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Billed as “the true tale of America’s Opiate epidemic,” Sam Quinones’s Dreamland is a pretty quick read considering it’s about 350 pages. The blurbs on the back promise “expert storytelling,” and I suppose it is. The storytelling is good enough to make me wonder how heavily Quinones selected for stuff that would make a good story, while other stuff, equally true and relevant, but less dramatic, got discarded along the way. Quinones focuses on the marketing of OxyContin as a safe prescription drug, its subsequent abuse, the spread of a new means of dealing black tar heroin, and the connection between these, telling the tale of several colorful characters along the way.
To Quinones, the spread of opiate use to white America – not just to impoverished “rust belt” regions, but also to the offspring of the wealthy, managerial class – is fraught with moral meaning, though perhaps contradictory moral meaning. Heroin tempts us when we’re too wealthy, when we’re too poor, because we feel entitled to pain relief, because we don’t feel entitled to stop when it hurts but instead succumb to pressure to tough it out by any means necessary; it tempts us when we’re underwhelmed by life, it tempts us when we’re overwhelmed… Opiates are both the new party drug and the new drug of social isolation… Addiction is simultaneously a moral indictment of American consumerist excess during the pre-crash boom, a testament to post-crash misery, and an illness which deserves less moral stigma than it gets. Forgive me for suspecting at times that, to Quinones, opiates serve mostly as a random moral generator.
Which isn’t to say Dreamland is a bad book. There seems to be plenty of impressive journalism in here, crime journalism especially, although the science journalism falls rather short: there are multiple errors in describing how drugs are metabolized; in describing the drugs derived from the opium poppy (in particular, using “the morphine molecule” as shorthand for all of them); and sometimes there’s just illiterate wording, like calling what’s not statistical mechanics “statistical mechanics” or calling a lumbar sprain “a sprained lumbar” (a sprained lumbar… what?). Still, for someone like me – someone who uses opioids conservatively as part of a pain-management regimen, considering them a not-very-fun occasional treatment reserved for pain that inhibits productivity even more than being doped up would – Dreamland is a tour of a world Quinones, if his story is to be believed, claims I could easily have become a part of, yet haven’t.
So I’m glad I read Dreamland. It’s a chance to see how “the other half” of opioid consumers lives. Only, it’s hard to tell just who this “other half” is supposed to be. It’s not just poor, out-of-work rust-belt residents or rich, bored, spoiled brats – or pain patients seeking doctors who’ll prescribe more than the absolute minimum necessary for the current flare-up (most pain patients, if they are sensible, will do that, even if the excess is only a half-dozen tablets to be split and used sparingly over the course of months). It’s not all of us whose personality is “addictive” in some sense, and who struggle to keep our bad habits in check. Making too many moral lessons out of why opiate addiction happens amounts to making none at all. Could that be the real moral lesson of Dreamland? I mean, aside from the moral that we should be blaming government less while blaming free markets more.
Quinones repeatedly insists that Americans blame government for too much and fail to blame insufficiently-regulated economic activity enough. Most of the heroes in the opiate epidemic are, as Quinones tells it, government workers – public health experts, cops, John Kasich (hey, Quinones said it, not me), DEA agents… Most of the villains and semi-villains are folks out to make a buck (big Pharma, heroin dealers, pill-mill entrepreneurs, health insurers) or out to spread the gospel that a great many patients can be trusted to use opioids responsibly. To be fair, Quinones has a great deal of sympathy for those who spread this gospel, most of whom present narcotic painkillers as only one pain-management strategy among many, all of which should be considered as part of a strategy to manage (rather than eliminate) chronic pain. In Quinones’s telling, the gospel-spreaders didn’t intend for their message to be interpreted as “let’s use these drugs as the first and only treatment!”; nonetheless, they bear culpability for failing to notice that that’s how their gospel would likely be received, given the limited time doctors typically have to see patients, what health plans typically do and do not cover, and who typically sponsors these gospel-spreading efforts (prescription narcotics vendors).
The one big government villain in Quinones’s book is Medicaid, because it facilitated the use of OxyContin as currency in impoverished rust-belt regions. Regions of the rust belt already had a culture of bootlegging, and of relying on worker’s comp and SSDI to survive long periods of unemployment, a casualty of the rough, dangerous labor – typically mining – that many men in the hardest-hit regions traditionally did:
A man would work down in the mines for twenty years, pay into his disability – a federal program known as Social Security Disability Insurance (SSDI) – and be out of the mines with black lung by age forty-five with a monthly check large enough to support a family. That became a life strategy in Eastern Kentucky.
But when the deep mines closed, strip mines took their place, using far fewer workers. Those who worked weren’t so easily injured. They didn’t qualify for workers’ compensation [at least not without the help of a shady pill-mill doctor]. As jobs disappeared, so did the disability income people could receive. Eventually, entire families grew up on SSI, which paid only a few hundred dollars a month. SSI, however, did come with a Medicaid card, and that made all the difference when OxyContin appeared.
Here’s how the Medicaid cards worked:
If you could get a prescription from a willing doctor – and Portsmouth [Dreamland’s canonical example of an afflicted rust-belt town] had plenty of those – the Medicaid health insurance cards paid for that prescription every month. For a three-dollar Medicaid co-pay, therefore, an addict got pills priced at a thousand dollars, with the difference paid for by U.S. and state taxpayers. A user could turn around and sell those pills, obtained for a three-dollar co-pay, for as much as ten thousand dollars on the street.
Combined with pill mills, the Medicaid card scam allowed prolific quantities of prescription medication to hit the streets. The more pills that sloshed around the region, the more people grew addicted, and the bigger the business grew, and the more people died. The Oxy black market might never have spread and deepened so quickly had addicts been forced to pay for all those pills with cash at market prices.
A bootlegging tradition breeds corruption in local government and contempt for the law. This corruption and contempt made it even easier for OxyContin to become the currency of the rust-belt economy. Like coinage, “Pills could not be altered or diluted. Pills held their value, and that value was printed on each pill.” Moreover, “The pill mills acted as central banks, controlling the ‘money supply’, which they kept constant and plentiful, and thus resisted inflationary or deflationary spikes.” Those willing to pay in pills could hire shoplifters who’d shoplift to order from the remaining legal merchants. The willing included middle-aged women struggling to raise their grandchildren when their young, single daughters couldn’t. “Some regarded pills as a grassroots response to economic catastrophe – the way some poor Mexican villagers view drug trafficking.”
Ultimately, though, Medicaid redeems itself and the heartland in Quinones’s eyes, as lawmakers like John Kasich, whom Quinones lauds, reform Medicaid so that, rather than financing pills as currency, it finances addiction recovery for the impoverished instead. Quinones is quite bullish on the addiction-recovery movement, despite his detailed description of how heroin dealers have in the past used recovery clinics to peddle their wares. Quinones sees recovered addicts as having what modern American culture in general lacks and needs: gratitude for simply being alive and a past so humbling that pride no longer keeps them from “doing the jobs Americans won’t do”. Quinones lays out how niches in the American economy that have lately been filled by illegal immigrants might be filled by recovering addicts instead, praising the “confident, muscular culture of recovery”:
Hard-held attitudes in conservative Scioto County [the Ohio county containing Portsmouth, Dreamland’s canonical town] softened. Recovering addicts now had an easier time finding work. Everyone had friends or family on dope. Some employers believed in second chances. Others saw little choice. Those who were in recovery were at least going to pass a drug test. A job wasn’t a panacea and many people relapsed even after finding work. But it was a start.
Getting clean awoke a creativity and imagination in those who made it back. At times it felt like a new workforce had moved in. Addicts in recovery were injecting Portsmouth with what other American cities relied on Mexican immigrants to provide: energy, optimism, gratitude for an opportunity.
Speaking of Mexican immigrants, much of Dreamland focuses on the transitory illegal immigrants from Xalisco, Mexico, who serve as salaried employees of what are perhaps best described as heroin franchises. That’s the most exciting, cops-and-robbers portion of Dreamland, and giving too much of it away would be a spoiler. What ultimately fascinates Quinones is how sober and, well, businesslike these dealers are. They don’t carry guns or get into turf wars, they agree to loan one another product of one of them runs out before the next (smuggled) shipment, and apparently they offer excellent customer service, discreet and – what really hooks Americans in Quinones’s telling – convenient.
Maybe the moral of Dreamland is meant to be that what Americans are really hooked on is convenience. Except, that is, when youth get hooked on the inconvenience and intrigue of scoring dope in their otherwise-bored lives. Even with dramatic improvements in heroin-delivery convenience,
Part of heroin’s new appeal was that it kept them at the edge of a hazardous yet alluring dreamland. Finding dope every day could take them on a wild ride through worlds they hadn’t known existed, which, however scuzzy or harrowing, left them with fantastical stories that awed their peers.
“You’re as much addicted to going and buying it as to going and using it,” one addict said. “You feel like James Bond. It’s a crazy fantasy.”
Here are some of the factors Quinones believes contributes to heroin addiction among American youth in the upper and middle classes:
- having their own private bedroom
- having their own car
- being occupied as a teen with “meaningless” unpaid activities of the type listed on college applications rather than a paying job
- being coddled
- being bored
- being isolated
- not working hard enough
- not being given chances to fail
- working too hard, to the point of chronic injury, if they’re student athletes
- facing huge chances to fail, and tremendous pressure not to, if they’re student athletes
- being protected from the consequences of their actions off the field, if they’re student athletes
As Quinones puts it, “I was coming to see football players as symbols of this American epidemic.”
While it’s true that student athletes can and do get away with stuff off the field because of their prowess on the field, they’re not the most intuitive archetype of kids who are bored, isolated, lazy, and insulated from failure. Indeed, many conservatives tout team sports as a way to get kids to understand the value of hard work, practice, teamwork, and risking failure. Nonetheless, student football players – who are often, in Quinones’s telling, just handed opiates without much guidance because they’re expected to find a way (any way) to persist in playing through pain and injury – strike Quinones as emblematic of the “special snowflake” (not his words, but that is what he’s describing) pain-intolerant indolence of America’s pampered youth. At least America’s more privileged youth. Presumably, the youth in hollowed-out towns where folks turn to opiates to escape the hopeless, prospectless misery of their lives have slightly different reasons for using.
Quinones admits, “I love a good underdog story,” especially one that “seem[s] exhilaratingly American.” Well, who doesn’t? Americans are supposed to love these sorts of stories, to be suspicious of suffering, self-inflicted or not, that isn’t fuel for an underdog story.
Dreamland ends by returning to the canonical rust-belt town of Portsmouth and telling the heartwarming story of how the last factory in its once-booming shoe industry was saved from closing because the locals just refused to see it die. The shoelace factory, which once employed five thousand, had dwindled to eighty employees before it faced bankruptcy. As shoelace manufacture came roaring back to life, “Forty people had their jobs back and more were coming on.” Portsmouth churches came together to organize seven prayer marches (‘Seven is God’s number’) to pray the dope away. The seventh march ended with storm clouds parting and a double-rainbow appearing right over the shoelace factory. You really can’t make this kind of wholesome Americana up. As Quinones puts it in his Afterword,
That’s the good news: We don’t just sit around and take the beating. We act. Like Americans always have. Heroin is fearsome enough to force us to action. What it does to users, their families, and their neighborhoods is so harrowing that heroin reminds those who live through it of the ties that bind them to others – producing in some places the opposite of the isolation that that produces in users.
So there are even times when I think I’m right – that perhaps heroin is the most important force for positive change in our country today.
Anyway, after years of writing about it, that’s what I’d like to hope. And if it is, and for all it has taught us and forced us to recognize about ourselves and how we live, as one woman told me, “we may thank heroin some day.”
That strikes me as a little too optimistic. It occurs to me, though, that one thing kicking an addiction gives you is a fantastic underdog story. Eking out life in a hardscrabble town, even if it means turning to drug-related crime and fraud to do so, is also, in its own way, an underdog story. Quinones complains Americans have grown complacent and get addicted to comfort and convenience. But I’m left wondering if Americans are also addicted to underdog stories.Published in