Dreamland | Sam Quinones

Summary of: Dreamland: The True Tale of America’s Opiate Epidemic
By: Sam Quinones


Prepare to delve into the harrowing journey of America’s opiate epidemic, as narrated in Sam Quinones’ ‘Dreamland: The True Tale of America’s Opiate Epidemic.’ This book summary provides an eye-opening account of the rise of OxyContin, a drug introduced by Purdue in the 1990s, and how its marketing tactics misled doctors and patients about its addictive risks. Gain insights into the emergence of heroin-seeking Xalisco Boys and the ever-growing economy of pill mills. Discover how the quest for a non-addictive painkiller and misinformation molded a devastating epidemic affecting millions of lives.

OxyContin’s Dangerous Legacy

The roots of the opiate crisis in the United States can be traced back to the early 1980s, with the release of Purdue’s MS Contin, a morphine-based, time-release pill. When OxyContin was introduced in 1996, it was marketed as a one-size-fits-all solution for doctors dealing with chronic pain. Aggressive marketing campaigns emphasized that its innovative time-release coating would lower potential addiction rates. However, the endorsement overlooked the differences in controlled usage, leading to widespread abuse, addiction, and a radical transformation of the pain management industry.

The current opiate crisis in the United States may seem new, but it has a long history that began in the 1980s. In 1984, Purdue launched MS Contin, a morphine pill with a time-release coating intended for patients experiencing severe pain from surgeries or terminal illnesses. The product’s success led to the release of another pain-relief drug in 1996 called OxyContin, which contained oxycodone – a derivative of opium. Like MS Contin, OxyContin had a time-release coating, but the two drugs differed in other ways.

The FDA approved OxyContin based on Purdue’s assertion that the time-release coating would minimize addiction by circumventing the fast-acting highs and lows typically associated with opiates. Consequently, they allowed the drug to be marketed with a unique “low potential for abuse” safety label. This claim would become the foundation of OxyContin’s promotion, positioning it as a virtual risk-free solution to chronic pain. They aggressively advertised that it had an addiction rate of less than 1% among patients; however, this low rate was attributed to the controlled hospital settings in which MS Contin was administered.

Doctors outside of hospitals, accustomed to prescribing opiates for chronic pain, began using OxyContin. Unlike traditional opiates that were accompanied by weaker dosages and abuse-deterrent agents, OxyContin was more potent and considered safe only because of its time-release component—something easily overlooked by doctors. Purdue wasted no time capitalizing on this, sending representatives to promote their product to doctors with all costs paid vacations and extravagant luncheons. They also offered doctors OxyContin merchandise and held medical seminars at luxurious resorts.

The aggressive marketing resulted in huge profits, with Purdue’s sales tripling and bonuses jumping from $1 million in 1996 to $40 million in 2001. By 2003, primary care physicians with minimal pain management training mainly prescribed OxyContin. Thus, the pain management industry was revolutionized: prescribing for pain became the norm rather than the exception, leading to the widespread prescribing of OxyContin – and consequently, the birth of the current opiate crisis.

Millennia-Long Opiate Infatuation

For thousands of years, humans have reveled in the effects of opiates, with opium’s appearance in Sumerian, Egyptian, Greek, Indian, and Arab cultures. Morphine, an active molecule within opium, gained popularity as a painkiller during the 19th century due to its effectiveness in dulling pain. However, the struggle to find non-addictive alternatives resulted in the synthesis of heroin by Dr. Alder Wright in 1874. Although initially advertised as a “safe” option, heroin caused addiction rates to skyrocket. The chemistry underlying the addictive properties of opiates such as morphine and heroin has been understood to be linked to the mu-opioid receptors in the brain, triggering euphoria and numbing sensations. Unfortunately, the severe withdrawal symptoms and lingering morphine molecules make recovery a daunting ordeal for addicts.

The fascination with opiates can be traced back thousands of years, appearing in historical accounts from ancient Sumerians, Egyptians, Greeks, Indians, and the Arab empire. The Sumerians even dubbed opium as the “joy plant.”

Though its active molecule, morphine, is present in several other plants, opium is characterized by the highest potency. Ever since morphine’s isolation in the early 1800s, its efficacious painkilling properties granted it widespread use, including during wartime. Alexander Wood, the hypodermic needle inventor, hoped that his creation would minimize drug abuse as users could measure their intake. Regrettably, his wife became the first recorded fatality resulting from an intravenous opiate overdose.

In a booming U.S. market, nineteenth-century patent medicines advertised as “miracle cures” often contained opiates unbeknownst to consumers. These products were so popular that annual sales reached $75 million by the early 20th century.

Amid this period, Dr. Alder Wright synthesized the potent opioid heroin in the search for nonaddictive morphine alternatives. Despite the doctor’s assurances, heroin’s highly addictive traits soon became apparent, as did surges in addiction rates. The addictive characteristics of morphine can be attributed to the molecule’s sleek assimilation with the brain’s mu-opioid receptors. These receptors usually respond to endorphins, releasing pleasure, but morphine’s presence overwhelms them, producing intense euphoria and numbness.

This pleasure, however, is countered by excruciating withdrawal symptoms that addicts must endure, including insomnia, intense pain, and diarrhea, which can last for weeks. In many cases, the severity of withdrawals drives addicts to extreme measures for their next dose. The lingering nature of the morphine molecule, which remains intact in the body instead of breaking down into glucose, exacerbates these problematic withdrawal symptoms.

Decoding the “Pseudoaddiction” Phenomenon

A single paragraph published in 1980 inadvertently contributed to an opioid crisis, due to the misinterpretation and overemphasis of its content. The medical field’s growing interest in pain management led to the illusion of an underdiagnosed problem, magnifying the relevance of the misleading research, ultimately creating the disputed term, “pseudoaddiction.”

In 1980, a ripple would begin that would course through medical history for years to come. A snippet of a study conducted by Dr. Hershel Jick of Boston University’s School of Medicine and his graduate student, Jane Porter, discovered that out of roughly 12,000 patients treated with narcotics at the hospital, a mere four suffered from addiction following their treatment. Little did they know, this casual letter published in New England Journal of Medicine would become the catalyst for widespread misunderstanding and misrepresentation.

During the same period, doctors were gaining a renewed curiosity in pain management. Long criticized for inadequately addressing patients’ chronic pain concerns, medical professionals began to emphasize the importance of this aspect of treatment. In 1996, the American Pain Society even designated pain as the “fifth vital sign.” This newfound focus on pain wound up paralleling an escalating push to prescribe opioids – a treatment often argued to have an “extremely low potential for abuse.”

Fearful of litigation due to neglect of patients’ pain, physicians began liberally doling out opioids under the assumption that they were supported by the study authored by Jick and Porter. Unfortunately, many individuals were quoting this letter without actually understanding its content, inaccurately passing it off as a thorough, scientifically backed research. Misrepresentations in publications like Scientific American and Time reinforced this notion, causing medical professionals to scrap previous wisdom regarding opioids.

The consequences of this misinformation led to the birth of the term “pseudoaddiction.” Pseudoaddiction reflects the appearance of addiction but is, in reality, a mere cry for adequate pain relief. In these cases, doctors were advised to increase opioid dosages “aggressively” to handle the discomfort.

In summary, the misinterpretation of Jick and Porter’s letter, combined with the medical community’s amplified interest in effectively treating pain, forged a dangerous path. This misunderstanding led to the era of “pseudoaddiction” – which stemmed from the incorrect belief that an “extensive study” supported the aggressive prescribing of opioids.

Rise of Portsmouth’s Pill Mills

Once a thriving American industrial town, Portsmouth, Ohio suffered from globalization and saw its economy decline. By the 1990s, the city became a part of America’s Rust Belt and witnessed the emergence of a new industry: pill mills. The struggling population turned to Medicare cards to fuel their addiction to OxyContin and other prescription drugs. People found ways to game the system, such as trading pills on the black market and exploiting those with drug dependencies. An increase in applications for Supplemental Security Income and the presence of less reputable doctors facilitated the growth of this dangerous subeconomy.

Portsmouth, Ohio, was a flourishing industrial town in its heyday, but globalization crippled the city, causing factories to shut down and jobs to vanish. By the late 20th century, it joined the ranks of the many declining cities within America’s Rust Belt. In the wake of this economic downturn emerged an insidious industry: pill mills.

Job opportunities were scarce in Portsmouth, but acquiring Medicare cards was considerably easier. The burgeoning economy was built upon these pill mills, where clinics churned out prescription after prescription with little care or oversight. The number of locals applying for the Supplemental Security Income government program notably spiked between 1998 and 2008.

Patrons of pill mills stocked up on drugs like OxyContin and engaged in lucrative black market trade for their necessities. Some entrepreneurial individuals even exploited addicts, taking them to clinics, covering their fees, and garnering half the prescribed pills as payment. Before long, an “Oxy” pill would fetch $1 per milligram, enabling trade for various goods, from electronics to household essentials.

The illegal market birthed related subeconomies, too. Drug buyers occasionally needed clean urine to pass tests and secure prescriptions, resulting in a profitable niche for purveyors – especially suppliers of rare, untainted child’s urine, which could fetch up to $40 per bottle.

Many pill mills were not established by doctors, so their success hinged on partnering with less reputable medical practitioners. This attracted those seeking temporary employment due to licensure issues, substance abuse, or insurance woes, particularly through “locum tenens” lists. Eventually, this thriving ecosystem of abuse caught the attention of established drug dealers, further expanding the cycle of addiction and illicit gain.

The Xalisco Boys’ Heroin Revolution

During the 1980s, the Rust Belt saw a surge in Oxy use, while a group called the Xalisco Boys began selling black tar heroin in California’s San Fernando Valley. The Xalisco Boys, originating from a Mexican village, revolutionized the heroin trade with their unique retail model that maintained the drug’s potency and leveraged a franchise-like system. This approach helped the cells thrive and rake in substantial profits.

As OxyContin consumption soared across the Rust Belt, the Xalisco Boys emerged in the San Fernando Valley, where they started peddling black tar heroin to local addicts. Hailing from a small village in Mexico, these dealers quickly achieved success by adopting a revolutionary retail strategy.

Unlike other kingpins, who sold low-quality heroin on a wholesale basis, the Xalisco Boys focused on retail sales. This allowed them to maintain the drug’s potency instead of diluting it through a chain of middlemen. Sourced directly from poppy fields near their hometown, the black tar heroin had a high purity level that attracted a loyal customer base.

The Xalisco Boys further distinguished themselves by operating in small, structured cells reminiscent of franchises. After securing supplies from a northbound wholesaler, each cell – consisting of an owner, manager, phone operator, and drivers – would sell the drugs at the street level. The operators fielded calls from addicts, orchestrating fleet-footed handoffs with drivers who carried single doses of heroin in small, inconspicuous balloons.

If confronted by law enforcement, drivers could discreetly swallow the evidence, safeguarding both the product and their cell. Placing loyalty above temptation, the Xalisco Boys paid their drivers a steady salary, removing any incentive to cheat the addicts or dilute the drugs. As a result of these innovative methods, the cells turned impressive profits, with daily earnings potentially tripling to $15,000 within a year. Thus, the Xalisco Boys’ cunning approach revolutionized the heroin market, benefiting both their business and the addicts seeking a higher-quality product.

Rise of Xalisco Boys

The invention of methadone in 1947 was initially seen as a breakthrough in treating drug addiction. Methadone clinics aimed to supply addicts with a regulated amount of methadone to prevent their addiction from worsening. However, over time, for-profit clinics began reducing the methadone dosage to wean addicts off heroin completely, leaving patients craving opiates. This created an opportunity for the Xalisco Boys, a drug cartel that expanded rapidly across the San Fernando Valley in the 1990s. Distributed free samples of heroin and provided phone numbers for addicts to call them, they quickly became the dominant drug dealers in many cities, causing a significant surge in heroin addiction and overdoses in the late 1990s.

The basis of methadone treatment stemmed from its unique characteristic as an opiate. Unlike other opiates, methadone users did not need to constantly increase their dosage. As a result, methadone clinics were established with the primary goal of managing addiction by providing a controlled supply of methadone to patients. However, the focus shifted as for-profit clinics emerged—aiming to eliminate heroin use altogether by steadily reducing methadone doses.

This development led to a phenomenon where patients were left craving for opiates, driving a desperate search for alternative sources. The Xalisco Boys, seeing an untapped market, devised a strategy to tap into the methadone clinic clienteles. The cartel’s drivers would show up at these clinics distributing free heroin samples and phone numbers for further orders. They honed this tactic by training new drivers to approach addicts inconspicuously and offer them the illicit drug.

With an expanding clientele, the Xalisco Boys quickly gained dominance in the drug trade throughout numerous cities. Their impact was evident at detox centers operated by Central City Concern, a nonprofit in Portland, Oregon. In the mid-1990s, only 5 to 10 percent of their patients sought help for opiate detox; however, by 1997, the number skyrocketed to 50 percent, indicating a surge of heroin addiction fueled by the Xalisco Boys’ narcotics.

It took Portland officials until 1999 to acknowledge the mounting crisis. Tragically, heroin-related deaths had risen from ten in 1991 to 111 in 1999, establishing it as the second-leading cause of death for men between 20 and 54 years old. The rapid growth of the Xalisco Boys’ heroin empire was directly linked to the unintended consequences of methadone clinic practices, culminating in widespread addiction and overdose epidemic in the 1990s.

Xalisco Boys’ Customer-Centric Approach

The Xalisco Boys stood out among heroin dealers with their customer-centric approach that targeted middle-class white kids by implementing effective marketing tactics and prioritizing customer satisfaction. Their unique business model minimized risk through non-violent operations and independent cells, ensuring competition and expansion. While law enforcement intervened with a large-scale operation, it unintentionally worsened the situation by leaving a void for competitors to increase their heroin supply across the country.

The Xalisco Boys were an innovative group of heroin dealers distinguished by their keen understanding of customer service and convenience. Focusing on middle-class white kids, they took the initiative to actively approach potential customers by offering free samples and pricing incentives. Their commitment to customer satisfaction involved follow-up calls, going-away presents of free heroin for rehab-bound customers, and even providing recently released prisoners with heroin to ensure their return as clients.

In a bold testament to their service quality, an undercover narcotics cop in Charlotte, North Carolina, deemed their service model superior to many legitimate retailers. The Xalisco Boys’ risk management strategies, such as avoiding violence and carrying limited heroin supplies, ensured lenient legal consequences upon apprehension, thereby attracting a continuous stream of aspiring dealers seeking financial gains with minimal risks.

Moreover, the group’s structure allowed for each cell to operate independently like a separate franchise. This facilitated competition among cells, driving them to excel in customer service and maintain competitive prices. This competitive spirit also pushed them to expand their reach into less saturated markets and enlist the help of addicts to bring in new customers or to gather information on fresh territories, rewarding them with free products for their assistance.

The expansive and deeply-rooted Xalisco network eventually caught the attention of law enforcement, prompting the FBI and the Drug Enforcement Agency to launch Operation Tar Pit on June 15, 2000. This operation represented the most expansive drug investigation in U.S. history, with busts spanning 27 cities and 22 states. Though seemingly effective, the operation generated unintended consequences.

In taking down the Xalisco Boys, Operation Tar Pit created a power vacuum that other heroin suppliers rushed to fill. The persisting presence of addicts and the absence of the Xalisco Boys fostered intense competition between new suppliers, consequently leading to reduced prices and increased supply of black tar heroin across the United States. This outcome demonstrated that while the authorities targeted a particular group, they inadvertently exacerbated the very problem they aimed to address.

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