Dreamland – How’d We Get Here?

(Spring 2016) Working Partners® educates our audiences about the contributing factors that led to America’s painkiller epidemic. Our education is based on extensive research. Against that background, we were awed by the additional details and comprehension we gained from reading Dreamland: The True Tale of America’s Opiate Epidemic by acclaimed journalist Sam Quinones.

We highly encourage our clients, partners and constituents to read this book. Quinones carefully chronicles the evolution of the prescription painkiller epidemic and its direct ties to America’s growing heroin epidemic. He helps the reader understand a tale of catastrophic impact; two economically deprived communities from different countries (Mexico and United States) undergo industrious capitalism and ignite epidemics as they intersect with each other. The sweeping constellation of dynamics that made fertile ground for this perfect storm took decades.

The Evolution of Prescription Painkiller Popularity

Key to the story is our society’s “quick-fix, take a pill for it” mentality. Quinones traces specific steps and correlations between this arch type and the fact that our medical community adopted (and is often required to manage) pain as a fifth vital sign. He gracefully points out the craziness of this given that measuring pain in a practitioner’s office is subjective unlike the objective methods for collecting the other vital signs such as pulse and blood pressure.

The book maps the timeline of worldwide scientific efforts to manage the morphine molecule, the essential element in all opiates, so it could be safely and effectively used to treat both chronic and acute pain conditions. Toward satisfying this quest, Quinones tracks the harnessing of the morphine molecule through to the production of time-released formulations such as OxyContin (1996), heralded as a pharmacological breakthrough – a breakthrough which played a significant role in popularizing the use of painkillers.

The history of sophisticated marketing models for direct sales of pharmaceuticals is examined. As American medicine and medical marketing aligned in the 1980s and ‘90s, effective direct mailing campaigns and face to face visits to physicians – very personalized and powerful – played a huge role in this unfolding saga. Quinones shares that as these marketing ideas took root, the 10-year span between 1995-2005 saw an increase from 35,000 to a record of 110,000 people traveling the country directly selling legal drugs in America.

Dreamland takes readers through the societal morphing from when we truly feared the addictive properties of the morphine molecule through subsequent periods of confusion and conflict.   He examines contributions to the confusion such as the journey of a select excerpt of information from a 1980 letter to the editor written by two doctors (Porter and Jick) published in The New England Journal of Medicine.

In it, they discuss a very narrow, controlled study that “resulted in less than 1% of the subjects being treated with narcotics developing an addiction to them.” There were many controlled variables referenced in the letter about the study, however, this excerpt was taken out of context and grossly misinterpreted. It became a mantra illustrated in charts and graphs and used by the largest single medical marketing movement ever experienced. The movement promoted time-released prescription painkillers and effectively shifted attitudes of learned persons as well as the general public as to the non-addictive attributes of opiates.

The movement was also very lucrative. In five years, Purdue Pharma went from paying its sales force $1 million to $40 million in bonuses tied to the sale of OxyContin. Eventually, the world realized the misperceptions about the addictive qualities of the time-release opiates. States sued Purdue Pharma for the role they played in the painkiller addiction and overdose of citizens. In one suit alone, Purdue Pharma pleaded guilty to misbranding and paid a settlement of over $630 million – a drop in the bucket when they reported profits in the billions.

Big business, a society hungry to expediently manage pain, an encumbered medical profession and more have contributed to America’s prescription painkiller epidemic. All the background and details about our prescription painkiller problem are enlightening. In Dreamland, Quinones relentlessly engrosses us with how this process paved the way for America’s heroin epidemic.

The Heroin Business Model Following Pharma

Dreamland traces the heroin story thread back to Xalisco, Mexico, an impoverished area where the livelihood of 29,000 people had been dependent upon the deteriorating sugar cane industry. Opportunists of the area took the availability of a desperately poor, unskilled workforce and fertile land and transformed it into a business dynasty with a brilliant, almost unbeatable, marketing and distribution system. The Xalisco Boys’ resources afforded them the capacity to produce very potent black tar heroin, and, because they had a ready workforce, they could control the quality and cost of their product from the field to the streets.

During the 1990s, the Xalisco Boys’ heroin cells refined their delivery system to minimize attention from America’s law enforcement community. They operated in small, inconspicuous, compartmentalized units with an individual receiving product orders and then using pagers to dispatch delivery runners.

The runners carried small amounts of product and knew very few details about the operation. If the runners were busted, they only possessed a small amount of product and minimal information with which to negotiate with authorities and, therefore, offered little value for prosecution. Generally, they were deported, but the heroin system lost little time – the busted individuals were immediately replaced by other runners brought in from impoverished communities in Mexico.

The system avoided the ire of another foe who sold heroin in America, large, organized cartels (Latin American and Chinese). Part of the Xalisco Boys’ strategy was to avoid operating in the larger metropolitan targets of the cartels. From the early 1980s through 1998, the Xalisco heroin industry built, refined and sophisticated its business model, operations and trade in America.

For Ohioans, Dreamland hits home as it details the Xalisco Boys’ movement from California through America. In 1998, for the first time east of the Mississippi River, Xalisco black tar heroin lands in Columbus, Ohio. The juxtaposition of heartland American towns and cities experiencing depleting economies in relation to the arrival of this heroin was devastating. Many of the economically withered communities which had already become unsuspecting victims of the darker side of the prescription painkiller industry – pain clinics – were now ready targets for cheap, potent black tar heroin.

OMGosh! Where do we go from here?

In a natural business progression, the mission to find easy answers to acute pain using the morphine molecule led to a path of addicting innocent people. Whether we are looking at a micro or a macro perspective, in simplistic terms this has been the path.

• Micro – the adolescent who gets injured on the football field and ends up addicted to painkillers.
• Macro – pain management professionals embraced the pharmacological findings and marketing efforts and over-prescribe painkillers resulting in addiction.

In addition to examining the root of the current epidemic, Quinones also provides hope. He traces and details grass-root accomplishments that are indeed at work to turn-the-tide one community at a time. He brings to life real people who have been impacted by the painkiller and heroin epidemics.   Dreamland gives a face to the suffering individuals and their families dealing with addiction and death; the treatment professionals desperately trying to meet the demand for services; the government officials try to find directions, answers and the dollars to defend against this devastation; and many others.

This book is a valuable and engaging read! We feel compelled to shout to all who will listen, “Please read this! We must learn from the lessons which are so well documented by Quinones!”

In the 24 years, Working Partners® has been in operation, we have seen the “same-song, different-drug” cycles repeatedly. Never have we reviewed such a thorough anthology of the cycle. This book provides a great learning opportunity. For the history we do not learn from, we are condemned to repeat.