone clinics were popping up around the country. These clinics quietly showed how a narcotic might be dispensed legally in a safe, crime-free environment. Methadone stabilized an addict and allowed him to find a job and repair damaged relationships. There were also no dirty needles, no crime, and addicts knew they couldn’t be robbed at the clinics. What’s more, methadone undercut and replaced the street heroin dealers’ trade with a clean, well-lighted place for opiates; everyone was better off.

Methadone clinics opened before sunrise. One reason for this was that many addicts, looking for trades easy to enter, had become construction workers, carpenters, painters. They had to get to these jobs early. Methadone users were like ghosts, showing up early in the morning for years on end, drinking their dose, and silently going about their lives. In time, though, methadone became a battlefield between those who thought it should be used to wean addicts off opiates, and those, like Vincent Dole, who saw it as a lifelong drug, like insulin for diabetics.

Methadone was a better alternative to weak powder heroin, which was more expensive and available only in dangerous housing projects or skid rows. But maintaining large numbers of people on any kind of opiate, particularly on low doses, made them easy prey for someone with a more efficient and convenient opiate delivery system. For years, though, no one could conceive of such a thing: a system of retailing street heroin that was cheaper than, as safe as, and more convenient than a methadone clinic. But in the mid-1990s, that’s exactly what the Xalisco Boys brought to towns across America. They discovered that methadone clinics were, in effect, game preserves.

The delivery drivers did tours of six months and then left. If they were arrested they were deported, not prosecuted, because they never carried large amounts of dope. The cases were always light. Baldessare first figured they were small-timers. Later he realized that, quite to the contrary, they had learned how drug investigations worked: prosecutors prized cases with large quantities of drugs. Crack and methamphetamine were the priorities then, each measured in kilos. As camouflage, these Mexican heroin guys used just-in-time supplying, like any global corporation, to ensure they had only tiny quantities in their cars or apartments. This, too, was sophistication Baldessare didn’t see in the heroin underworld.

Gang members robbed their drivers and they did nothing. Several times clients put knives to Enrique’s throat. He spit the balloons into their hands, remembering a saying from his father: “Die for what’s yours, but not for what’s others.”

The CPDD funded chemists and pharmacologists, academics and industrial scientists, toward the goal of finding a nonaddictive painkiller. Novocain, invented in 1905, avoided the need for addictive cocaine in dentistry.

The Farm contained a section known as the Addiction Research Center (ARC). For decades, the ARC tested on inmates every major opiate that Committee-sponsored chemists produced: Dilaudid, Demerol, darvon, codeine, as well as Thorazine and many tranquilizers and sedatives. Experiments at the Farm showed that methadone lasted longer and spared junkies the severe highs and lows of heroin that spurred their frenzied attempts to score. Thus, they concluded, methadone could act as a replacement for heroin.

In 1972, a British company called Napp Pharmaceuticals developed a controlled-release formula, known as Continus, that the company first put to use with an asthma medicine. One day Twycross suggested to some Napp reps that their company might use Continus to develop a timed-release morphine pill. Napp eventually did so, and this proved important to this story. It offered doctors a new tool for treating pain in dying patients. Napp, also, is owned by Purdue, the laxative manufacturer that Arthur Sackler and his brothers had purchased in the 1950s.

WHO published a book in more than twenty languages laying out simple pain treatment steps, which came to be known as the WHO Ladder. Within it, morphine was deemed “an essential drug” in cancer pain relief. WHO went further. It claimed freedom from pain as a universal human right. The Ladder was accompanied by a concept relevant to our story that moved public and medical opinion. It was this: If a patient said he was in pain, doctors should believe him and prescribe accordingly. This attitude grew from a patients’ rights movement that sprung in part from the Nuremberg Trials, where Nazi doctors were found to be experimenters who disregarded patients’ autonomy, and later from the 1960s counterculture that suspected the motives of all established institutions, medicine included. With the WHO Ladder, doctors’ concern over the use of opium-derived drugs began to ease. They were, after all, remarkably effective at knocking down pain, which was now a human right. Worldwide morphine consumption began to climb, rising thirtyfold between 1980 and 2011.

The UW pain clinic set itself against trends in medical marketing. Those Valium ads that years before insisted that one pill could solve a patient’s problems were wrong, researchers at UW believed, at least where pain was concerned. Pain was complicated. But “there is a philosophy among many patients—‘I’m entitled to be free of pain,’” said Loeser. “People are entitled to health care. Health care should be a human right. Pain management must be a part of health care. But they are not entitled to pain relief. The physician may not be capable of providing them with pain relief. Some problems are not readily solvable. A patient is entitled to reasonable attempts to relieve the pain by reasonable means. You’re not entitled to pain relief any more than you’re entitled to happiness. “But usually the patient says, ‘I come to you, the doctor. Fix me.’ They treat themselves like an automobile. People become believers in the philosophy that all I need is to go to my doctor and my doctor will tell me what the problem is. That attitude has been fostered by the medical community and Big Pharma. The population wants to be fixed overnight. This is the issue we addressed with chronic pain patients. They have to learn it’s their body, their pain, their health. The work is done by them.”

Portenoy and Foley wrote a paper reporting those observations and submitted it to a medical journal called Pain. Opiates themselves were not inherently addictive, the authors suggested; a lot depended on the people taking them. Cited among the footnotes supporting the paper was a letter to the editor, by Jane Porter and Dr. Hershel Jick out of Boston, in a 1980 edition of the New England Journal of Medicine. It was headlined “Addiction Rare in Patients Treated with Narcotics.”

Doctors and medical associations, however, were worried. Prescribing these drugs might lead to addiction. They demanded legal clarity. So, beginning with California, states passed laws exempting doctors from prosecution if they prescribed opiates for pain within the practice of responsible health care. Numerous states approved so-called intractable pain regulations: Ohio, Oregon, Washington, and others. Soon what can only be described as a revolution in medical thought and practice was under way. Doctors were urged to begin attending to the country’s pain epidemic by prescribing these drugs. Interns and residents were taught that these drugs were now not addictive, that doctors thus had a mission, a duty, to use them. In some hospitals, doctors were told they could be sued if they did not treat pain aggressively, which meant with opiates.

“The fifth vital sign” was a “concept, not a guide for pain assessment,” one report read. Along with the pain number scale, a doctor ought to ask numerous questions about a patient’s pain history, the pain’s location, severity, impact on daily life, as well as the patient’s family history, substance abuse, psychological issues, and so on. In fact, pain was really not a vital sign, after all, for unlike the four real vital signs it cannot be measured objectively and with exactitude.

Years after his Pain paper, suggesting that pain patients treated with opiates might not be at risk of addiction, Portenoy said it was based on “weak, weak, weak data” and called it “a little paper [that] turned into an important paper.”

Every narcotics agent in the 1990s had the Bloods and Crips crack warfare as a precedent, and the Colombian cocaine cowboys in Miami before that. The Nayarits weren’t that way. With faith in their addictive product, they didn’t need to shoot it out for territory. These drivers knew each other, and would stop to chat or meet for lunch. Even as they competed and drove down each other’s prices, they did so in peace. They went out of their way to avoid attention. It helped that the drivers had no investment in how much they sold, and that they didn’t use. There was no incentive for them to cut their dope. They didn’t make any more money if they cut it than if they sold it as it came. They were employees, guys on a salary, with their costs covered and a stipend of several hundred dollars a week. The last thing they wanted was violence.

By the 1990s, it would have alarmed Dr. Hershel Jick, out in Boston, to know that his letter to the editor of the New England Journal of Medicine, which he had long forgotten, had become a foundation for a revolution in U.S. medical practice. This was wildly beyond anything Herschel Jick intended when he penned it. But that’s what happened. The revolution extended to hospitals, medical clinics, and family practices across the country. It’s unclear who retrieved the Porter and Jick letter from obscurity. But it appears to have been cited first as a footnote in Kathy Foley and Russell Portenoy’s 1986 paper in Pain. In time, the paragraph became known simply as Porter and Jick. That shorthand, in turn, lent prestige to the tiny thing and the claim attributed to it: that less than 1 percent of patients treated with narcotics developed addictions to them. That “less than 1 percent” statistic stuck. But a crucial point was lost: Jick’s 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. These were not chronic-pain patients going home with bottles of pain pills. It was a bizarre misinterpretation, for Jick’s letter really supported a contrary claim: that when used in hospitals for acute pain, and then when mightily controlled, opiates rarely produce addiction. Nevertheless, its message was transformed into that broad headline: “Addiction R...

Porter and Jick appeared in that bible of scholarly and journalistic rectitude, the New England Journal of Medicine. Medical professionals assumed everyone else had read it. But only in 2010 did the NEJM put all its archives online; before that, the archives only went back to 1993. To actually look up Porter and Jick, to discover that it was a one-paragraph letter to the editor, and not a scientific study, required going to a medical school library and digging up the actual issue, which took time most doctors didn’t have. Instead, primary care docs took the word of pain specialists, who pointed to Porter and Jick as evidence that opiates were far less addictive for chronic-pain patients than previously thought.

Use of opiates, meanwhile, changed medical thinking. Usually, a patient demanding ever-higher doses of a drug would be proof that the drug wasn’t working. But in opiate pain treatment, it was taken as proof that the doctor hadn’t yet prescribed enough. Indeed, some doctors came to believe that a pain patient demanding higher doses was likely to be exhibiting signs of “pseudoaddiction,” looking for a dose large enough to kill the pain—the cure for which was more opiates.

OxyContin is a simple pill. It contains only one drug: oxycodone, a painkiller that Germans synthesized in 1916 from thebaine, an opium derivative. Molecularly, oxycodone is similar to heroin. OxyContin riffed off an earlier Purdue product: MS Contin. MS Contin was Purdue’s first foray into pain management using the Continus timed-release formula invented by Napp in England. MS Contin sent morphine into a patient’s bloodstream continuously—hence Contin—over several hours. To accomplish this, MS Contin came in large doses of morphine: 15, 30, 60, 100, and 200 mg. Purdue marketed it to cancer patients and people just out of surgery, and MS Contin apparently served them well. Likewise, OxyContin contains large doses of oxycodone—40 and 80 mg typically—wrapped in a timed-release formula that slowly sends the drug into the body over several hours. It has legitimate medical uses, and has assuaged the pain of many Americans, for whom life would otherwise be torture.

But MS Contin wasn’t sold as a virtually risk-free panacea for chronic pain. Other opiate painkillers had been confined to small doses and combined with acetaminophen or Tylenol to make them hard to liquefy and inject. These drugs were Vicodin, Lorcet, Lortab, Percocet, and others. Yet even those were abused. Moreover, no one had imagined that a pill containing a drug similar to heroin would be marketed almost like an over-the-counter drug. But by 1996 American physicians were tenderized to accepting opiates for chronic pain. Undertreated pain was an epidemic and physicians now had the duty, the calling, to relieve it using the new tools and drugs the pharmaceutical companies were inventing.

The FDA approved a unique warning label for OxyContin. It allowed Purdue to claim that OxyContin had a lower potential for abuse than other oxycodone products because its timed-release formula allowed for a delay in absorbing the drug. “No other manufacturer of a Schedule II narcotic ever got the go-ahead from the FDA to make such a claim,” Meier wrote. “It was a claim that soon became a cornerstone of the marketing of OxyContin.” The warning label also inadvertently told addicts how to abuse the pill, warning patients not to crush the tablets because that would release “a potentially toxic amount of the drug.” That was like an invitation to a junkie. A 2003 U.S. GAO report on the company’s OxyContin marketing efforts, requested by members of Congress, found that the FDA didn’t realize that “the drug could be dissolved in water and injected.”

The salesmen would arrive every few months to provide docs an elaborate lunch of steak, salad, and dessert. They had slides and graphics that presented the startling idea that the company’s new drug, OxyContin, was virtually nonaddictive. Less than 1 percent of patients ever grew addicted, they said in their presentations. This claim startled Prior because OxyContin contained large doses of the opiate called oxycodone. Prior had attended medical school in the early 1980s, where he had learned opiates were generally to be avoided. He’d remembered a study that concluded that daily usage of 30 mg of oxycodone was enough to cause withdrawal.

Purdue offered OxyContin coupons to physicians, who could in turn give them to patients for a onetime free prescription at a participating pharmacy. By the time Purdue discontinued the program, thirty-four thousand coupons had been redeemed.

By 2003, more than half of the prescribers of OxyContin nationwide were primary care doctors, who had little pain-management training and were under pressure to get patients in and out of their offices. Oxy prescriptions for chronic pain rose from 670,000 in 1997 to 6.2 million in 2002. Those for cancer pain rose from 250,000 to just over a million over the same time.

The state of Nayarit lies along 180 miles of Pacific Ocean coastline, and stretches inland into the western Sierra Madre Mountains. In the centralized politics of Mexico, Nayarit was an afterthought. Following Mexican Independence, the small territory remained part of the state of Jalisco for a century. Even when it was separated from its larger neighbor, Nayarit remained a military district. Only in 1917 was it made autonomous—becoming the fifth smallest of Mexico’s thirty-one states. Its population didn’t top one million people until 2010. The state is surrounded by some of Mexico’s behemoth states; Zacatecas and Durango are nearby. Sinaloa, the state streaking up the coast north of Nayarit, is the birthplace of Mexican drug trafficking. Tiny Nayarit rarely made the news.

The next day, he bought a used car—a brown Cadillac Cimarron, a model so poorly conceived and designed that many marked it as a seminal event in the decline of Detroit.

Around northern Kentucky and southern Ohio, Procter’s docs were initially hailed for coming to the area. In truth, they were vinegar in the mouth of a crucified region.

Weird metaphor