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
The medical community stigmatized opiates for much of the 20th century. Doctors who prescribed them were considered “virtual outlaws.” However, this began to change substantially in the 1970s. Cicely Saunders, an English hospice nurse who worked with cancer patients, discovered that opiate painkillers were immensely successful in relieving pain in patients with terminal illnesses. England applauded Saunders’s work, but the US remained comparatively stigmatizing and archaic in its views. In Britain, Napp Pharmaceuticals came out with a “controlled-release formula” called Continus. Originally used as an asthma medication, the drug would later serve as a model for time-release painkillers.
The medical community’s decision to refer to doctors who prescribed opiates as “virtual outlaws” highlights the fine line between the business of condoned drug-dealing and the business of illegal drug-dealing. It also shows how significantly cultural stigma influences which drugs are perceived as good and which drugs are perceived as bad: doctors considered “outlaws” pre-1970 would have been readily accepted at the height of the pain movement in the late-1990s. Saunders’s work with opiates was limited to pain patients with terminal illnesses, though her philosophies would later be extended for use in patients with non-terminal illnesses, as well. Continus is important because its formula would be used as a model for OxyContin.
Themes
During this time, Swedish cancer doctor Jan Stjernsward became chief of the World Health Organization’s cancer program. Stjernsward had experience working with dying patients in Kenya and saw the relief that morphine granted these patients who had no access to curative treatment. Stjernsward set out to normalize morphine in treating U.S. cancer patients, emphasizing the moral and cost benefits of such treatments. Stjernsward met Vittorio Ventafridda, who also worked with the terminally ill. Ventafridda introduced Stjernsward to his “ladder of treatment,” which outlined principles for treating the dying. The ladder dictated that increasingly stronger doses of opiates should be administered to the dying if they remained in pain. The World Health Organization also started to view “freedom from pain as a universal human right.” These views guided the popular medical opinion toward a gradual acceptance of opiates. Opiate use began to climb in wealthy countries, who would consume over 90 percent of all morphine.
The cost effectiveness of treating patients with opiates would become a big problem down the road when insurance companies began to offer better reimbursements for cost-effective opiate prescriptions than other methods of treating pain, like therapy and counseling, which, though effective, took more time and were more costly. WHO’s idea that “freedom from pain [was] a universal human right” plays into the larger belief that life should always be painless, at all costs. Quinones believes that this kind of thinking created a contemporary American culture unable and unwilling to deal with pain and discomfort.
Themes
American doctors like Dr. Kathleen Foley and Dr. Russell Portenoy, of Sloan Kettering Cancer Center in New York, were appalled by patients in other countries who suffered as a result of physicians’ stigmas against opiates. Foley believed opiates should be used to treat all kinds of pain. Portenoy arrived at Sloan Kettering to study under Foley in 1984. Together, they helped normalize the new practice of palliative care, which grew out of the philosophies of Cicely Saunders, among others. At the root of palliative care was the notion “that death should be dignified.”
Palliative care was originally restricted to terminally ill patients. In addition to opiates, it involved other forms of treatment like therapy and counseling, emphasizing the importance of human connection and compassion. Like so many ideas to come out of the pain movement, palliative care grew out of well-intentioned, morally upright philosophies that were corrupted over time as pharmaceutical businesses seized on an opportunity to capitalize on the medical industry’s newly open attitude toward narcotics.
Themes
The introduction of palliative care into the American medical world coincided with Purdue’s release of MS-Contin in 1984, which was developed for use in surgery and in cancer patients. Russell Portenoy saw new drugs like MS Contin as “far less addictive” by virtue of their time-release attributes and was optimistic about humanity’s new ability to manage pain in the suffering through innovative drugs and the industry’s transformed views toward pain.
The invention of MS-Contin, a time-release narcotic, seemed like a step toward finding the “Holy Grail” that had fueled the work of researchers at the Narcotic Farm decades earlier.
Themes
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