"Dreamland" by Sam Quinones is a gripping account of America's opioid epidemic, tracing its origins and devastating impacts across the country. The book weaves together multiple storylines to paint a comprehensive picture of how prescription painkillers and black tar heroin from Mexico converged to create a public health crisis. Quinones combines meticulous reporting with compelling storytelling to illuminate the complex factors that fueled the epidemic and the human toll it has taken.
The book's title refers to a popular swimming pool in Portsmouth, Ohio that was once the heart of the community but was eventually paved over - a metaphor for how the opioid crisis has hollowed out many American towns. Through extensive research and interviews, Quinones reveals how changes in medical approaches to pain treatment, aggressive pharmaceutical marketing, economic decline in the Rust Belt, and an innovative heroin distribution network all intersected to create a perfect storm of addiction.
While the subject matter is often bleak, Quinones also highlights stories of resilience, recovery, and communities coming together to fight back against the epidemic. "Dreamland" offers crucial insights into one of the most pressing public health and social issues facing America today.
The Rise of OxyContin
At the heart of the opioid crisis is a tiny pill that played an outsized role: OxyContin. In 1984, the drug company Purdue released MS Contin, a time-release morphine pill for treating severe pain in dying patients or those just out of surgery. Building on this success, in 1996 Purdue released OxyContin, which used the same time-release coating but with oxycodone as the active ingredient instead of morphine.
Crucially, the FDA approved OxyContin based on Purdue's claim that the time-release coating would limit addiction by preventing the rapid highs and lows associated with opiates. This allowed Purdue to market OxyContin with a unique safety label stating it had less potential for abuse than other painkillers. This claim became the cornerstone of OxyContin's aggressive marketing campaign.
Purdue promoted OxyContin as a wonder drug - the only painkiller doctors would ever need to prescribe, with supposedly minimal risk of addiction. Their sales representatives visited doctors frequently, taking them to lavish lunches and emphasizing how the time-release coating made addiction a non-issue. They showered doctors with OxyContin merchandise and invited them to luxury resorts for medical seminars.
The marketing blitz was hugely successful. Purdue's sales tripled and by 2003, OxyContin was predominantly being prescribed by primary care doctors with little pain management training. The entire industry had been transformed - prescribing opioids for pain had become the norm rather than the exception.
This marked a dramatic shift in how pain was treated in America. For years, doctors had been reluctant to prescribe opioids except in cases of severe, short-term pain or for dying patients. Now, OxyContin was being prescribed for all kinds of chronic pain conditions. The concept of pain as the "fifth vital sign" took hold, and doctors became fearful of lawsuits if they didn't adequately treat patients' pain.
A pivotal moment came when advocates pushing for more opiate prescriptions began citing a 1980 letter to the New England Journal of Medicine by Dr. Hershel Jick. The letter, barely a paragraph long, mentioned that of 12,000 hospitalized patients treated with narcotics, only four became addicted. This letter was mischaracterized and blown out of proportion, treated as a landmark study proving opioids weren't addictive when used for pain. In reality, it was just a casual observation about a specific hospital setting.
Armed with this flawed evidence and aggressive marketing, long-held wisdom about the addictive nature of opioids was thrown out the window. If patients asked for higher doses, it was seen as a sign the current dose was insufficient rather than potential addiction. A new term, "pseudoaddiction," was coined to explain away signs of addiction as merely undertreated pain requiring more aggressive dosing.
The History of Morphine and Opiates
To understand the current crisis, it's important to look at the long history of opiate use and abuse. Humans have been using opiates for thousands of years, with ancient civilizations like the Sumerians, Egyptians, and Greeks all utilizing opium. The active molecule in opium is morphine, which was first isolated in the early 1800s.
The invention of the hypodermic needle in the 19th century was thought to reduce drug abuse by allowing for precise dosing. Instead, it led to new forms of addiction. In the U.S., patent medicines containing opiates were widely marketed as cure-alls in the late 1800s and early 1900s. Even children were dosed with Mrs. Winslow's Soothing Syrup to calm them down.
Heroin was first synthesized in 1874 as an attempt to create a non-addictive alternative to morphine. Ironically, it turned out to be even more addictive and was prescribed for everything from coughs to menstrual cramps before its dangers became apparent. The chemistry of addiction lies in how perfectly the morphine molecule fits into receptors in the brain, producing intense euphoria.
However, this euphoria comes at a cost. Opiate withdrawal is notoriously brutal, driving addicts to extreme lengths to avoid it. The body becomes dependent on the drug, leading to ever-increasing tolerance and dosages. Unlike many other drugs, morphine is not easily broken down by the body, allowing it to linger and create powerful addictions.
This long history of opiate use and misuse set the stage for the current crisis. When OxyContin arrived on the scene, it tapped into America's existing cultural familiarity with opiates while purporting to be fundamentally different and safer.
The Spread of Pill Mills
As OxyContin prescriptions skyrocketed in the late 1990s and early 2000s, a new phenomenon emerged in economically depressed areas: pill mills. These were clinics where doctors did little more than write prescriptions for opioid painkillers, often with minimal examination or medical justification.
Portsmouth, Ohio exemplifies how pill mills proliferated in the American Rust Belt. Once a thriving industrial town, Portsmouth had been decimated by factory closures and job losses. In this economic vacuum, a new industry arose based on exploiting Medicare cards and the growing demand for prescription opioids.
Pill mills drew people from all over, with some entrepreneurial individuals organizing van loads of people to visit clinics in exchange for a cut of their pills. A black market economy sprung up around OxyContin, with pills becoming a de facto currency that could be traded for other goods. Even clean urine became a valuable commodity, as addicts needed it to pass drug tests and keep getting prescriptions.
The pill mills relied on a steady supply of doctors willing to prescribe opioids with few questions asked. Many were recruited from "locum tenens" lists of physicians looking for temporary work, often due to problems with licenses, substance abuse, or inability to get malpractice insurance.
This created a perfect ecosystem of abuse. Established drug dealers got involved, seeing an opportunity to expand their business into prescription pills. The line between legal prescriptions and illegal drug dealing became increasingly blurred.
The Xalisco Boys' Heroin Empire
While prescription opioid abuse was exploding in the Rust Belt, a sophisticated heroin distribution network was expanding across the country. This network originated in the tiny Mexican village of Xalisco and operated unlike any previous drug trafficking organization.
The so-called Xalisco Boys began selling black tar heroin in California's San Fernando Valley in the early 1980s. Their business model was revolutionary in several ways:
They sold heroin retail rather than wholesale, maintaining its purity instead of cutting it repeatedly.
They operated like a franchise system, with independent cells supplied by wholesalers.
Drivers were paid a salary rather than commission, reducing incentives to cut the product.
They focused on customer service, even making follow-up calls to ensure satisfaction.
They avoided violence and flashy lifestyles, preferring to operate discreetly.
This approach allowed the Xalisco Boys to rapidly expand into new markets across the U.S. They targeted areas with large populations of prescription opioid addicts, offering heroin as a cheaper alternative. Methadone clinics became prime locations for recruiting new customers, as addicts dissatisfied with their treatment were easy targets.
The Xalisco network's marketing tactics were remarkably sophisticated. They gave out free samples, made follow-up calls, and even provided "going away" gifts of free heroin to customers entering rehab. Their customer service was so good that one undercover cop remarked it was better than many legitimate businesses.
The franchise-like structure encouraged competition between cells, driving constant expansion into new territories. Addicts were incentivized to help find new customers or provide information about potential markets. This created a self-perpetuating system that spread rapidly across the country.
By the late 1990s, the Xalisco Boys dominated the heroin trade in many U.S. cities. Their impact was staggering - in Portland, Oregon, the percentage of detox patients addicted to opiates rose from 5-10% to 50% after their arrival. Heroin overdose deaths in the city increased tenfold in just eight years.
The authorities eventually took notice, launching Operation Tar Pit in 2000 - the largest geographic drug investigation in U.S. history, spanning 22 states. However, this massive bust ultimately caused more problems than it solved. It created a vacuum that was quickly filled by new suppliers, driving prices down and actually increasing the availability of heroin.
The Pain Revolution and Opiate Triumph
By the early 2000s, the "pain revolution" that began in the 1990s had reached its apex. Opiates emerged as the dominant treatment for chronic pain, with most of America's 100 million chronic pain sufferers receiving opiate prescriptions. The U.S. was consuming a staggering 86% of the world's oxycodone and 99% of its hydrocodone.
Hydrocodone became the most prescribed drug in America, with 136 million prescriptions written annually. Opiate painkillers as a class were the most prescribed type of medication. This explosion in prescriptions had major ripple effects:
Recreational use of prescription opioids skyrocketed. Between 2002 and 2011, 25 million Americans used prescription pills non-medically.
Users were getting younger. In 2004, 2.4 million people aged 12 or older tried prescription pills non-medically for the first time - more than those trying marijuana for the first time.
Opiate overdose deaths rose from 10 per day in 1999 to 48 per day in 2012.
Emergency room visits related to prescription painkillers tripled between 2004 and 2011.
By 2011, an estimated 6.1 million Americans (2.4% of the population) had abused OxyContin.
While addiction to weaker opiate painkillers like Vicodin had existed before, OxyContin represented a new level of danger. Its high doses and lack of abuse-deterrent ingredients made it far more potent and addictive. The time-release coating, touted as a safety feature, could be easily defeated by crushing the pills.
As tolerance built, many users transitioned from oral use to snorting or injecting OxyContin for a stronger high. This primed them for the switch to heroin, which was cheaper and more readily available. Between 2007 and 2011, the number of heroin users in the U.S. rose from 373,000 to 620,000. Crucially, 80% of these new heroin users had started with prescription painkillers.
The Backlash Begins
As the scale of opiate abuse became impossible to ignore, a backlash against unnecessary prescriptions slowly began to form. Some of the first to notice and speak out were those on the front lines of the crisis:
Joe Hale, a public defender in Ohio, filed the first wrongful death lawsuit against Purdue Pharma in 2001 after noticing widespread OxyContin abuse in his community.
Ed Socie, working in Ohio's health department, noticed a spike in accidental poisoning deaths in 2005. Further investigation revealed these were almost all opiate-related.
Christy Beeghly, Socie's supervisor, helped bring attention to the fact that overdose deaths were about to surpass auto accidents as the leading cause of accidental death in Ohio.
Their research showed a clear correlation between painkiller prescriptions and overdose deaths, both of which had risen over 300% between 1999 and 2008.
The first major criminal case against opiate manufacturers came from John Brownlee, a U.S. attorney who began investigating Purdue Pharma in 2001. After subpoenaing marketing records, Brownlee found evidence that Purdue had been actively misleading in their promotion of OxyContin as non-addictive.
Brownlee's case showed that:
Purdue had no evidence to support claims to the FDA that OxyContin was less addictive than other painkillers.
Sales reps were taught to claim OxyContin was harder to abuse, despite Purdue's own research showing otherwise.
The company falsely claimed patients could stop taking up to 60mg of OxyContin without withdrawal symptoms.
Purdue ultimately pled guilty to criminal misbranding in 2007, paying a $634.5 million fine. Three executives pled guilty to misdemeanor charges and received probation and community service.
Brownlee went on to prosecute other pharmaceutical companies, including a $3 billion settlement with Pfizer for false advertising of several drugs.
Victims Speak Out
Despite the growing death toll, it took years for the opiate epidemic to be widely acknowledged as a national crisis. Only a handful of parents' groups formed to raise awareness in the early years. One such parent was Jo Anna Krohn, whose son died after accidentally shooting himself while high on OxyContin. Krohn formed SOLACE, a support group for parents who lost children to opiates, and began giving talks at schools about the dangers of prescription drug abuse.
Others found creative ways to draw attention to the crisis. Brad Belcher, a recovering addict in Marion, Ohio, ordered 800 large signs reading "HEROIN IS MARION'S ECONOMY" and posted them around town one night. While most were quickly taken down, a photo of one sign went viral online, forcing the town to confront its heroin problem.
It often took high-profile deaths to focus national attention on the epidemic. The 2014 overdose death of acclaimed actor Philip Seymour Hoffman seemed to be a turning point, with media outlets across the country suddenly realizing the scale of America's opiate problem - some 15 years after it began.
The Tide Begins to Turn
Two decades after the start of the pain revolution, a new consensus began to form. Opiates were no longer seen as necessary or safe for treating most chronic pain conditions. Studies showed that up to 24% of patients were reporting "aberrant" usage of prescribed opioids.
Purdue finally added abuse-deterrent features to OxyContin in 2010, making it harder to inject or snort. However, this came far too late to prevent the epidemic. The FDA began requiring drug companies to educate doctors and patients about addiction risks for time-release painkillers, but again, this action was long overdue.
Despite growing awareness of the dangers, OxyContin sales continued to rise, netting Purdue $3 billion annually. Meanwhile, heroin overdose deaths tripled between 2010 and 2013 as prescription opioid users transitioned to the cheaper street drug.
The scale of overprescribing remained staggering. In Scioto County, Ohio (population 80,000), pill mills legally prescribed 9.7 million pills in their last year before being banned. Even two years after the pill mills closed, doctors in the county were still prescribing 7 million pills annually.
Signs of Recovery
While the opioid crisis continues to claim lives, there are signs of hope and recovery emerging from some of the hardest-hit areas. Portsmouth, Ohio - once ground zero for pill mills - has seen a remarkable transformation:
As former addicts get clean, they're seeking healthier lifestyles. New gyms have opened to meet this demand.
Recovering addicts are opening counseling centers to help others escape addiction.
Attitudes are shifting, with less stigma attached to former addicts seeking employment.
A sense of community is growing as people come together to address the crisis.
People from across the Rust Belt now travel to Portsmouth to get clean, reversing the town's previous reputation as a destination for drug seekers. This quiet rejuvenation shows that even areas devastated by the opioid epidemic can recover and rebuild.
The Mexican Connection: From Xalisco to Main Street USA
One of the most fascinating and tragic aspects of the opioid crisis is how it intertwines with immigration and drug trafficking from Mexico. The story of the Xalisco Boys illustrates how global forces and local conditions combined to fuel the epidemic.
Xalisco is a small town in the Mexican state of Nayarit, known for growing opium poppies. In the 1980s, young men from Xalisco began migrating to the U.S. to sell black tar heroin. What set them apart was their innovative business model:
They focused on customer service, delivering heroin like pizza and treating addicts well.
They avoided violence and flashy lifestyles that attracted police attention.
They operated in small cells, making it harder for law enforcement to bring down the whole network.
They targeted small cities and towns, avoiding competition with established drug gangs in major urban areas.
This approach allowed the Xalisco Boys to rapidly expand across the country, often following patterns of Mexican immigration. They found fertile ground in areas where prescription opioid abuse was already rampant, offering heroin as a cheaper alternative.
The Xalisco network's success was also tied to changing dynamics in Mexico. As NAFTA devastated small-scale agriculture, many young men saw the heroin trade as their best economic opportunity. The decentralized structure meant that even if individuals were arrested or deported, the network as a whole continued to thrive.
This created a tragic cycle: economic conditions in Mexico drove young men into the drug trade, while economic decline and overprescribing of opioids in the U.S. created a ready market for their product. The victims on both sides of the border were often working-class people with limited opportunities.
The story of the Xalisco Boys highlights the complex interplay between immigration, economics, and drug policy. It shows how attempts to address the opioid crisis must consider these broader factors rather than focusing solely on law enforcement or medical approaches.
The Role of Big Pharma
While much attention has been paid to illegal heroin trafficking, the roots of the opioid crisis lie in the legal pharmaceutical industry. Companies like Purdue Pharma played a central role in creating the conditions for widespread addiction.
Purdue's marketing of OxyContin was unprecedented in its scale and aggression. They spent millions wining and dining doctors, sponsoring medical education, and funding pain patient advocacy groups. Their sales representatives were trained to downplay addiction risks and encourage higher doses for patients who showed signs of tolerance.
What made this marketing especially insidious was how it tapped into existing trends in medicine:
There was growing concern that pain was being undertreated, especially chronic pain.
Managed care was pressuring doctors to see more patients in less time, making quick fixes like opioid prescriptions appealing.
Patient satisfaction surveys included questions about pain management, incentivizing doctors to prescribe opioids.
Purdue exploited these trends, positioning OxyContin as a compassionate solution for suffering patients. They funded research and education that portrayed opioids as safe and effective for long-term use in treating chronic pain, despite a lack of evidence.
Other pharmaceutical companies followed Purdue's lead, aggressively marketing their own opioid products. This created a self-reinforcing cycle: as more doctors prescribed opioids, it became the standard of care, making those who were cautious about prescribing seem callous or behind the times.
The pharmaceutical industry's influence extended beyond marketing to doctors. They lobbied government agencies, funded professional organizations, and shaped public policy around pain management and drug regulation. This created a regulatory environment that favored opioid manufacturers and distributors.
The case of Purdue Pharma shows how corporate profit-seeking can have devastating public health consequences. It raises serious questions about the ethics of pharmaceutical marketing and the adequacy of government oversight in protecting public health.
The Failure of Institutions
The opioid crisis represents a massive failure of multiple American institutions:
The medical establishment embraced opioids for chronic pain without sufficient evidence of long-term safety and efficacy.
The FDA approved OxyContin with minimal scrutiny and allowed misleading marketing claims.
The DEA failed to recognize and respond to the growing diversion of prescription opioids to the black market.
State medical boards were slow to discipline doctors who were clearly overprescribing.
The media largely ignored the growing crisis until it reached epidemic proportions.
Congress, influenced by pharmaceutical industry lobbying, passed laws that hampered the DEA's ability to go after drug distributors.
Law enforcement often focused on street-level dealers rather than addressing the source of pills.
This systemic failure allowed the crisis to grow unchecked for years. It highlights the need for better coordination between different agencies and institutions in addressing public health threats.
The Human Cost
While statistics can illustrate the scale of the opioid epidemic, they can't fully capture its human toll. Quinones brings this home through individual stories of those affected:
Families torn apart by addiction, with parents losing children or children losing parents.
Communities hollowed out as addiction and overdose deaths become commonplace.
Addicts driven to crime to support their habits, filling jails and prisons.
The shame and stigma that prevent many from seeking help.
The long, difficult road to recovery for those who manage to get clean.
These stories humanize the crisis and show how it cuts across all demographic lines. They also illustrate how addiction is often rooted in trauma, mental health issues, or lack of economic opportunity.
The Path Forward
While "Dreamland" paints a bleak picture of the opioid epidemic, it also offers hope for the future. Quinones highlights several promising approaches:
Medication-assisted treatment: Using drugs like buprenorphine or methadone to help addicts stabilize their lives and reduce cravings.
Drug courts: Offering treatment instead of incarceration for non-violent drug offenders.
Harm reduction: Strategies like needle exchanges and naloxone distribution that keep addicts alive until they're ready for treatment.
Community-based recovery: Programs that provide support, housing, and job training for recovering addicts.
Prevention education: Teaching young people about the risks of opioids and other drugs.
Changing prescribing practices: Encouraging doctors to use opioids more judiciously and explore alternative pain treatments.
Holding pharmaceutical companies accountable: Using litigation and regulation to change industry practices.
The book argues that addressing the opioid crisis will require a multifaceted approach involving healthcare, law enforcement, education, and economic development. It will also require changing cultural attitudes about pain, addiction, and recovery.
Conclusion
"Dreamland" is a comprehensive and compassionate look at America's opioid epidemic. By tracing its origins in both the pharmaceutical industry and drug trafficking networks, Quinones shows how multiple factors converged to create a perfect storm of addiction.
The book is a damning indictment of institutional failures, from overzealous pharmaceutical marketing to lax government oversight. But it's also a testament to human resilience, showcasing individuals and communities fighting back against the epidemic.
Quinones argues that the opioid crisis is a uniquely American phenomenon, rooted in cultural attitudes towards pain, healthcare, and individualism. Addressing it will require not just policy changes, but a fundamental shift in how we think about pain, addiction, and community.
While the situation remains dire, "Dreamland" offers reasons for hope. It shows how understanding the complex roots of the crisis can point the way towards more effective solutions. By bringing together the many threads of this epidemic, Quinones has created an essential resource for anyone seeking to understand and address one of America's most pressing public health crises.
The book serves as both a warning and a call to action. It shows how easily good intentions (like addressing undertreated pain) can go awry when combined with profit motives and inadequate oversight. But it also demonstrates the power of individuals and communities to make a difference, even in the face of overwhelming challenges.
Ultimately, "Dreamland" is a deeply American story - one of innovation gone wrong, of communities torn apart and rebuilt, of a nation struggling to reconcile its ideals with harsh realities. It's a difficult but necessary read for anyone seeking to understand the forces shaping modern America.