Dreamland: The True Tale of America’s Opiate Epidemic by Sam Quinones tells the story of two powerful drug industries—that of prescription opiates and that of black tar heroin—driven by capitalism and greed, and the cultural and medical institutions that allowed these industries to prosper. The book begins with an anecdote about Dreamland, a community pool in Portsmouth, Ohio. Dreamland served as a central meeting place of the community where people connected, socialized, and had fun with one another. Today, however, there is no Dreamland—it exists only in the memories of the generations who grew up visiting it. Whereas Portsmouth, Ohio was once a bustling, tight-knight All-American City, today the town has been largely abandoned.
Quinones’s research on the opiate epidemic is fueled by anecdotal accounts of addiction relayed by addicts and their families. The first of these accounts comes from the Schoonover family, of Columbus, Ohio. Matt, the Schoonovers’ youngest son, began using prescription painkillers in college before switching to heroin. In 2012, at age 21, Matt died of an overdose. The Schoonovers’ response to Matt’s death was one of shock and disbelief. When they first learned that Matt was abusing pills, they were worried but not overly concerned for their son: doctors prescribed pills, so they couldn’t be that dangerous. It never occurred to them that Matt’s drug abuse would lead to heroin addiction and death. Tragically, the Schoonovers’ misplaced trust in the medical industry and their shock that something as sinister as heroin could enter into their ordinary, middle-class lives become sentiments that are shared among the families that the reader encounters throughout Dreamland.
The introduction of OxyContin into the American medical industry might have been the literal cause of addiction, but the origins of the American opiate epidemic are based in a drastic transformation of the way the medical industry viewed and treated pain. Prior to the 1970s, opiates were highly stigmatized in America. Doctors who prescribed opiate painkillers were seen as “outlaws,” as opiate painkillers were highly addictive. The stigmatization of opiates, though somewhat warranted, resulted in the suffering of many patients in legitimate need of pain relief. For decades, researchers and medical professionals searched, in vain, for a “Holy Grail,” a drug that would allow for pain relief without the undesirable side effect of addiction. In the latter half of the 20th century, attitudes toward pain and its treatment began to change with the introduction of palliative care, or “treating the pain and stress of the seriously ill.” One influence of palliative care was the work of Cicely Saunders. Saunders, an English nurse and researcher, treated cancer patients with opiates. Saunders believed “that death should be dignified,” and that patients were entitled to pain relief in their final days.
This revolutionary notion that patients were “entitled” to pain relief factored heavily into the work of Russell Portenoy and Kathleen Foley, American doctors who introduced Palliative care into mainstream American medicine. In 1986, Foley and Portenoy published a paper in the medical journal Pain advocating for wider use of opiate painkillers. These philosophical shifts in the way American doctors and their patients viewed pain and pain treatment created an American medical community whose new trust in opiates was quickly exploited by big pharmaceutical companies like Purdue and Pfizer.
In 1996, Purdue released OxyContin and, using aggressive sales tactics invented by the adman Arthur Sackler, marketed the highly addictive opiate painkiller as a treatment for chronic pain. Salespeople advertised the pill as “virtually non-addicting,” and doctors in whom the pain movement had instilled a blind faith in opiates prescribed the pills frequently and without discretion. Unwitting patients soon found themselves addicted to the drug, and underground markets developed in which people scammed willing doctors, like David Procter, for phony prescriptions they would sell on the streets for profit. The increase in opiate painkiller prescriptions created a new class of addicts in parts of the country that had never before seen such rates of addiction. Many patients were under the false assumption that painkillers were risk-free because their doctors—informed by pain advocates and the pharmaceutical giants like Purdue and Pfizer—told them so. Increasingly, America’s addicts became white and middle-class.
Driven by astute business sensibilities and the seduction of social advancement, an innovative, illegal heroin distribution group known as the Xalisco Boys recognized and pounced on this new, largely untapped market of opiate addicts. Beginning in the early 1990s, Xalisco Boys established small cells of heroin distribution groups that resembled small businesses. Unlike big drug cartels, the Xalisco operations were small and decentralized. These attributes allowed them to evade law enforcement for many years. The Xalisco Boys were successful because they were able to recognize what America’s new class of addicts wanted and adjust their business to meet those needs: customers wanted convenience, so the Xalisco Boys distributed their heroin via a delivery service. To keep customers returning, they offered free samples and special deals. Quinones documents the life of a young Mexican man known as Enrique who worked his way up in the drug trade to show how, just like other legitimate businesses, the Xalisco system provided the opportunity for its workers to rise in the ranks from humble origins to respected business owners.
Throughout Dreamland, Quinones demonstrates the parallel ways the Xalisco Boys and the modern pharmaceutical industry took advantage of an American population desperate to be rid of pain, drawing comparisons between the Xalisco Boys’ system of heroin trafficking and the Purdue’s “trafficking” of OxyContin in order to show how heavily the opiate epidemic was driven by exploitative forces of capitalism run amok by corruption and greed. Both the Xalisco Boys and Purdue Pharma provided America with a product that delivered, conveniently and effectively, the simple and complete pain relief America was conditioned to believe it was entitled to.
Ironically, opiate addiction inflicted as much pain on America’s small towns and cities as the pills themselves were promised to keep at bay. Still, Dreamland’s ultimate conclusions are optimistic. In the end, Quinones revisits Portsmouth, Ohio, one of the towns most affected by the epidemic, and finds promising signs of recovery and renewal. Throughout Dreamland, he positions America’s opiate obsession as a haphazard attempt to find a convenient, easy answer to the pains and fears that are an unavoidable part of life. He sees addiction and the epidemic as both a symptom and a result of America’s growing sense of fear, despair, and aversion to pain and discomfort. Ultimately, he sees “community” as the antidote. Towns like Portsmouth have started to recover, Quinones believes, because its residents have chosen to open themselves up to their neighbors and address problems and pains together—not with the isolating, numbing aid of pills. In this way, Dreamland is ultimately an analysis of the economic and cultural conditions of mainstream America that made the opiate epidemic logistically and philosophically possible.
