Monday, May 29, 2017

Book Review: 'Dreamland: The True Tale of America’s Opiate Epidemic' by Sam Quinones

From `Dreamland’ to Nightmare in One Generation

Sam Quinones, Dreamland–The True Tale of America’s Opiate Epidemic
New York; Bloomsbury Press, 2015

By George Canning

“Dreamland.”  The very name invokes the Earthly paradise of cities and suburbs of yesteryear, and journalist Sam Quinones begins his “True Tale” with a prefatory chapter on Dreamland’s story.  It was a real place – the name of the shining, sprawling, modern swimming pool complex, built in the 1920s, in Portsmouth, Ohio that entertained families well into the 1960s.  Today, it is gone, and the Dreamland saga that Quinones captures brilliantly, is the saga of America’s heartland in decay.  Gone are the jobs, the industries, stores, the pool, and all the hope that went with those things.  Today, Dreamland is one of the many “ground zero” centers of the opioid epidemic in the United States, an epidemic that claimed more than 500,000 dead between 2000 and 2015, and whose number of dead is still climbing.
Portsmouth became the area in which opiate-dispensing “pill mills” were first developed, and Quinones’s narrative returns to that town repeatedly to discuss different aspects of the problem.
The discovery that death rates were rapidly rising among white middle-aged Americans burst into the news headlines in the Fall of 2015 with publication of a paper by economists Anne Case and Angus Deacon at Princeton University.  These death rates were driven by suicide, alcohol, and drug poisoning, and long-term alcohol effects e.g. on the liver — which Case and Deacon labelled in a subsequent paper as “deaths of despair.”  Newspaper stories focused particularly upon the element of rapidly increasing numbers of drug overdose deaths.
These frequently anecdotal articles describe people, particularly in economically devastated Middle America, who were prescribed pain pills for various injuries and became addicted, in such numbers that in some regions such as the Ohio River Valley (Dreamland’s locale), pills replaced cash as a local currency.  The articles have frequently reported that many of these addicts switched to heroin because of lower cost, without further explanation.  The fact that heroin had suddenly become available in the 1990s, in areas of the U.S. which had previously been as safe and clean and happy as Dreamland itself once was, is rarely examined, and one of the merits of Quinones’s book is that it traces how heroin came to small cities and towns in Middle America.  Case and Deacon in fact cite Dreamland regarding heroin sales expansion.
Dreamland elaborates, in a highly readable style, the story of how a growing tide of heroin trafficking moving west to east across America beginning in the late 1990s, met and fed on another tide moving, more or less, in the opposite direction:  The vast expansion of usage of “controlled prescription drugs,” especially “pain pills” such as OxyContin.  In brief chapters which could almost stand on their own as short news stories, Quinones develops three major themes:  the heroin expansion; the earlier reversal in pain-treatment philosophy from an “anti-narcotics” stance to an embrace of legal opiates; and the mass-marketing of those legal opiates.  The latter two themes have been addressed elsewhere, but Quinones elaborates them in greater detail than the typical newspaper article, and more accessibly than medical-journal articles.
Dreamland traces out the medical profession’s shift in the 1970s and ’80s, away from avoidance of prescribing narcotics for pain, to alleviation of dying cancer patients’ excruciating pain with morphine; similar treatment of the pain of post-surgical patients soon followed.  In the 1980s, some researchers went a step further, arguing for use of opiates in treating chronic pain from ongoing conditions such as back or knee pain.  Clinics for chronic pain had begun in America in the early 1960s, and often involved teams of specialists prescribing therapy and life-style changes, with drugs playing a small role.  But such programs were gradual, and required intensive work by the patients and doctors, and the medical insurance companies were generally unwilling to pay for therapy and counselling.  Many pain clinics’ business model shifted toward the simpler solution of simply prescribing pain pills.

The 1% Solution

Meanwhile, new opiate pain relief pills, led by Purdue Pharma’s OxyContin, were approved by the FDA in the mid-1990s and were vigorously marketed to non-specialist primary care doctors. Doctors’ fear of causing drug addiction was assuaged by sales reps of Purdue Pharma, who told them in published papers, in personal visits, and in big “continuing education” conferences, that “studies” had shown only about 1% of patients given opiates for pain developed addiction.  This statistic was drawn in fact from a brief 1979 letter to the New England Journal of Medicine based simply on analysis of data about hospitalized patients.  Quinones notes that use of opiates in a hospital setting, monitored and controlled by medical professionals, is an entirely different matter than pain-sufferers being given bottles of pills to handle their treatment themselves.
In addition, the drug companies pushed the claim that drug addiction was unlikely with OxyContin because it delivered the oxycodone opium-derivative in a time-release fashion, and/or because the “elation” hitting the nervous system along with the drug’s pain-relief properties was countered by the sensations of pain in the patient’s nervous system.  The problem is, no one really knows whether these propositions are true.  Apparently, the FDA had been sold on OxyContin’s safety by similar arguments — surprising for a regulatory process widely portrayed as involving arduous and expensive testing to demonstrate a medication to be safe and effective.
OxyContin prescriptions for chronic pain rose from 670,000 in 1997 to 6.2 million in 2002, and people who received repeated prescriptions for legal opiates built up a tolerance to the standard dosages, so more pills were needed to achieve relief.  People who were unable to obtain the legal opiates through the established medical system began to buy them from pharmacies affiliated with “pill mill” clinics consisting of a doctor and a prescription pad, or worse yet, through non-medical drug pushers.  With the illicit street-price of OxyContin at $1 per milligram for 40- or 80-mg pills, an addict with a 100-mg a day habit would have to spend $100 a day.  Eventually, users unable to afford the pills, either legally or illegally, switched to heroin (which, from accounts of “black tar” around the country cited by Quinones, serviced an addict for $20 to $40 a day).  This shift had been anticipated by some of the heroin pushers.  One of Quinones’s sources (whom he calls “The Man”) had been a major figure in the heroin expansion east of the Mississippi into new areas in the late 1990s.  When The Man came to a new town, he targeted its methadone-maintenance clinics to lure their patients back to heroin.  Later, “When he heard about OxyContin, he began to follow it, knowing that if he did, he would soon have a market.”

Mexican Black-Tar Heroin

Enter the third theme:  the reconfiguration and expansion of the heroin trade, which was, in the 1960s, centered in Turkey and Southeast Asia.  After the ebb of heroin’s popularity in the U.S., in the 1970s, the heroin trade had focused on addicts with big habits, generally in major urban centers.  In the early 1980s, Mexicans began sending black tar heroin north, which began to supplant other varieties in the established urban markets.
Now new heroin markets were developed in small American cities and towns, and Dreamland tells this story.  Beginning in the San Fernando Valley northwest of Los Angeles, migrants from the town of Xalisco in the tiny Mexican state of Nayarit started selling black tar heroin, using “cell” organizations owned and overseen, back in Nayarit.  Perhaps uniquely, the Nayarit cells produced, transported, and sold the heroin, owning it “from flower to arm.”  In the late 1980s, the “Xalisco Boys” ceased selling heroin on street corners, and developed a system in which addicts would phone in small orders to a cell’s call center, and the heroin would be delivered to them by the cell’s young Mexican drivers. Many of Quinones’s law enforcement sources analogized this system to the pizza-delivery business.
As the Xalisco system flourished, more Nayarit cells flooded the sales area, to share in the bonanza.  Intensifying competition led to consumer-friendly practices such as high-quality product (tested by the FBI at 80% purity) far surpassing what had been previously known in America’s urban centers (where heroin was sold and resold and diluted at each step until the addict received heroin that was about 12% pure).  But ultimately, the rising competition among Xalisco cells for sales had only one solution:  expansion to other markets, in other cities.  By the mid-1990s, Nayarit cells were reported to be operating in a dozen major metropolitan areas in the western United States.  But as the markets in western-U.S. cities became saturated, the Xalisco Boys began, in the late 1990s, to move east, spearheaded by American-born junkie-traffickers, who could obtain sales leads from their addict-customers.  During his campaign spreading black tar heroin east of the Mississippi, The Man discovered the legal pain-killer market on a trip to West Virginia.  Unknowingly, Quinones says, The Man had stumbled on the explosion of opiate addiction in central Ohio — the biggest metro area in a five-state region where, two years into the Purdue Pharma promotional campaign, opiate addiction was exploding due to abuse of OxyContin.
It appears that now the Xalisco Boys as such are largely a thing of the past, apparently superseded by their neighbors in the powerful Sinaloa Cartel.  But the Xalisco black tar story begs certain questions which remain relevant today.

Who Ran the Nayarit Heroin Scheme?

Who designed the evolution of the “Nayarit system” – the switch from street sales to the “pizza delivery” system, improving “customer service,” and finally branching out all over the United States?  Quinones accepts the explanation of his sources such as The Man, that this was all the product of small-business entrepreneurship in a system of sales-cells each acting independently of the others.  But, at the same time, he includes reports that suggest a more top-down organization, such as a Charlotte, N.C. cop saying that he figured that it was “higher-ups in Xalisco” who “were imposing the quality control of a Fortune 500 company.”  A Portland, Ore. health officer said that during a year-long study of the heroin sales in that city, they were told there was “a marketing strategy that had changed from selling to a small number of addicts who had expensive habits and toward a large number of addicts with cheap heroin.”  And, when The Man was recruited to work for one of the Xalisco drug clans, it was not simply to sell dope, but explicitly to help drive the further expansion into new markets.  Were the small businessmen in Xalisco just incredibly clever, or did they have some higher-up business consultants?
How was the production of opium in the nearby mountains, and its processing into heroin in Xalisco, and its shipment into the U.S., all financed in the sugar-cane farming economy of Nayarit?
And just how much in heroin profit were the Xalisco cells in America sending back to that little town on Mexico’s Pacific Coast, and what happened to those enormous profits? Rough calculations, based on the few figures Quinones mentions, suggest about $15 million a year (probably an under-estimate), and while that pales in comparison to the large Mexican cartels, it’s a lot of money to have been pouring into rural Mexico.  Quinones tells of a house-building boom that went on during the peak period, but was that all done in heroin-cash, or was it driven by loans issued from banks flush with heroin deposits?
Dreamland has provided the initial groundwork for answering these questions, which will be crucial for designing a strategy focused on financing and logistics, which can defeat the Mexican cartels today


This review was originally published at readbtl.info.

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