Dreamland: The True Tale of America's Opiate Epidemic

by Sam Quinones

Dr. Frederick Cohn worked for Procter before relocating to an abandoned supermarket in the town of Paintsville (pop. 3,400) in eastern Kentucky, where he saw as many as 146 patients a day, three minutes each, while lines formed outside. Cohn had preprinted prescriptions for various narcotics, including OxyContin, Lortab, Soma, and Xanax. He prescribed the same pills in the same amounts over and over throughout the day, no matter the patient’s complaint— 2.7 million pills in one year.

Dr. Fortune Williams worked for Procter before moving to Garrison, Kentucky, where he worked in a clinic owned by Nancy Sadler, a former Procter employee. On some days, he saw patients for ninety seconds at a time, and issued forty-six thousand controlled-substance prescriptions—for a total of 2.3 million pills—in nine months.

Once these businesses got going, they didn’t just prescribe opiate painkillers, such as Vicodin or OxyContin. There also emerged in the wake of David Procter a taste in the Rust Belt and Appalachia for the class of psychoactive drugs known as benzodiazepines. Valium was the first benzo, but Xanax bars were the most popular. As Procter showed his clients, benzodiazepines combined with opiates were especially potent and addictive. Both were depressants and very dangerous when taken together. But addicts grew to love the two together as benzos seemed to enhance the euphoria of the opiates. The combined prescription of opiates and benzos was a hot ticket at pill mills in Portsmouth and elsewhere.

Procter was returned to Kentucky, where he had already testified against Drs. Williams and Santos in court in return for a lighter sentence in his own case. He eventually served eleven years in prison.

The city of Columbus, Ohio, in many ways is a fine replica of the United States. Its income and age distribution, its racial demographics and diversity of opinion, make Columbus a microcosm of America, and one that marketers especially prize. There’s a large white population, and moderate numbers of blacks. Unlike other parts of Ohio, Columbus has sizable immigrant groups—from Mexico, Somalia, Nepal, and other parts of Asia—who flocked to town to fill the low-end service jobs. A large college-student population at Ohio State and other schools has kept it vibrant and edgy. No place, apparently, represents the country more faithfully and for that reason Columbus, Ohio, has been known as “the test-market capital of the United States” for several years now. These days it’s no longer Peoria but Columbus that marketers use as a barometer of America. White Castle and Wendy’s and more than a dozen other fast-food chains headquarter there. Many companies have used the town to gauge interest in new product offerings, placing them in stores in Columbus first before rolling out those products nationally. McDonald’s tested its McRib in Columbus, and Wendy’s and Panera have tested prototype stores there as well. Taco Bell’s BLT Tacos were tested in the Columbus market. R. J. Reynolds tried tobacco in the form of a mint that did away with secondhand smoke. Giant Eagle’s massive Market District supermarket in Columbus tests a variety of concepts, among them the sale of wine by the glass.

By the fall of 1999, two more crews were in Columbus. One belonged to a former driver, now venturing out on his own. Two more followed. A kind of “Go east, young man” ethos took hold among the Xalisco Boys. The price of heroin in Columbus fell. No crew leader could cut his dope unless he wanted to lose his clients. So the product stayed strong even as it got cheaper. Competition, as always, attuned the Xalisco crews to customer service. They even crossed the city to keep a customer, and gave away free dope to any client hinting at quitting.

Aurelio

Worldwide pharmaceutical opiate production rose steadily. But it was the United States, the country where the Englishman Robert Twycross once smelled “the fear of addiction” as he stepped from an airplane, that now consumed 83 percent of the world’s oxycodone and fully 99 percent of the world’s hydrocodone (the opiate in Vicodin and Lortab). “Gram for gram,” a group of specialists wrote in the journal Pain Physician in 2012, “people in the United States consume more narcotic medication than any other nation worldwide.”

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.

A decade after OxyContin’s release, meanwhile, 6.1 million people had abused it—that is to say, 2.4 percent of all Americans.

Baltimore, with a robust heroin market dating back decades, is considered the country’s heroin capital—with the DEA and the city’s health department estimating that roughly 10 percent of the city’s residents are addicted.

Either way, a government survey found that the number of people who reported using heroin in the previous year rose from 373,000 in 2007 to 620,000 in 2011. Eighty percent of them had used a prescription painkiller first. But all this took years to become clear.

The state of Washington’s workers’ compensation system is one of only five in the country that hold monopolies on insuring workers. The state insures two-thirds of all Washington’s 1.2 million workers; it oversees the rest, workers at companies large enough to insure themselves.

Mai possessed an intense need for order. Sloppiness and unanswered questions were anathema. She cleaned her house a lot because it helped her destress and think things through, while restoring order. She loved to garden, as much to instill order as for the love of plants.

If you could get a prescription from a willing doctor—and Portsmouth had plenty of those—the Medicaid health insurance cards paid for that prescription every month. For a three-dollar Medicaid co-pay, therefore, an addict got pills priced at a thousand dollars, with the difference paid for by U.S. and state taxpayers. A user could turn around and sell those pills, obtained for that three-dollar co-pay, for as much as ten thousand dollars on the street. Combined with pill mills, the Medicaid card scam allowed prolific quantities of prescription medication to hit the streets. The more pills that sloshed around the region, the more people grew addicted, and the bigger the business grew, and the more people died. The Oxy black market might never have spread and deepened so quickly had addicts been forced to pay for all those pills with cash at market prices.

Some large though immeasurable amount of the merchandise supporting addiction, as the opiates settled on heartland America, was mined from the aisles of Walmart, where Main Streets had gone to die.

Forget you have children. This advice was given to Mario, an illegal immigrant, by his new boss from Xalisco, Nayarit. Mario was preparing for what turned out to be a short career as a dispatcher for a black tar heroin cell in Columbus, Ohio, a few years after the Man brought the drug there. “Forget that people may do to your kids what you’re doing to the children of others,” his new boss told him in a restaurant one day. “Otherwise you won’t sleep.

Like Purdue, but quite unlike traditional heroin dealers, the Xalisco Boys didn’t sit around waiting for customers to come to them. They targeted new ones using come-ons, price breaks. They followed up sales to good clients with phone calls that amounted to customer satisfaction surveys. Was the dope good? Was the driver polite?

The drivers were not career thugs, as far as Gatehouse could tell. They were farm boys hoping for a better day through black tar. Sheena Gatehouse went back and forth on the wisdom of the tough approach. The damage they did clearly required it. But, she said, “we’re sending a farm boy away for twenty years and have had no impact.”

L&I came up with a guideline for general practitioners when prescribing these drugs. It went like this: If doctors had patients taking more than 120 mg a day with no reduction in pain, then they should stop and get a pain specialist’s opinion before prescribing higher doses. It was simple and reasonable enough, particularly in light of the new overdose deaths among workers. But it was contrary to an idea central to the pain revolution: that there was no limit on how much opiate painkiller a patient might be prescribed. The guideline Mai and Franklin were proposing would make Washington the first in the country to even suggest some control on how many narcotic pills doctors were prescribing.

Not long after that, a Spokane doctor named Merle Janes sued L&I. Dr. Janes was assisted by five law firms, four of which were from outside Washington State. The guideline, they alleged in a court brief, was an example of “an extreme anti-opioid discriminatory animus or zealotry known as Opiophobia that informs, permeates, and perniciously corrupts the development and management of public health policy” in Washington. So L&I’s prescribing guidelines hung in limbo for two years. Twenty-five workers, each of whom had gone to a workers’ comp doc with an injury, died of opiate overdoses in 2008; in 2009, thirty-two more died.

Drug overdoses passed fatal vehicle accidents nationwide for the first time in 2008. But it happened first in Ohio, where two complementary opiate plagues met and gathered strength in the late 1990s: prescription painkillers, especially Purdue’s OxyContin, moving east to west; the Xalisco Boys’ black tar heroin moving west to east.

The number of Ohioans dead from drug overdoses between 2003 and 2008 was 50 percent higher than the number of U.S. soldiers who died in the entire Iraq War.

In 2005, Ohio’s overdose deaths exceeded those at the height of the state’s HIV/AIDS epidemic in the mid-1990s.

Fatal overdoses came regularly after that. The office had a small budget and dead junkies would have been easy not to autopsy. But Johnson sent the bodies to medical examiners in larger counties better prepared to do full autopsies and blood tests. These invariably turned up opiates, usually combined with benzodiazepines, the old Dr. Procter cocktail.

He was immediately shocked at the patients in the UW clinic. “These were people on tons of opioids for a long time, completely broken and abused. We’re talking hundreds of milligrams of morphine-equivalent doses. Doses I’d never seen in my life: four hundred, five hundred, six hundred milligrams a day.” What’s more, no one tracked the effects of opiates on a patient’s pain, function, depression, sleep. He called colleagues elsewhere and found this to be true across the United States. “Not one center had measurements-based pain care. This is 2008,” he said. “It would all be subjective: They’re doing fine or not doing fine. There was a pain rating scale: one to ten. It was insane. A multibillion-dollar industry was based on no measurements whatsoever.”

There Alex Cahana ran into the problem John Loeser faced. An insurance company would reimburse thousands of dollars for a procedure. But Cahana couldn’t get them to reimburse seventy-five dollars for a social worker, even if it was likely that some part of a patient’s pain was rooted in unemployment or marital strife. “Nobody thinks those things are of value. Talk therapy is reimbursed at fifteen dollars an hour,” Cahana said. “But for me to stick a needle in you I can get eight hundred to five thousand dollars. The system values things that aren’t only not helpful but sometimes hurtful to patients. Science has shown things to have worked and the insurance companies won’t pay for them.”

a region where OxyContin had already tenderized a generation of folks to opiate use.

“It’s taken sixteen years to convince the legislature that it is cheaper to put them [in drug treatment] than to put them in prison,” he said. The cost savings weren’t what did the trick, though. Treatment has always been more effective and cheaper than prison for true drug addicts. What’s changed, Norman said, is that no longer are most of the accused African American inner-city crack users and dealers. Most of the new Tennessee junkies come from the white middle and upper-middle classes, and from the state’s white rural heartland—people who vote for, donate to, live near, do business with, or are related to the majority of Tennessee legislators.

Yes the fact was that, coincidentally or not, this change of heart was happening among conservatives just as opiate addiction was spreading among both rural and middle-class white kids across the country, though perhaps most notably in the deepest red counties and states. Drug enslavement and death, so close at hand, were touching the lives, and softening the hearts, of many Republican lawmakers and constituents. I’ll count this as a national moment of Christian forgiveness. But I also know that it was a forgiveness that many of these lawmakers didn’t warm to when urban crack users were the defendants. Let’s just say that firsthand exposure to opiate addiction can change a person’s mind about a lot of things. Many of their constituents were no longer so enamored with that “tough on crime” talk now that it was their kids who were involved. So a new euphemism emerged—“smart on crime”—to allow these politicians to support the kind of rehabilitation programs that many of them had used to attack others not so long ago.

He had lived in Portland, working legally as a mechanic as he watched the Xalisco system expand. “In Portland,” he said, “I’d see [the police] grab people with twenty or thirty balloons and they’d let them go. That’s why people began to come to Portland, because they weren’t afraid. They saw there were no consequences. ‘We get caught with this and they let us go.’” Word spread back in Xalisco that cells did well in Portland, and, furthermore, arrested drivers were only deported. More cells crowded into town, he said.

Portland’s catch-and-deport policy was an important reason why. The policy was designed for the small-time street addict/dealer who city officials didn’t want taking jail space from more serious felons. The Xalisco Boys’ drivers worked hard to look small-time. In reality, they were the only visible strands of large webs that sold hundreds of kilos of black tar a year across America, by the tenth of a gram. So for many years, when they were caught they were deported and faced little jail time, and no prison time. As farm boys on the make, they drew a very different message from leniency than what these Portland officials intended. To them, catch and release looked more like an invitation.

As I tried to chart the spread of the opiate epidemic, one thing dawned on me: Other than addicts and traffickers, most of the people I was speaking to were government workers. They were the only ones I saw fighting this scourge. We’ve seen a demonization of government and the exaltation of the free market in America over the previous thirty years. But here was a story where the battle against the free market’s worst effects was taken on mostly by anonymous public employees.

Cocaine in the early 1980s came with Colombians who shot up Miami strip malls, levitating the murder rate and inflaming the public. My first week as a crime reporter in Stockton, California, in 1989, I walked a street lined by two-dozen crack dealers. When I opened the front gate to a dilapidated house, the crackheads fled like roaches. Bloods and Crips came and warred across Stockton. One of their drive-by shootings paralyzed a toddler. I often wonder what became of her. She would be in her midtwenties by now. Next came methamphetamine, made in labs that exploded. Meth left users scabbed and twitching. None of that blight, violence, and outrage accompanied the morphine molecule as it swept the United States. As opiates quietly killed unprecedented numbers of kids, it was as if the morphine molecule narcotized public ire as well.

They once thought addiction a moral failing, and now understood it as a physical affliction, a disease. They had thought rehabilitation would fix their son. Now they saw relapse was all but inevitable, and that something like two years of treatment and abstinence, followed by a lifetime of 12-step meetings, were needed for recovery.

After kicking opiates, “it takes two years for your dopamine receptors to start working naturally,” Paul said. “Nobody told us that. We thought he was fixed because he was coming out of rehab. Kids aren’t fixed. It takes years of clean living to the point where they may—they may—have a chance. This is a lifelong battle. Had we known, we would never have let Matt alone those first few vulnerable days after rehab. We let him go alone that afternoon to Narcotics Anonymous (NA) his first day out of rehab. He had his new clothes on. He looked good. He was then going to play golf with his friend. Instead of making a right turn to go to the meeting, he made a left turn and he’s buying drugs and dying.

Then on Super Bowl Sunday 2014, America awoke to the news that one of its finest actors was dead. Philip Seymour Hoffman, forty-six, was found that morning in his Greenwich Village apartment, a syringe in his arm and powder heroin in packets branded with the Ace of Spades near his corpse. Blood tests showed he had heroin in his system, combined with cocaine, amphetamine, and benzodiazepine. The Oscar-winning actor—a father of three—had checked into rehab the previous May for ten days, and then, pronouncing himself sober again, left to resume a hectic film schedule.

Two decades into the pain revolution, a consensus had emerged that opiates were unhelpful, even risky, for some varieties of chronic pain—back pain, headaches, and fibromyalgia among them. Several clinics and doctors I spoke with had policies against using them for those ailments. One 2007 survey of studies of back pain and opiates found that “use disorders” were common among patients, and “aberrant” use behavior occurred in up to 24 percent of the cases. It was unclear, the authors found, whether opiates had an effect on back pain in the long term.

By the end of the 2000s, it was already common for people to go from abusing OxyContin to a heroin habit. Purdue Pharma recognized this and in 2010 reformulated OxyContin with an abuse deterrent, making the drug harder to deconstruct and inject. The intent was to make Oxy less abusable. It did. Had the company done this in 1996, our story might have been different. But now there was a swollen population of OxyContin addicts nationwide. Without Oxy, they flocked to heroin in even greater numbers.

The arms race left behind massive lawsuits and criminal cases for misbranding and false advertising. Purdue was hardly the only company to have been sued. Its $634.5 million fine was soon dwarfed. Pfizer alone paid more than $3 billion in fines and legal penalties to settle lawsuits alleging, among other things, the misbranding and false advertising of several drugs. That included $2.3 billion to settle a criminal suit in 2009 alleging the company illegally marketed its blockbuster painkiller Bextra. The sum was the largest criminal fine of any kind, though it amounted to less than three weeks of the company’s sales, the New York Times observed.

We have been using morphine clinically for a hundred years and we’ll be using it a hundred years from now. I’m not going to say it’s never going to happen, but I don’t see how it’s going to happen.” Then, as if thinking out loud, he added, “If we could only stop the euphoria but not the analgesia, I think we would actually have what I would call the Holy Grail.”

VanDerKarr wears a black robe and sits high on the bench, and a very large gavel is mounted on the wall behind him. But the atmosphere is relaxed, resembling a group meeting more than court. A table to one side offers stacks of brochures about treatment centers and drug and mental health resources for veterans. VanDerKarr calls several clients before him, applauds their days clean, and asks about their job searches and whether they have 12-step sponsors. Each must seek counseling, submit to random drug tests, and attend ninety NA meetings in ninety days. After that, they attend his session every week for up to two years. Almost half finish the program. But many relapse; some die.

One way to view all that had happened was as some enormous social experiment to see how many Americans had the propensity for addiction. I ran this idea by an addiction specialist named Dr. Richard Whitney in the wealthy Columbus suburb of Dublin. “That’s an interesting way to put it: Let’s feed this to everybody in the society and see what pops up,” he said. “Let’s, as a society, watch all of our potential alcoholics become opiate addicts instead. Had these opiates not appeared, I think we’d have seen a similar number of alcoholics, but later in life. My field used to be middle-aged alcoholics. It usually took twenty years of drinking to get people in enough trouble to need treatment. But with the potency of these drugs, the average age has dropped fifteen years and people get into trouble very quickly with oxycodone, hydrocodone, and heroin.”

A deeper understanding was emerging of how addiction was created in the brain. Functional MRI scans had revealed a lot since the 1990s about the brain’s pathways of reward. “It verified a lot of what we did intuitively,” Whitney said. “Once people get addicted they really lose the power of choice. It takes thirty to ninety days for the brain to heal enough to make decisions. Otherwise, it’s like putting a cast on a broken bone and expecting someone to run five miles.”

Nationwide, attitudes toward addicts and addiction seemed to be shifting, though slowly. Addicts were not moral failures, deviants, and criminals—the image that stuck in the popular mind following the Harrison Act. Instead, they were coming to be seen as afflicted with a disease that happened to manifest itself in stealing and conning in the relentless search for dope to calm the beast.

As I followed this story, I took as given that kicking opiate addiction required a dozen attempts at rehabilitation. The figure I kept hearing was one in ten—the number of people who succeeded in each rehab. That was true, Whitney said, only because so few people get the full treatment they need. Too often they go in for three weeks or six weeks. Brain chemistry needs far more time to recover from the blast it takes from opiates. “We have as good or better treatment results as they do for asthma or congestive heart failure—if we have the tools to work with,” he said. “But people do not get enough treatment to get well. It’s as if we said you only get half the chemotherapy you need to treat your cancer. People wouldn’t stand for that. Insurance companies don’t want to [fund] addiction treatment with enough duration and intensity because we as a society do not demand it.”

Keating retired and his three sons took over. Around town, the Keating boys were known as “third-generation.” In Portsmouth, and probably in most of America’s Rust Belt, that was shorthand: the first generation built their companies; the second, with business degrees, managed and expanded them; but the third generation was raised with an appetite for leisure and their companies often declined. A lot of folks around Portsmouth had seen far too much third generation.

“It took individuals to say, ‘No more,’” Davis said. “‘We’re not going to lose any more jobs and we’re not going to lose another industry in this town.’ We were the last bastion of what was a great shoe industry: shoelace manufacture. And we were going to let it go.” Three floors of the plant were empty. Davis took that to mean there was room to grow. By the time I visited, Davis said, Sole Choice had three hundred customers—up from twenty-four. Forty people had their jobs back and more were coming on. The company exported shoelaces to thirty countries, including China and Taiwan. “The outsourcing mentality has cost us millions and millions of jobs. We have now done that for thirty-some years and we have literally destroyed our manufacturing base in this country. It’s all been about money, the mighty dollar. The true entrepreneurial spirit of the U.S. has to be about more than that. It has to be about people, relationships, about building communities. Money—that comes. You’ll get that eventually, but happiness comes from these other things.”

The Scioto County pill mills illustrated how generalized opiate prescribing had become in America. In their last year of operation, 9.7 million pills were legally prescribed in the county of eighty thousand. But even two years after the pill mills were done, 7 million pills were still prescribed there.

Scott Douthat, the sociology professor at Shawnee State, had a class study the town’s problems and propose solutions that required no extra budget. Douthat and colleagues had earlier surveyed residents. What bothered them most “wasn’t crime, it wasn’t drugs, it wasn’t the economy,” Douthat said. “It was the way the city looked.” City officials first ignored the survey. “We don’t need no egghead academics coming in here and telling us how to do our jobs,” said one. But since then, there’d been turnover at city hall. So when Douthat’s students shaped proposals, they were heard. The students urged the city to apply for a federal Community Oriented Policing Grant, which it won. Now there were more officers on the streets. Buy a floodlight for a beleaguered downtown park, the students suggested. Prostitutes magically moved elsewhere. Students proposed a fifty-dollar annual fee on each rental property to pay for code inspectors, and volunteered to input the rental-property data. The town hired code inspectors, whose presence motivated landlords. The students suggested including litter pickup as part of each probationer’s sentence and volunteered to help a judge organize the program because the city didn’t have money for staff. Probationers picked up ninety tons of litter in the first three months.