Dreamland: The True Tale of America's Opiate Epidemic

by Sam Quinones

Crime was at historic lows, drug overdose deaths at record highs. A happy façade covered a disturbing reality.

Like a lover, no other molecule in nature provided such merciful pain relief, then hooked humans so completely, and punished them so mercilessly for wanting their freedom from it.

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.

Nevertheless, a movement was born, radiating out from a simple one-paragraph statement in 1980. Other documents were used as well. Portenoy and Foley’s own 1986 paper about thirty-eight patients—citing Porter and Jick—was among them. So, too, was a 1982 survey of supervisors at ninety-three burn units that found no patients growing addicted to opiate painkillers, and a 1977 study of drug dependency in patients with chronic headaches. But it appears that none was cited, nor misinterpreted, as often as Porter and Jick.

Had that not happened—had there been no insistence that pain was undertreated and that pain was now a fifth vital sign—OxyContin would likely not have found the market it did.

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.

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.

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.

Above all, investigators had to share information. This was because, unlike traditional Mexican drug organizations, Xalisco cells actually shared supplies, even with competitors. Xalisco cases tended to connect like webs. This was forcing investigators to discard turf battles.

The U.S. medical system is good at fighting disease, Cahana believes, and awful at leading people to wellness.

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.”

“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.”