Themes
Key
LitCharts assigns a color and icon to each theme in Dreamland, which you can use to track the themes throughout the work.
Pain Management and the Normalization of Narcotics
The Drug Business
Stigma, Shame, and the Opiate Epidemic
Community as a Remedy to Addiction
Summary
Analysis
Biggs Lane, in South Shore, Kentucky, spans a length of only 100 yards. South Shore is a small town, with a population of just 2,100. Just north of the town is the Ohio River, across which lies Portsmouth, Ohio. In 1979, Dr. David Procter, by then South Shore’s only doctor, opens a clinic on Biggs Lane and calls it Plaza Healthcare. Procter, who is from Canada, is “flashy” in a way that is at odds with much of small-town Kentucky; one nurse compares him to Liberace.
Procter’s status as South Shore’s only doctor gives him something of a monopoly over the town’s healthcare business. By the mid-1990s, his Plaza Healthcare will be regarded as the nation’s first pill mill, or medical facility known for dispensing prescription narcotics liberally and often inappropriately.
Themes
Portsmouth, Ohio is an industrial town along the Ohio River. It used to be a lively, thriving place for workers to let loose after days spent on barges. Shoe factories made Portsmouth a prosperous place, and the Detroit Steel Company employed thousands of people from Ohio and Kentucky. However, Portsmouth’s economy, unready for globalization, began to collapse in the 1970s. Many residents left Portsmouth for larger cities. Portsmouth’s former industrial businesses were replaced by pawnshops, check-cashing stores, and scrap metal yards. Across the river in South Shore, David Procter’s clinic blossoms, and he expands his business to Portsmouth.
Quinones depicts Procter’s clinic as replacing many of Portsmouth’s former businesses, thus distinguishing medical establishments as businesses, and doctors like Procter as businessmen.
Themes
As the city’s unemployment rate grows, so too does the number of citizens on disability. Though many of the unemployed people who apply for disability or workers’ compensation are legitimately disabled, a good number are not. All that is required to get disability checks is a doctor’s diagnosis, and Procter is willing to give out many. Procter is an extreme embodiment of America’s new attitude toward pain: patients are “always right” when it comes to pain, and their requests for pills they “needed or wanted” should be honored. Procter is an early advocate of increased opiate use in medicine, which remained a contentious subject in the mid-1980s. He prescribes opiates for everything from neck pain to arthritis.
Procter’s practice of signing workers’ compensation paperwork indiscriminately could be his attempt help unemployed patients obtain disability payments that allow them to scrape by in times of financial instability. Ultimately, however, Procter and other pill mill doctors will use this as a business model to make a profit from overprescribing prescription painkillers. Procter’s belief that the patient is “always right” is reflective of the “customer is always right” mindset of customer service practices in business, thus building another parallel between the practices of the medical industry and the larger business world.
Themes
In 1996, a prison guard from Lucasville named Randy goes to Procter after a fight with an inmate leaves him badly bruised. Procter charges Randy $200 and prescribes him a month’s worth of OxyContin. In retrospect, Randy recalls, his injury was not substantial enough to warrant the use of such a strong painkiller.
Procter prescribed Randy pills for his pain because it was an easier, more efficient method of treatment than, say, physical therapy. In turn, Randy might have accepted the prescription because it allowed him (at first) to return to his obligations after the injury. This idea of efficiency over true effectiveness betrays the capitalistic impulses of the medical industry, as well as the desire for an easy way out of pain that Quinones sees as central to America’s shifting attitude toward pain and discomfort.
Themes
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After 30 days on OxyContin, Randy feels better and doesn’t return for a refill. However, he immediately becomes horribly ill with withdrawal symptoms. He goes back to Procter, who prescribes him more OxyContin. Randy returns to Procter once a month after this, and his appointments last a maximum of three minutes. Each time, he leaves with a new prescription. Procter’s waiting room is always full to capacity, mostly with scammers faking ailments to get prescriptions. Soon, whenever he runs out of OxyContin before the month is up, Randy starts getting opiates on the streets, and he returns to work a full-fledged opiate addict. His addiction lasts just three years, but the worst of the opiate epidemic has just begun.
Randy quickly became addicted to pills prescribed to him by a legitimate doctor. The narrative of the downward trajectory from functional normalcy to addiction is typically associated with illegitimate, stigmatized drugs like crack or meth. Quinones shows that Randy’s addiction was enabled not by a seedy, back-alley dealer, but by a legitimate, condoned medical professional, demonstrating how a lack of stigma attached to the medical industry caused a new, increased population of unwitting addicts.
Themes
