Dreamland: The True Tale of America's Opiate Epidemic

by Sam Quinones

Via pills, heroin had entered the mainstream. The new addicts were football players and cheerleaders; football was almost a gateway to opiate addiction. Wounded soldiers returned from Afghanistan hooked on pain pills and died in America. Kids got hooked in college and died there. Some of these addicts were from rough corners of rural Appalachia. But many more were from the U.S. middle class. They lived in communities where the driveways were clean, the cars were new, and the shopping centers attracted congregations of Starbucks, Home Depot, CVS, and Applebee’s. They were the daughters of preachers, the sons of cops and doctors, the children of contractors and teachers and business owners and bankers. And almost every one was white.

A new attitude was taking hold in American medicine at the time. The patient, it held, was always right, particularly when it came to pain. The doctor was to believe a patient who said he was in pain.

Ask to buy a large quantity of dope, the informant said, and they’ll shut down their phones. You’ll never hear from them again. That really startled the informant. He knew of no other Mexican trafficking group that preferred to sell tiny quantities. Moreover, the Xalisco cells never deal with African Americans. They don’t sell to black people; nor do they buy from blacks, who they fear will rob them. They sell almost exclusively to whites. What the informant described, Chavez could see, amounted to a major innovation in the U.S. drug underworld. These innovations had every bit the impact of those in the legitimate business world. 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. The Xalisco traffickers’ innovation was literally a delivery mechanism as well. Guys from Xalisco had figured out that what white people—especially middle-class white kids—want most is service, convenience. They didn’t want to go to skid row or some seedy dope house to buy their drugs. Now they didn’t need to. The guys from Xalisco would deliver it to them.

The finished houses of migrant Mexico often had wrought-iron gates, modern plumbing, and marble floors. These towns slowly improved as they emptied of people whose dream was to build their houses, too. Over the years, the towns became dreamlands, as empty as movie sets, where immigrants went briefly to relax at Christmas or during the annual fiesta, and imagine their lives as wealthy retirees back home again one day. The great irony was that work, mortgages, and U.S.-born children kept most migrants from ever returning to Mexico to live permanently in those houses they built with such sacrifice. But the Xalisco heroin traffickers did it all the time. Their story was about immigration and what moves a poor Mexican to migrate as much as it was a tale of drug trafficking. Those Xalisco traffickers who didn’t end up in prison went back to live in those houses. They put down no roots in this country; they spent as little money in America as they could, in fact. Jamaicans, Russians, Italians, even other Mexican traffickers, all bought property and broadcasted their wealth in the United States. The Xalisco traffickers were the only immigrant narcotics mafia Chavez knew of that aimed to just go home, and with nary a shot fired.

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. 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. This was due to prejudice against opiates and regulations on their use in poor countries, on which the WHO Ladder apparently had little effect. An opiophobia ruled these countries, and still does, as patients are allowed to die in grotesque agony rather than be provided the relief that opium-based painkillers offer. India, a major opium producer, has mi...

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.” Bonica’s protégés at the University of Washington were suggesting a comprehensive approach to treating pain, in which opiates played only a small role. By the early 1990s, hundreds of clinics in America followed the UW model. Yet, almost from the beginning, insurance companies balked. In time, they stopped funding crucial parts of multidisciplinary treatment that weren’t strictly medical: physical, occupational, and psychological therapy, in particular. Loe...

In 1986, Russell Portenoy, then thirty-one, and his mentor, Kathy Foley, published what became a declaration of independence for the vanguard of pain specialists interested in using opiates for chronic pain, though Portenoy hardly intended it as such. Other researchers had been issuing papers saying that many chronic-pain patients using opiates invariably ended up addicted. Portenoy and Foley hadn’t seen that. They reviewed the cases of thirty-eight of their cancer patients with chronic pain who used opiate painkillers. Only two grew addicted, and they had histories of drug abuse. The rest functioned well and most of them without pain, to boot. 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.” The idea in the Pain paper, Portenoy said later, was that “these drugs have certain characteristics, which, when interacting with a certain kind of brain, can lead to bad outcomes; but it’s not inherent in the pill such that everybody given that pill becomes an addict.” From that gradually grew the idea that opiates might be prescribed not only to people dying...