Dreamland: The True Tale of America's Opiate Epidemic

by Sam Quinones

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.

The morphine molecule exerts an analogous brainwashing on humans, pushing them to act contrary to their self-interest in pursuit of the molecule. Addicts betray loved ones, steal, live under freeways in harsh weather, and run similarly horrific risks to use the molecule.

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.

One strategy or the other might well have worked. But the worst of both emerged at many clinics. Methadone was often dispensed as if the goal was kicking the habit, with small doses. But as methadone clinics became for-profit affairs, many cut the counseling and therapy that might help patients kick opiates altogether.

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.

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.

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.”

An idea advanced that pain counteracted opiates’ euphoric effect and thus reduced the risk of addiction. In a statement on its website, the American Pain Society claimed that risk of addiction was low when opiates are used to treat patients in pain. There appeared to be no ceiling on the dose of opiate painkillers a pain patient might take. Pain, the APS went on, acted against the tendency of opiates to stop the lungs from breathing. Thus, withholding the drugs “on the basis of respiratory concerns is unwarranted.”

The Wong-Baker FACES scale is now a standard in gauging pain in children. There are other versions for adults. Patients are asked to quantify their pain according to a scale—numbered from 0 to 10, 10 being worst. These scales were highly subjective, but they were about the only pain-measurement tools medicine had to offer.

With the managed care movement of the 1980s and 1990s, insurance companies cut costs and reduced what services they’d pay for. They required that patients give up their longtime physicians for those on a list of approved providers. They negotiated lower fees with doctors. To make up the difference, primary care docs had to fit more patients into a day. (A Newsweek story claimed that to do a good job a primary care doctor ought to have a roster of eighteen hundred patients. The average load today is twenty-three hundred, with some seeing up to three thousand.)

I found at least two studies that showed that prescribing of all kinds rose as doctor visits shortened. Not surprising. As every doctor knows, nothing cuts short a patient visit like a prescription pad.

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.

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.”

“They told us to say things like it is ‘virtually’ non-addicting. That’s what we were instructed to do. It’s not right, but that’s what they told us to say … You’d tell the doctor there is a study, but you wouldn’t show it to him.”

“My fellowship director even told me, ‘If you have pain, you can’t get addicted to opiates because the pain soaks up the euphoria.’ Now you look back and it sounds so preposterous. That’s actually what people thought. You can think what you want in the face of ten thousand years of reality.”

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).

In a 2004 survey by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), 2.4 million people twelve years or older had used a prescription pain reliever nonmedically for the first time within the previous year—more than the estimated numbers using marijuana for the first time.

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 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.

“This drug is following the same marketing [strategy] of every other product out there. ‘I’ll give you good heroin at a great price. You don’t have to go to the bad neighborhoods. I’ll deliver it for you.’” In a culture that demanded comfort, he thought, heroin was the final convenience.

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.

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.