The Perfect Storm of the Opioid Epidemic

Book review: Dreamland, by Sam Quinones

Crime was at historic lows, drug overdose deaths at record highs. A happy façade covered a disturbing reality.
I grew consumed by this story. It was about America and Mexico, about addiction and marketing, about wealth and poverty, about happiness and how to achieve it. I saw it as an epic woven by threads from all over. It took me through the history of pain and a revolution in U.S. medicine.

That menacing 1970s horror paperback cover with a fear-mongering, FOX news-y description sums up this book better than I could. But sensationalizing aside, this is an eye-opening and important read.

Sam Quinones wrote this accessible, surprisingly page-turning account of the perfect storm of circumstances that led to the opiate epidemic America is currently facing and struggling to address.

Quinones tracks the primary culprits in the 1990s through early 2000s boom of cheap black tar heroin in suburban areas and smaller cities that previously lacked the high number of addicts, drug trade business, or drug-related deaths that major heroin centers like New York City or Baltimore had. They also didn’t have the telltale sign of gangs controlling drug distribution. So what was going on?

Two major things: first, more people had become dependent on opioid pain medication. As Quinones relates in a clear but extensive history of the development and marketing of pain medication, doctors were aggressively marketed to by drug companies and encouraged to prescribe opioids without fear of addiction. Obviously that’s not true, and the background is complicated and absolutely worth reading. It verges on the unbelievable but it’s true.

Unscrupulous or overworked doctors, common misunderstandings of pain and what pain management should entail for long-term health and care, people with prescriptions spotting a business opportunity, and pushy advertising are some of the culprits. These portions of the book, looking at the pharmaceutical industry’s role in the epidemic, were as sickening as those describing illegal drugs.

Something like that happened to David Procter [a physician known for easily prescribing opiates]. More patient complaints in the 1990s prompted a second state investigation. By then, those records show, he regularly prescribed Valium, Vicodin, the sedative Soma, Xanax, and a steady regimen of Redux diet pills—all with almost no diagnosis or suggestions for other treatment, such as physical therapy. Nor was there any discussion of improving diet as a way to lose weight and reduce pain. As I read the Licensure Board investigative reports, it seemed that many years in deindustrialized America seeing vulnerable people and manipulative people who used drugs and the government dole to navigate economic disaster had corroded any medical ethics Procter once possessed.

The second factor is the so-called “Xalisco Boys”, a network of young Mexican men hailing from the city of Xalisco in the state of Nayarit. They had access to opium poppies grown in the nearby hills, and developed a streamlined, pizza-delivery-style system for distributing cheap, strong black tar heroin in American cities that were underserved in this area, so to speak.

The Boys remained decentralized, resilient, and adaptable. They embodied America’s opiate epidemic: they were quiet, nonviolent. They focused on new opiate markets where the only customers they wanted were the white people. They were, it seemed to me, the Internet of dope, a drug delivery system for the twenty-first century, working in as many as twenty-five states, and all of this coming out of one small town in Mexico. These drivers had their own addiction nipping at their heels. It was the ranchero’s dream to return home a king, to pay the banda, to dance with the girls, to see other men’s envy, and to feel the embrace of their families as they opened boxes containing precious Levi’s 501s and designer jeans.

Their business model is really something unbelievable. It’s such a well-oiled machine, every aspect relating to drivers, phone operators, and preparation areas is meticulously overseen and organized. They’re adaptable, interchangeable, and heavily customer service-oriented, making courtesy calls and dispensing freebies. Their product is also extremely strong, which has led to even more unintentional overdoses in addition to easily hooking their “customers”.

Quinones has an interesting perspective into the Mexican roots of this crisis, as he’s spent time living and working in the same kind of small, clannish Mexican villages like Xalisco where the black tar heroin export business was born. This was such a troubling element of this story – the men, and sometimes boys, dealing through the Xalisco network in America weren’t drug users themselves or gang members. They came temporarily, they were salaried employees so never had incentive to push, oversell, or commit crimes, and operated on a strong customer service-based business model. They followed group rules to collect their salaries and return home to the Mexican villages, able to buy luxury items like Levi’s 501s and elevate their status in this social system. Any moral feelings remain entirely unaddressed. It seems they’re absent.

Quinones does good work fleshing out this social structure, painting a picture of social and economic life so as to demonstrate where this new breed of dealer was coming from.

This thirst for Levi’s 501s…is part of what propelled the Xalisco system as it began to expand out of the San Fernando Valley and through the western United States in the mid-1990s.

Maybe it’s really just that devastating and hard to fathom – heroin has taken over large swaths of states, even of the country, helped along in part thanks to an insatiable, competitive desire for designer jeans and one-upping a cousin in Mexico. Of course it goes deeper than this, but that’s a powerful theme throughout. This is an extremely informative but not at all uplifting or positive read.

Some segments and details or facts become repetitive. It sometimes reads like a series of journalistic pieces, like magazine articles, pulled together. But it’s not too detrimental, since the narrative shifts frequently enough that it’s not such a bad thing to be reminded of the major points and players involved.

Quinones profiles so many figures to cover angles in this story, including former addicts, drug and law enforcement agents, affected communities and their members, medical professionals, imprisoned dealers and key characters from the Mexican side, providing a wealth of information on how these shifts in supply and demand in both legal and illegal opioids grew, was exploited, and filled niches.

The book’s title references the idyllic past of suburban, working class America, beginning with a metaphor of a swimming pool called Dreamland in Portsmouth, Ohio – part of a region currently suffering extremely in the epidemic that’s been ramping up since the mid-90s. I wasn’t always on board with the metaphor or this imagery, but overall his descriptions of how cheap heroin coupled with misunderstood or undervalued pain management and care changed the core of so many American cities are vividly affecting.

Incredibly fascinating, sad and scary. As the country tries to address this epidemic, however feebly, it’s important to know its roots and what allowed it to grow in the first place. 4/5

Dreamland: The True Tale of America’s Opiate Epidemic
by Sam Quinones
published April 2015 by Bloomsbury Press

Book Depository

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