Dreamland: The True Tale of America’s Opiate Epidemic

Nonfiction | Book | Adult | Published in 2015

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Preface-Part 1

Part 2

Parts 3-5

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Part 2Chapter Summaries & Analyses

Part 2, Pages 187-221 Summary

Quinones describes how the emergence of another dreamland in the 2000s—this time, a countrywide fantasy built on consumer debt and rising real estate values—was echoed by the entrenchment of a culture that believed relief from pain through nonaddictive opiates was possible. This contributed to a situation where the United States consumed 83% and 99% of oxycodone and hydrocodone, respectively, with opiates the most prescribed class of drugs. Meanwhile, overdose deaths had risen to one every 30 minutes by 2012. Only 2.4% of all Americans had abused OxyContin, but this was still enough “to throw hospitals, emergency rooms, jails, courts, rehab centers, and families into turmoil, especially in areas where abuse was new” (191). As people became addicted to OxyContin and their tolerance rose, they took higher doses and began injecting the drug for a stronger rush. From here, it was only a short jump to heroin use, causing the number of heroin users to nearly double from 2007 to 2011.

Part of this jump was due to the rise of pain clinics in places like Scioto County, Ohio, particularly Portsmouth. By this time, Portsmouth was in steep decline. The Dreamland pool had closed and was replaced by a mall; as the sense of community that Dreamland had represented ebbed away, opiates rose in popularity, and many of the town’s young people became addicted or used the surge of OxyContin addicts to make money, such as by taking out prescriptions at pill mills in their own name and selling the drugs on the street. Many of these prescriptions were paid for through Medicaid, which pays for prescriptions for those on state welfare or federal disability: “the Oxy black market might never have spread and deepened so quickly had addicts been forced to pay for all those pills with cash at market prices” (210). This created an economy in Portsmouth in which everything was measured and paid for with pills, from dentist visits to clean urine for drug tests with probation officers. In turn, many things were sold to procure pills—particularly from Walmart, which was the only retailer left in many Midwest towns. This OxyContin economy—and the addiction that fueled it—was the only option for many people in Portsmouth’s younger generation. It drove the community’s decline even as heroin fueled Xalisco’s upward trajectory.

Meanwhile, a pharmacist working for Washington’s worker compensation system noticed large numbers of overdose deaths for people whose original complaints were small injuries like sprained backs; this pharmacist wrote a paper documenting the deaths associated with prescribing opiates from non-cancer pain. At the same time, a district attorney in Virginia noticed the number of pill mill doctors and subpoenaed the company marketing these drugs—Purdue Pharma—for its records on OxyContin, realizing that salespeople across the country were marketing the drug as nonaddictive even as the opposite was clearly true.

Part 2, Pages 222-246 Summary

Having laid out the path by which the OxyContin belt was established in Appalachia, Quinones moves on to discuss how it led to the proliferation of black tar heroin cells in those same communities. Not only were the Xalisco Boys providing heroin to people who had first gotten hooked on opiates through OxyContin, but their marketing and delivery philosophy closely resembled that of the maker of the prescription pills: “The safe and reliable delivery of balloons containing heroin of standardized weight and potency. The addict’s convenient everyday solution” (224).

Meanwhile, the opiate epidemic—including black tar heroin—was expanding beyond poor communities and into wealthier towns like Charlotte, North Carolina. Charlotte police officers and prosecutors faced with a growing heroin problem tried to target Xalisco Boys cells but noticed that the drivers and dealers they busted were almost immediately replaced with more young men from Mexico, “farm boys hoping for a better day through black tar” (229). Unlike past drug crises, many of the people hooked on this heroin were young, wealthy, and white—a fact many, including the parents of victims, found hard to believe. In other American communities, such as Portland, Oregon, families were similarly struggling to come to grips with the fact that their children, who had never used, were becoming addicted to OxyContin and black tar heroin. Many of these, like Toviy Sinayayev, who died in 2011 from an overdose, were children of conservative Russian Pentecostals. Further spread of the opiate epidemic was driven by addicts who had originally gotten hooked on OxyContin in Appalachia but who, as states like Kentucky tried to limit the amount of opiates that could be prescribed, fanned out into neighboring states, even as far afield as Florida, in search of pills. But until the late 2000s, many still failed to recognize the extent of the crisis.

Elsewhere at this time, many physicians were likewise struggling to come to terms with mounting evidence of the danger of prescription opiates. Having been told for many years there was no limit on the amount they could prescribe, some couldn’t accept the idea that there were risks. When researchers and practitioners suggested state guidelines for general practitioners, they were met a letter of objection from Purdue Pharma and a lawsuit from a Washington State doctor alleging anti-opioid discrimination—a lawsuit in which the doctor was represented by four out-of-state law firms.

Part 2, Pages 247-269 Summary

Quinones starts this section with a description of Ohio Department of Health epidemiologist Ed Socie, who was among the first to appreciate the extent of the opiate epidemic in Appalachia. In 2007 Socie showed a supervisor what he’d found—that 95% of poisoning deaths in the state were drug overdoses, mostly from prescription pills, and these deaths were about to surpass car crashes as the top cause of injury death (which happened at the end of 2007). This striking statistic was “a stunning moment in the history of U.S. public health” (249). Further analysis showed that the amount of prescriptions for painkillers had also risen exponentially; the correlation between the amount of pain pills dispensed and overdose deaths from opiates was so strong that “Ohio could all but predict one overdose death for roughly every two months’ worth of prescription opiates dispensed” (252).

As researchers and doctors realized the full extent of the opiate epidemic, traffickers in black tar heroin began to appreciate its role in fueling their business. By the 2000s, the synergy between the two—and the aggressive marketing of black tar heroin—had changed Xalisco, as money from the drug trade led to stores and services opening in town. The town’s annual fair began to have semipro basketball games, with teams sponsored by heroin cells, and more houses with modern conveniences were built. Many young men from Xalisco, seeing what it brought, looked for opportunities to sell heroin up north. With demand in the United States increasing—and vacancies in the market, because many Xalisco Boys were arrested in Operation Tar Pit—there were positions open. The heroin business was booming, even after another operation, Operation Black Gold Rush, led to the arrest of many members of the Sanchez heroin clan, which sold in North Carolina. After the operation, the network quickly reconstituted with new members.

Finally, Quinones describes a development of a different kind of criminal case—the one against Purdue Pharma for knowingly misbranding OxyContin as nonaddictive. Led by US attorney for Western Virginia John Brownlee, the suit led to Purdue Pharma pleading guilty to a felony count for misbranding OxyContin, for which it paid a $634.2 million fine.

Part 2 Analysis

Having laid out the background of America’s opiate epidemic in Part 1, Quinones examines its effect in Part 2, describing how increasingly available opiates contributed to, and echoed, the rapid descent of communities such as Portsmouth, even as black tar heroin enriched Xalisco. In doing so, Quinones demonstrates how salesmanship, ignorance, and desperation came together to create a juggernaut that, once started, proved very difficult to stamp out.

An important site in the opiate epidemic was the pain-management clinic, and especially the pill mill, which existed to churn out large numbers of opiate prescriptions for people paying $200 or more per visit. These clinics were particularly prevalent in Portsmouth, where Dr. David Procter had established a blueprint for other pain clinics that allowed for the mass distribution of opiates. Soon, the county had more pain clinics per capita than anywhere in America; Portsmouth was “America’s pill mill capital” (197). While many pain-management clinics were staffed by unscrupulous or incompetent doctors, others started with a sincere intention to treat pain and were “simply pushed off course by patients’ constant demands” (197). Ignorance also played a role in this; many doctors were unaware of the addictive potential of the opiates they were prescribing and even resisted the idea that opiates could be so addictive, as Quinones illustrates through the anecdote of a 2005 meeting between an epidemiologist who was charting skyrocketing overdose deaths from opiates and prominent doctors who were skeptical of the data.

As Quinones explains, doctors were not entirely to blame; Purdue claimed in its advertising that OxyContin was less addictive and prone to abuse than other pain medications, but it never offered any studies to back up those claims. Meanwhile, salespeople showed physicians charts that falsely illustrated that OxyContin’s timed-release formula had fewer peaks and troughs in euphoria, making it less risky. Even doctors who contributed to Purdue’s marketing material were sometimes unaware of how their research was used by the company; Dr. Hershel Jick, who authored a 1980 letter to the New England Journal of Medicine talking about how few people became addicted to opiates, was unaware of the role he’d inadvertently played in supporting Purdue’s claims until he was subpoenaed to appear before a grand jury in the federal case against Purdue for misrepresenting its product.

Desperation also played a role. Quinones describes how changing economic circumstances in places like Floyd County, Kentucky, left many people with only $500 in federal disability to support their families; once these people were able to access OxyContin prescriptions—obtained through pill mills—using their Medicaid cards, they could generate thousands of dollars in extra income for themselves. OxyContin abuse was so prevalent in Portsmouth that it came to form the basis of the community’s economy, with some people in the economically depressed town seeing the drugs “as a grassroots response to economic catastrophe—the way some poor Mexican villages view drug trafficking” (218). In this way, Quinones demonstrates the interlocking factors that fueled the opiate crisis on the prescription drug side of the equation.

In Mexico and elsewhere in the United States, a parallel shift was shaping the trajectory of black tar heroin. Despite the widespread arrests of Operation Tar Pit, discussed in Part 1, heroin was as available as ever. This was due to the Xalisco Boys’ decentralized structure: Every driver or manager who was arrested was replaced by another young man from Xalisco. Apart from the ready availability of cheap labor, the network thrived because of their aggressive marketing; dealers asked customers if their interactions with drivers had been polite and if the product was good, queries that “amounted to customer satisfaction surveys” (224). At the same time, dealers—who didn’t use themselves, and who were from a place in which drug use was frowned upon—chose willful ignorance about heroin’s impact on the lives of those to whom they sold, avoiding close interactions with their clients and forgoing asking themselves too many questions about the damage they were inflicting on addicts. The need for this ignorance extended through the entire community of Xalisco, as the sale of heroin came to drive more of the town’s wealth. And for many of the men who lived frugally in the United States while selling heroin, while spending lavishly at home, the need to keep up a pretense of wealth drove them to return to the heroin trade again and again, driven by desperate need for the rush from the quick cash generated from heroin sales.

In the final section of Part 2, Quinones deploys his characteristic literary style to describe how these two worlds collided in Southern Ohio, as salesmen—first from Purdue Pharma, and then from the Xalisco Boys—acted in sequence to create a phenomenon that would once have been inconceivable: “rural, white heroin junkies” (269).