Book Review - Dreamland

Americans really love drugs. If it can be quaffed, huffed, snorted, smoked, swallowed, inhaled, or injected, chances are we have figured out how to use it to get us high. We are, after all, the country that has extracted a buzz from bath salts, Redi Whip, Robitussin, lighter fluid, and aerosol cans before even rolling a single joint, measuring out a line of cocaine, or dropping one piece of LSD-soaked blotter paper on our tongues.

Today, the scourge of opiate addiction is in the spotlight and a clear line has been drawn between the overprescribing of prescription pain medications, heroin use, and a skyrocketing number of overdoses across the country. That story is told with great eloquence by Sam Quinones, whose recently published book Dreamland is an invaluable source for people who want to understand how this phenomenon happened. Quinones’s story is, in many ways, quintessentially American. A primary focus of the book is the Mexican town of Xalisco, Nayarit, home to hard scrabble farmers who show that most cherished of American traits – the entrepreneurial spirit - to devise a new method of delivering heroin to the U.S. that owed more to McDonald’s than the Mafia. From this remote part of Mexico, these men set up shop in small and mid-sized cities, avoided violent crime, paid salaried drivers to deliver their dope, and followed-up with their customers to ensure loyalty and satisfaction. That the drivers were expendable – if arrested, they rarely carried a meaningful amount of drugs and never had weapons, so they were simply deported, to be replaced before they made it home – did not use the product, and delivered like Domino’s Pizza, generated massive profits for these drug traffickers while, for a time, flying under the radar screen of law enforcement.

Meanwhile, a revolution in the way doctors interacted with and treated patients created a massive potential customer base for the Xalisco Boys. Based largely on a one paragraph letter in a medical journal published in 1980 that claimed a mere 1% addiction rate among patients prescribed pain killers and to a lesser extent the move toward managed care, which deemphasized doctors taking time to work with patients in favor of a more factory line approach, pain management shifted from a holistic approach of exercise, weight loss, and lifestyle changes to one dominated by the prescription pad. Where once doctors limited the use of Percocet, Vicodin, and OxyContin, they began doling out these highly addictive medications like candy. Oxy became a particularly pernicious choice because its effect mimicked heroin so closely. When patients could no longer afford the drug, the Xalisco black tar heroin slid in as a replacement. That the drug, cheap, reliable, and potent, was basically delivered to your door step removed much of the risk – of being arrested or victimized – that typically affects drug users.  

Mix it all together, and you get an epidemic that hit communities at all rungs of the income ladder while lurking largely in the shadows as more well-to-do families shunned publicizing their loved one’s struggles because of the stigma associated with heroin addiction. What was once a drug associated with dirty needles, seedy motels, and lost jazz legends had migrated into the suburban McMansions of upper middle class America.

Quinones does an excellent job tracing these two narratives as they inexorably converge to a single point. His chapters are brief, usually no more than a few pages, as he ping pongs between the sugarcane fields of Mexico to decimated cities like Portsmouth, Ohio, hard by the Kentucky border and a sort of “patient zero” of economic decline that morphed into a hub of pill mills (doctor’s offices where any ache or pain was treated with hard core opiates) that begat junkies who burgled and bartered for the black tar heroin that became a substitute for pharmaceutical opiates when the authorities shut down these rogue operations.

The human toll is devastating. As the dual tracks of prescription drug abuse and heroin addiction converge in cities across the country, the destruction of millions of families fall in their wake. Even as law enforcement gets wise to the Xalisco tactics, their victories are short-lived, if not pyrrhic. Cells are quickly reformed and even as dealers and drivers are shipped back to Mexico or locked away in prison, the wave of black tar continues largely unabated. Threaded through this catastrophe is the impact of deindustrialization in rural parts of Appalachia, where the unemployed seek out disability diagnoses to collect Medicaid which in turn allows them to receive the opiates they use or sell and, on the other side of the spectrum, the easy access to addictive pain pills provided to wealthy suburbanites who can easily afford their addiction even after they cross the line to heroin.

The book offers a few grace notes. There are the addicts who get treatment and kick their habit, the researchers, doctors, and government bureaucrats who try to raise the alarm on overprescribing, and the law enforcement officers doing what they can to fight this often invisible foe. In their stories you see the humanity beneath the darkness, the unheralded attempts to help that go on behind the scenes, and the small victories that can accumulate over time. Indeed, the clear shift in how opiate addiction is treated by law enforcement speaks volumes about how policy can change. Instead of the harsh penal consequences of three strikes laws and mandatory minimum sentences that defined the “war on drugs” in the 1980s and 1990s, the focus is now on treating addiction, arming police officers with Narcan to revive those who overdose, and encouraging families to speak out when loved ones succumb to their inner demons. That so many lives have been destroyed  to get to that point is a story that Quinones tells beautifully.

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