Dreamland details the rise of black tar heroin in the United States as the result of a distribution group consisting of business-savvy Mexican immigrants alongside Americans’ growing addiction to OxyContin. Quinones creates a parallel between the Mexican distribution group’s heroin trade and the United States pharmaceutical industry, suggesting that the opiate epidemic was the result of both organizations’ innovative and successful business ventures. His decision to focus on the business side of the opiate epidemic shifts society’s judgment away from drug users (who are often seen as morally corrupt or deficient) and onto the larger system that supports and facilitates addiction. In Quinones’s assessment, capitalism is the largest driving force of addiction—not the shortcomings or flaws of the addict.
Quinones shows how the advent of pharmaceutical advertising in the mid-20th century allowed prescription painkillers like OxyContin to become so widespread. In 1951, Arthur Sackler, an adman with the firm William Douglas McAdams, took on Charles Pfizer and Company as a client. Charles Pfizer and Co. (which would later become Pfizer) had developed a new drug called Terramycin, a “synthetic antibiotic.” Instead of licensing Terramycin to a drug company, as was standard practice, “Pfizer wanted to sell the antibiotic itself.” Sackler insisted “that with a large enough advertising budget […] he could turn Charles Pfizer and Company into a household name among doctors.” Sackler’s Terramycin campaign was successful, “aim[ing] at frequent contact with individual doctors,” which was unheard of at the time. Sackler’s firm sent postcards advertising Terramycin to doctors, and sales representatives visited doctors in person. The advertising campaign generated “forty-five million dollars in sales in 1952.” Pfizer flourished. Sackler’s Terramycin campaign “marked the emergence of modern pharmaceutical advertising.” Sackler and his brothers went on to purchase a drug company that was unknown at the time: Purdue Fredrick (later Purdue Pharma). He acquired the right to sell Valium, which was new at the time, and employed the same method of direct sales approaches. In his quest to sell Valium, Sackler went so far as to have sales representatives go to doctors’ offices bearing free samples of Valium, further breaking down the boundaries between pharmaceutical companies and doctors and revolutionizing how those companies could advertise to the medical community.
The revolutionary, aggressive marketing campaigns of Terramycin and Valium served the model for Purdue when, years later, it put OxyContin on the market. Other pharmaceutical companies like Pfizer followed suit, and the 1990s resembled something of an arms race, with pharmaceutical companies competing with each other to create, market, and sell their own “blockbuster” drug. The pharmaceutical industry’s business model was to create a medication “and then promoting it with growing number of salespeople.” Between 1995 and 2005, the number of American pharmaceutical representatives increased from 35,000 to 110,000. These sales representatives “crowded into doctors’ offices” and employed aggressive sales tactics and presented misleading, faulty information to doctors to get them to buy the drugs. Purdue, in particular, created incentive for sales representatives to sell so aggressively by “increase[ing] the sales quota of OxyContin needed to make bonuses.” Still, the fervor for prescription painkillers (created by transformed attitudes toward pain and narcotics in the medical community) among patients and doctors caused sales representatives to surpass these raised quotas. The bonuses earned by sales representatives during this time were outrageous. Quinones writes that “some Purdue reps […] were reported to have made as much as a hundred thousand dollars in bonuses in one quarter” in the early years of OxyContin. Quinones posits that these bonuses “bore […] a striking similarity to the kinds of profits made in the drug underworld.” In making this comparison, Quinones draws an explicit parallel between the business successes of the condoned, legitimate pharmaceutical industry and the black-market drug world.
Although it was not sanctioned by any legitimate institutions, the Xalisco Boys heroin distribution group possessed a similar business sensibility as pharmaceutical companies like Purdue and Pfizer. Specifically, the Xalisco Boys business model relied on dependable customer service and the “feet on the street” style of relentless, in-person direct sales that was also employed by pharmaceutical sales representatives. The Xalisco Boys were successful heroin traffickers because, like Arthur Sackler, their business model was innovative and efficient. Quinones often compares it to a fast food franchise or pizza delivery service. The heroin cells, or “franchises” that operate in the United States have an “owner” in Xalisco, who supplied the heroin. He didn’t come to the U.S., so he relied on a network of telephone operators and drivers. The operators fielded orders placed by addicts, who then passed along these orders to the drivers who delivered the orders of heroin to addicts around town. The reader should note Quinones’s purposeful inclusion of words evocative of business and finance, such as “owner” and “franchise,” to describe the Xalisco Boys. Similar to pharmaceutical sales representatives bringing free samples of Valium to doctors’ offices, Xalisco drivers were encouraged to incentivize potential buyers (addicts) by “offer[ing] special deals to addicts […]: fifteen dollars per balloon [of heroin] or seven for a hundred dollars.” Just like Purdue and Pfizer, who catered to and took advantage of the medical industry’s newfound trust and demand for narcotics, the Xalisco Boys identified and oriented their business around the needs of their clientele. The growing addiction to painkillers among white, middle-class Americans created a new market for heroin. Xalisco Boys responded to the needs of this new market: “Guys from Xalisco had figured out that what white people—especially middle-class white kids—want most is service, convenience. They didn’t want to go to skid row or some seedy dope house to buy their drugs.” The Xalisco delivery system meant this new wave of opiate addicts could get what they wanted.
In Quinones’s formulation, the successes of drug traffickers—legitimate and illegitimate alike—stem from their innovative and customer-oriented business tactics. In emphasizing the shared business logistics of both sanctioned pharmaceutical companies like Pfizer and Purdue, as well as underground drug organizations like the Xalisco Boys, Quinones positions monetary profit as a driving force behind America’s opiate epidemic.
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The Drug Business Quotes in Dreamland
All these guys running around Denver selling black tar heroin are from this town of Xalisco, or a few small villages near there, the informant told Chavez. Their success is based on a system they’ve learned. It’s a system for selling heroin retail. Their system is a simple thing, really, and relies on cheap, illegal Mexican labor, just the way any fast-food joint does.
But heroin was never about the romantic subversion of societal norms. It was instead about the squarest of American things: business—dull, cold commerce. Heroin lent itself to structured underworld businesses. Addicts had no free will to choose one day not to buy the product. They were slaves to a take-no-prisoners molecule. Dealers could thus organize heroin distribution almost according to principles taught in business schools, providing they didn’t use the product. And providing they marketed.
Everyone could have his own business, be his own boss. The Xalisco system was a lot like the United States in that way. America fulfilled the promise of the unknown to rancheros, and an escape from humiliation for Mexico’s poor from villages just like Enrique’s. The Xalisco heroin system did it faster.
The new discipline gave Russell Portenoy “the talking points I needed to mold my work life,” he once wrote. As an emerging discipline, palliative care appealed to the bright young doctor interested in staking out his own ideas. Comforting the seriously ill and dying touched on the altruistic reasons why anyone would enter medical school in the first place. […] Watching people struggle with pain, and talking to families who faced the loss of a loved one, gave Portenoy a touch of idealism, a bit of the crusader pushing up against conventional wisdom.
The new pain movement pushed past these doubts. It acquired a quasi-religious fervor among people seared by the nontreatment of pain of years past. A pendulum began to swing. The cruelty of earlier times discredited those who might question the emerging doctrine of opiates for chronic pain. Pain specialists working toward a new day felt gratitude to pharmaceutical companies for developing the drugs and devices that made possible the humane treatment of pain.
“We realized this is corporate,” Stone said. “These are company cars, company apartments, company phones. And it all gets handed to the next guy when they move on.”
“We can get away from these silly elixirs and cocktails into tablets that people take once or twice a day, and we’re into a revolutionary field of pain management…It was the drug-delivery service that changed, not the drug, and with that the whole mentality, ‘Well now that we have this drug, we can treat pain.’ Really extraordinary.”
Some Purdue reps—particularly in southern Ohio, eastern Kentucky, and other areas first afflicted with rampant Oxy addiction—were reported to have made as much as a hundred thousand dollars in bonuses in one quarter during these years. Those were unlike any bonuses ever paid in the U.S. pharmaceutical industry. […] Whatever the case, the bonuses to Purdue salespeople in these regions had little relation to those paid at most U.S. drug companies. They bore instead a striking similarity to the kinds of profits made in the drug underworld.
Many of these methods—premiums, trips, giveaways—were time-tested strategies that grew from the revolution Arthur Sackler began and were refined over time by many pharmaceutical companies. Only this time, the pill being marketed contained a large whack of a drug virtually identical to heroin.
In Portsmouth, it began with what came to be called pill mills, a business model invented in town, but growing from the aggressive nationwide prescribing of opiates, particularly OxyContin. A pill mill was a pain-management clinic, staffed by a doctor with little more than a prescription pad. A pill mill became a virtual ATM for dope as the doctor issued prescriptions to hundreds of people a day.
As the pain revolution was taking hold across the country, however, Procter and his physician progeny showed a beat-down region a brand-new business model. Before long some of the first locally owned businesses in years opened in Portsmouth, known to folks in town as the “pain managements.”
“It was not only okay, but it was our holy mission, to cure the world of its pain by waking people up to the fact that opiates were safe. All those rumors of addiction were misguided. The solution was a poppy plant. It was there all along. The only reason we didn’t use it was stigma and prejudice.”
Amid this madness, the sons and daughters of Portsmouth’s business owners, the children of sheriff’s captains and doctors and lawyers, saw a future in OxyContin. Some regarded pills as a grassroots response to economic catastrophe—the way some poor Mexican villagers view drug trafficking. Dealers who could not have found a legitimate job in moribund Portsmouth bartered pills to support themselves and feed their kids.
They were dope traffickers for a new age when marketing is king and even people are brands. Purdue branded OxyContin as the convenient solution to disruptive chronic-pain patients. The Xalisco Boys branded their system: the safe and reliable delivery of balloons containing heroin of standardized weight and potency. The addict’s convenient everyday solution. The one to start with and stay with.
“Nobody thinks those things are of value. Talk therapy is reimbursed at fifteen dollars an hour,” Cahana said. “But for me to stick a needle in you I can get eight hundred to five thousand dollars. The system values things that aren’t only not helpful but sometimes hurtful to patients. Science has shown things to have worked and the insurance companies won’t pay for them.”
Katz admired Portenoy, who, he said, had spent a career searching for better ways to relieve his patients’ real and considerable pain. Portenoy had helped make pain a topic of research. Moreover, Portenoy was always clear that pain treatment needed balance and time; doctors needed to be selective in the patients who received this treatment. But “people want simple solutions,” Katz said. “People didn’t want to hear that and the commercial interests didn’t want to emphasize that.”
