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Dreamland
The True Tale of America's Opiate Epidemic
Sam Quinones
read on February 15, 2018

Having moved back to the USA, I've got a backlist of books and topics that I want to get more educated on.  US history and social studies are broadly at the top of it, though I suspect I'll be reading much more fiction this year as well. (Hopefully, I'll be able to slide in a bit of European history as well, for old time's sake). "The Opioid Crisis" is something I've seen reference to for years, but has really ramped up the last 5 or so (mainly during the 2016 US election, as one of the only substantial topics that got attention prior to the cycle going full circus). Since I don't know anyone addicted to opioids, I had no context for this at all. Was it really as big a deal as I was hearing? If so, where? And why?

Turns out: Yes, everywhere, all the most obvious reasons. My interpretation of the key drivers are below, though the book isn't really framed this way.

  1. Purdue Pharma is an immoral dumpster fire operating in a capitalist system without regulation.
    1. Basically, this company created an opiate (Oxycontin) that they claimed was impossible to get addicted to, because of its patented slow-release system. Purdue pushed this claim super hard, and despite zero scientific evidence supporting it (famously there was a single 1-paragraph op-ed that supported this fact, which was [unbeknown by the author] cited as evidence for decades), it was accepted as gospel in the medical community. Anytime they got even a whiff of someone saying Oxy was addictive they would sue for defamation.
    2.  Nevermind that Oxy actually was easier to abuse that valium, because if you just dissolve the coating in water, or crush the pill and snort it, you can get the full hit of opium at once. (Valium and other opiates were mixed with other meds, like aspirin, which diluted the opium).
    3. Purdue lied about this for decades, and spent millions advertising Oxy to doctors, flying them out to expensive retreats, etc, getting them to prescribe it, which got people addicted to it.
    4. Purdue aggressively lobbied and advertised to enforce the growing idea that painlessness is a human right. Over decades, this changed perspective doctors had when treating patients, making sure to address pain first, and creating unrealistic expectations about recovery experiences.
  2. American health insurance systems are horrible, and don't incentivize recovery.
    1. Doctors were highly incentivized to just prescribe pain meds rather than actually heal patients (via diet, exercise, etc). They want to crank through as many patients as possible. Because Oxy was classified as a schedule 2 narcotic, you could only legally prescribe one month of pills at a time. For doctors, this effectively created a subscription based income stream. Prescribing Oxy meant that you'd have someone in your waiting room once a month - literally addicted to you. That person would need to pay $250, at least, for the appointment, (received either in cash from the addict or if applicable, the patient's health insurance - eventually these docs went all cash, because given their market demand, they didn't need to bother with insurance). This, of course, ultimately led to "pill mills" in the mideast, where doctors would see hundreds of patients per day, literally for only 30 seconds each, only to "evaluate" them and prescribe another month of Oxy. It was a racket. Only the least scrupulous doctors did it first, but after creating so much incentive for them to do it, no one should be surprised, and eventually most doctors did it. These doctors had thousands of patients, thousands of people they pushed Oxy on. And of course, when the addicts ran out of money for pills, their only choice was black tar heroin.
    2. Patients that qualified for medicaid could purchase monthly pills for a $3 medicaid copay. The pills they received cost the medicaid system $1,000 (which was paid to Purdue Pharma, courtesy of US taxpayers). The street value of the pills was $10,000. Imagine a system where, for a $3 copay, you can obtain a product worth $10,000, that customers are literally addicted to and dying to have. Who can be surprised at how terribly this would blow up?
  3. Other American institutions fueled it;
    1. Middle-class white families were too ashamed to discuss publicly what was happening. When their children died from heroin overdoses, they would tell friends and family that it was a car accident, or heart attack, or whatever made-up story. There are some remarkable passages in the book describing funerals where word gets out that it was a drug overdose, and all at once all the parents realize that they all have the same problem.
    2. In 2.2., above, people needed money to buy drugs from pill sellers, but didn't have cash. So they would steal from Walmart and pay with stolen goods. Or they would steal and then return the items without a receipt for store credit, and then trade store credit coupons (at ~50% face value) for pills. Eventually, Walmart started requiring a receipt even for store credit - so addicts hung out in parking lots looking for discarded receipts, and after finding them would steal whatever had been bought on that receipt. Hilarious story about how someone would go to the children's area of Walmart and grab the biggest box play-pen or slide or whatever, and just empty the box, and then wheel it around the store filling it full of DVD players - and then roll through checkout and just scan the box for the $20 slide and walk out the door. Nuts. Anyway, point being that Walmart employees were both oblivious and also totally un-vested in caring about this. They're making minimum wage and don't give a crap if stuff is stolen, and certainly aren't about to get in the way of a desperate addict. Whereas, if the US had smaller mom-and-pop stores that were locally owned and had more visibility, it would have been much harder to pull off such theft. Walmart became a de-facto midwest money laundering operation for pill addicts.
  4. (Distant fourth) Mexicans went to the central US and setup super efficient black tar heroin sales operations. They would deliver the drugs to users. They would be clean, and organized. They drove around with only a few small heroin balloons in their mouths that they would swallow if pulled over. They weren't greedy, and they weren't violent, and because of that it was about a decade before police realized the extent of the problem.

The book is entirely apolitical, but overall this was highly educational and a disgusting expose of how screwed up core American institutions are. Advocates against heavy-handed government regulation are always quick to point out how burdensome red tape can deter innovation, be bad for jobs, etc, etc, etc, but seem blind to the tens of thousands of lives lost and ruined for generations to come due to entirely avoidable crises like this one.

Additional reference:

WaPo Article 2018

Author Bio:

Sam Quinones (born 1958) is an American journalist from Los Angeles, California. He is best known from his reporting in Mexico and on Mexicans in the United States. He was a reporter for the Los Angeles Times from 2004 to 2014.