Dreamland – A Review

 

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.

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  1. Arahant Member
    Arahant
    @Arahant

    I wonder why a guy named Quinones would get involved in drugs.

    • #1
  2. Arahant Member
    Arahant
    @Arahant

    Midget Faded Rattlesnake: But I’m left wondering if Americans also are addicted to underdog stories.

    Of course, and even people like Oprah are taken in by them.

    • #2
  3. Front Seat Cat Member
    Front Seat Cat
    @FrontSeatCat

    I heard on the radio today that Arizona has declared an official public health hazard – they have had a 70% increase and need state and federal help to deal with it.

    • #3
  4. Titus Techera Contributor
    Titus Techera
    @TitusTechera

    Midget Faded Rattlesnake: Forgive me for suspecting at times that, to Quinones, opiates serve mostly as a random moral generator.

    Well, the fact that it’s a party drug for the privileged & an easy death for the immiserated says nothing random. If you want to be suspicious, accuse the man of a middle class bias against the top & bottom. Not middle class = not responsible.  As for Americans learning that pleasure might lead to pain, you surely see how that fits with the middle-class moral intuitions.

    I’m not sure I’ve any other editing remarks.

    This is a good, & needful, review on a subject we don’t much talk about. Let’s get this published!

    • #4
  5. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    Titus Techera (View Comment):

    Midget Faded Rattlesnake: Forgive me for suspecting at times that, to Quinones, opiates serve mostly as a random moral generator.

    Well, the fact that it’s a party drug for the privileged & an easy death for the immiserated says nothing random. If you want to be suspicious, accuse the man of a middle class bias against the top & bottom.

    Ah, but Quinones thinks he is indicting middle-class morality! Perhaps that is why he comes across as treating the morality of drugs as a random moral generator.

    Not middle class = not responsible. As for Americans learning that pleasure might lead to pain, you surely see how that fits with the middle-class moral intuitions.

    True. Although Quinones also suggests lack of pain leads to lack of happiness. He says, sometimes, that he expects we can’t gain a portion of heaven without gaining the equal portion of hell. He suspects the American middle-class mentality especially of wanting to have something for nothing. As you say, perhaps he’s accusing the middle class of morality that’s not traditional middle-class morality.

    I’m not sure I’ve any other editing remarks.

    This is a good, & needful, review on a subject we don’t much talk about. Let’s get this published!

    Thanks!

    • #5
  6. Titus Techera Contributor
    Titus Techera
    @TitusTechera

    Yes, the flight-from-pain is the middle class abandoning its ways. I suspect there is more to say on that, but this is probably not the place.

    The things the man says are moralistic, perhaps overly so, but not random. It might be he goes beyond what his subject will admit of, but he goes in a specific direction, it seems.

    • #6
  7. I Walton Member
    I Walton
    @IWalton

    Russ Roberts interviews Quinones in early 2017 on his book.   A good interview on fascinating new developments in the narcotics business, especially the new franchise like business and the government fostered prescription drug epidemic.   It’s useful to look at the drug issue, the war on drugs with economists tools, and Russ does his usual good job.  It’s not a moral issue nor a policing problem it’s an incredibly profitable business with perverse incentives which our governments have created.

    • #7
  8. Chris Member
    Chris
    @Chris

    I Walton (View Comment):
    Russ Roberts interviews Quinones in early 2017 on his book. A good interview on fascinating new developments in the narcotics business, especially the new franchise like business and the government fostered prescription drug epidemic. It’s useful to look at the drug issue, the war on drugs with economists tools, and Russ does his usual good job. It’s not a moral issue nor a policing problem it’s an incredibly profitable business with perverse incentives which our governments have created.

    I too thought of that interview and would recommend it as a complement to this OP.

    • #8
  9. Titus Techera Contributor
    Titus Techera
    @TitusTechera

    I Walton (View Comment):
    Russ Roberts interviews Quinones in early 2017 on his book. A good interview on fascinating new developments in the narcotics business, especially the new franchise like business and the government fostered prescription drug epidemic. It’s useful to look at the drug issue, the war on drugs with economists tools, and Russ does his usual good job. It’s not a moral issue nor a policing problem it’s an incredibly profitable business with perverse incentives which our governments have created.

    You mean the government has created some of the perverse incentives–but no more? The business is there independent of the government and the government has failed to stop it.

    But who can really believe that death by oxy is not a moral issue?

    • #9
  10. I Walton Member
    I Walton
    @IWalton

    Titus Techera (View Comment):

    I Walton (View Comment):
    Russ Roberts interviews Quinones in early 2017 on his book. A good interview on fascinating new developments in the narcotics business, especially the new franchise like business and the government fostered prescription drug epidemic. It’s useful to look at the drug issue, the war on drugs with economists tools, and Russ does his usual good job. It’s not a moral issue nor a policing problem it’s an incredibly profitable business with perverse incentives which our governments have created.

    You mean the government has created some of the perverse incentives–but no more? The business is there independent of the government and the government has failed to stop it.

    But who can really believe that death by oxy is not a moral issue?

    The government created the oxicontin epidemic and has the capacity to rein it in.   It created the illegal narcotics business as we know it today with cocaine and heroine with it’s war on drugs.  Of course most things have moral dimensions and that dimension helps explain why individuals fail, get caught up in drug use addiction and die.  They also explain why some people get pulled into the business, or foster the business through political and bureaucratic self serving actions, but if we want to understand the business, do something to ameliorate its destructiveness we have to understand it as a business and an economic phenomena.

    • #10
  11. Joe P Member
    Joe P
    @JoeP

    I Walton (View Comment):
    Russ Roberts interviews Quinones in early 2017 on his book. A good interview on fascinating new developments in the narcotics business, especially the new franchise like business and the government fostered prescription drug epidemic. It’s useful to look at the drug issue, the war on drugs with economists tools, and Russ does his usual good job. It’s not a moral issue nor a policing problem it’s an incredibly profitable business with perverse incentives which our governments have created.

    I’ve listened to this same interview. It’s great, though it also made me wonder about whether Quinones can think clearly about the ethics of this.

    I didn’t read the book, so I don’t know if the book presents the story differently (“random moral generator” makes me think it does), but in the interview, the heroin epidemic is presented quite clearly as something that emerged from the unintended consequences of giving out opioids to people outside of hospice care and the fact that Medicare and Medicaid turned Doctors in the rust belt into the first and last line of defense against economic uncertainty (because they need the Doctor’s note to get the welfare or SSDI or whatever). He and Russ Roberts discuss this in great detail and with clarity. Yet, at the end of the interview it’s the drug company who is somehow the villain here, who only provided what every other actor in this play demanded. As if the drug company just landed in a spaceship and began handing drugs out, and that was the real problem here. At the very end of the interview, all of the prior clarity gives way to derangement.

    I don’t understand how he can paint a very clear picture of it as being an unintended consequence of what doctors and the government wanted, yet blame drug companies for it. Even if he claims that drug companies should have known better or acted differently, they weren’t the ones who created this system where the country doctor doles out dope and welfare to keep the retired coal miners quiet.

    • #11
  12. Joe P Member
    Joe P
    @JoeP

    Midget Faded Rattlesnake: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

    At the risk of sounding sarcastic, the problem is that American youth in the upper and middle classes are… American youth in the upper and middle classes?

    And some of these are contradictory, aren’t they? They’re being coddled, but they’re isolated. They’re not working hard enough, but they’re working too hard.

    • #12
  13. Chris Member
    Chris
    @Chris

    Joe P (View Comment):

    Midget Faded Rattlesnake: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

    At the risk of sounding sarcastic, the problem is that American youth in the upper and middle classes are… American youth in the upper and middle classes?

    And some of these are contradictory, aren’t they? They’re being coddled, but they’re isolated. They’re not working hard enough, but they’re working too hard.

    One could take it even further to include most kids in America if you exclude a private room and a car as the list is potential – not necessary – factors.   There are challenges kids face – whether the coddling is via a helicopter parent or via a school system that just passes kids to move them through the system.   It just seems over broad, as was his indictment of “student athletes” when my gut feel is he heard several high profile cases of football players getting addicted and then he suffered from some liberal confirmation bias about football players.  But I’ve only heard the interview and not read the book, so he may well have examples of softball players, track and field kids, and swimmers too.  There’s no denying there is a crisis, but they can’t all be football players.

    On a related note, @midge, did the author indicate what these meaningless unpaid activities were?  School sponsored like chess club or Model United Nations, or community activities like working the food bank?  Scouting?  I don’t disagree that kids should be working, but I have trouble believing he’d condemn everything outside of class time and a part time job although this is the impression.

     

     

    • #13
  14. I Walton Member
    I Walton
    @IWalton

    Joe P (View Comment):

    I Walton (View Comment)

    I thought Roberts brought out most of my objections to Quinones thesis.  What fascinated me was the new marketing model.   Whenever something is really screwed up, you can usually find governments inept corrupt hands.    Pharmaceutical companies work with the government to get the most propitious set of regulations for their interests given that the government is going to do things that impinge on them, regulate them, restrict them etc.  Big intrusive government will always be captured by big corporate management because that’s the way it works.  It doesn’t have to be this way but if government is going to regulate, subsidize, punish, reward it will be.

    • #14
  15. Kozak Member
    Kozak
    @Kozak

    I blame a lot of the opiate epidemic on the academics who pushed the “ you don’t need to worry about your patients getting addicted to narcotics” , coupled with the  JCAHO  ” pain is the 5 th vital sign” campaign that along with the “customer service model” of medicine pushed us to prescribe way way more narcotics then we used to.

    • #15
  16. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    Chris (View Comment):

    I Walton (View Comment):
    Russ Roberts interviews Quinones in early 2017 on his book. A good interview on fascinating new developments in the narcotics business, especially the new franchise like business and the government fostered prescription drug epidemic. It’s useful to look at the drug issue, the war on drugs with economists tools, and Russ does his usual good job. It’s not a moral issue nor a policing problem it’s an incredibly profitable business with perverse incentives which our governments have created.

    I too thought of that interview and would recommend it as a complement to this OP.

    Thanks for the recommendation, guys!

    As for whether or not it’s a moral issue, I’m wondering how you mean “moral” if it isn’t at some level. Whether it’s the business of government to meddle or not, yes, of course there’s a moral dimension to managing pain and pursuing pleasure, especially, I think, when either overwhelming pain or overwhelming pleasure is likely to leave you incapacitated. I think most of us would consider it not just stupid, but wrong, to drive drunk, for example: others do not deserve the harm you’re more likely to cause them if you’ve chosen to drive incapacitated. (Not that people deserve the harm you could cause them if you’re involuntarily incapacitated behind the wheel, either, but sometimes that can’t be helped.)

    • #16
  17. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    Chris (View Comment):
    It just seems over broad, as was his indictment of “student athletes” when my gut feel is he heard several high profile cases of football players getting addicted and then he suffered from some liberal confirmation bias about football players.

    Yes, he thinks of football as symbolic because he investigated student football overdose deaths specifically.

    But I’ve only heard the interview and not read the book, so he may well have examples of softball players, track and field kids, and swimmers too.

    No, it was football players. Possibly because high school football is the sport in regions of Ohio that overlap with the pill mills and heroin runners.

    There’s no denying there is a crisis, but they can’t all be football players.

    On a related note, @midge, did the author indicate what these meaningless unpaid activities were?

    Not specifically. Just that they’re the stuff “helicopter parents” push their kids into doing (or that’s how he sees it – wholesome activities can also be a healthy way of getting away from helicopter parents), and that he suspects that kids get bored despite all these activities because the kids suspect there’s not much real or meaningful about them.

    • #17
  18. I Walton Member
    I Walton
    @IWalton

    Midget Faded Rattlesnake (View Comment):

    Chris (View Comment):

    I Walton (View Comment):
    Russ Roberts interviews Quinones in early 2017 on his book. A good interview on fascinating new developments in the narcotics business, especially the new franchise like business and the government fostered prescription drug epidemic. It’s useful to look at the drug issue, the war on drugs with economists tools, and Russ does his usual good job. It’s not a moral issue nor a policing problem it’s an incredibly profitable business with perverse incentives which our governments have created.

    I too thought of that interview and would recommend it as a complement to this OP.

    Thanks for the recommendation, guys!

    As for whether or not it’s a moral issue, I’m wondering how you mean “moral” if it isn’t at some level. Whether it’s the business of government to meddle or not, yes, of course there’s a moral dimension to managing pain and pursuing pleasure, especially, I think, when either overwhelming pain or overwhelming pleasure is likely to leave you incapacitated. I think most of us would consider it not just stupid, but wrong, to drive drunk, for example: others do not deserve the harm you’re more likely to cause them if you’ve chosen to drive incapacitated. (Not that people deserve the harm you could cause them if you’re involuntarily incapacitated behind the wheel, either, but sometimes that can’t be helped.)

    I’m simple minded.  Morality pertains to individuals.  We receive it from family and the rest of our culture.  It’s accretions of millennia of notions successful for individuals, families and communities, but pertains to individual behavior.  The way to study and understand the business of harmful narcotics is not through a moral lens of why an individual finds himself addicted, or open to addiction, or willingly destroys people’s lives to make a quick buck, or murders competition, or exploits a person already addicted or almost addicted through medical treatment etc.  but as a business with incentive, elasticities, costs and benefits, risk takers and consumers, some of whom come willingly others are roped in.  And the battle against it must be based on an understanding of the business.  Individuals caught up in it, addicted, or driving while drugged raise medical, legal and moral issues and once we get the anti drug policy right, we can focus on those things but we can’t start there.  That’s really been one of the reasons we can’t come to grips with it.  As long as there are profits of 20000 percent and as long as their are dumb kids who do dumb things and incredible incentives to hook them there will be a drug business.  The actors are interchangeable and will always be there until we change the overall incentives that drive the business.

    • #18
  19. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    Joe P (View Comment):
    At the risk of sounding sarcastic, the problem is that American youth in the upper and middle classes are… American youth in the upper and middle classes?

    And some of these are contradictory, aren’t they? They’re being coddled, but they’re isolated. They’re not working hard enough, but they’re working too hard.

    Well, coddled and isolated can go together, but yeah.

    I wonder if Quinones didn’t realize exactly what he was saying. He would talk about individual cases of people developing addictions in the course of pushing themselves too hard, but mostly, his thoughts on why Americans use “quick fixes” revolved around the immorality of using quick fixes, not the reality that quick fixes have a special appeal to those very driven to achieve.

    One anecdote he includes is of a man named Alex Cahana, who dedicated himself to spreading the word that opiates alone should not be used to treat pain, while rebuilding a pain clinic devoted to multidisciplinary pain management. Well, while Cahana’s “overwork” won numerous awards and got heroic achievements accomplished, Cahana got fat and started taking pills (not pain pills, but anti-cholesterol pills and so forth) as quick fixes. In Quinones’s words, Cahana “seemed to be living like an addict”. Cahana resigned from his heroic work, took a more modest job, and devoted himself to physical fitness so he wouldn’t have to use pills to treat the ill effects of being fat. Which is fine. But it seems strange not to notice that while Cahana was “addicted” to an unfit lifestyle, he got a lot done!

    Quinones wishes Americans lived more balanced lives, which is understandable. But Quinones has such a romanticized ideal of what hard work is that I’m not sure he always recognizes hard work when he sees it. It’s almost as if Quinones treats “overwork” as an evil categorically different from hard work, rather than overwork as an excess of a virtue he professes to admire. I find that puzzling, and it contributes to some of the “random moral generator” feel of Dreamland.

    • #19
  20. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    Joe P (View Comment):
    I don’t understand how he can paint a very clear picture of it as being an unintended consequence of what doctors and the government wanted, yet blame drug companies for it.

    Part of it has to do, I think, with the fact that he investigated and reported on the prosecution of a case where three executives of Purdue Pharma, the manufacturer of OxyContin, copped a plea in order to avoid jail time:

    Abingdon, Va., July 20 — After hearing wrenching testimony from parents of young adults who died from overdoses involving the painkiller OxyContin, a federal judge Friday sentenced three top executives of the company that makes the narcotic to three years’ probation and 400 hours each of community service in drug treatment programs.

    In announcing the unorthodox sentence, Judge James P. Jones of United States District Court indicated that he was troubled by his inability to send the executives to prison. But he noted that federal prosecutors had not produced evidence as part of recent plea deals to show that the officials were aware of wrongdoing at the drug’s maker, Purdue Pharma of Stamford, Conn.

    Given the opportunity to speak, [the parents] both memorialized their lost children and lambasted Purdue Pharma and its executives, saying they bore a responsibility for those deaths. They also urged Judge Jones to throw out the plea agreements and send the executives to jail.

    • #20
  21. skipsul Inactive
    skipsul
    @skipsul

    Joe P (View Comment):
    I don’t understand how he can paint a very clear picture of it as being an unintended consequence of what doctors and the government wanted, yet blame drug companies for it. Even if he claims that drug companies should have known better or acted differently, they weren’t the ones who created this system where the country doctor doles out dope and welfare to keep the retired coal miners quiet.

    Ohio sued several drug companies last week on the claims that the drug companies paid and pushed docs to push Oxy where it wasn’t really necessary.

    I’m sure it feels good to our state A/G to do this (Mike Dewine has been a notorious moralist over drugs and alcohol and a close ally of MADD – itself an organization well off the rails for a long time now – ever since he lost a daughter to a drunk driver), but this seems to me to be more a case of revenge and scapegoating well after the fact, and not something that will solve anything.  It seems to me that Ohio is putting itself into the same position as states did in the 90s and early 00s over the tobacco settlement – making themselves addicted to the financial payouts.

    • #21
  22. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    Kozak (View Comment):
    I blame a lot of the opiate epidemic on the academics who pushed the “ you don’t need to worry about your patients getting addicted to narcotics” , coupled with the JCAHO ” pain is the 5 th vital sign” campaign that along with the “customer service model” of medicine pushed us to prescribe way way more narcotics then we used to.

    The academics who published the two studies everyone cited have wryly observed that their studies did not say exactly what people wanted them to say:

    Then came two small accounts in medical journals that helped lay the groundwork for an expanded role for prescription narcotics. The first, a hundred-word letter to the editor published in 1980 in the New England Journal of Medicine, reported that less than one per cent of patients at Boston University Medical Center who received narcotics while hospitalized became addicted. The second, a study published in 1986 in the journal Pain, concluded that, for non-cancer pain, narcotics “can be safely and effectively prescribed to selected patients with relatively little risk of producing the maladaptive behaviors which define opioid abuse.” The authors advised caution, and said that the drugs should be used as an “alternative therapy.” They also called for longer-term studies of patients on narcotics; we’re still waiting for those to be performed.

    To paraphrase, “Hey, our small study shows that when people are given narcotics in carefully-controlled hospital settings, they don’t seem to get addicted!” (Porter and Jick) and “we followed 38 patients, and 2 could not manage their opiate use, but those two had a history of prior abuse – opiates can be used safely, but let’s study this more and proceed with caution” (the second study) are hardly ringing endorsements of indiscriminate opiate use. They’re both very small, very specific, preliminary studies.

    You’re obviously not alone in blaming these academics – Quinones does, too, on the grounds that they should have noticed sooner how their studies were being (mis)interpreted, especially by infomercial material (including “Pain is the 5th vital sign!”) Purdue Pharma sponsored (one reason Quinones blames Purdue so much).

    • #22
  23. I Walton Member
    I Walton
    @IWalton

    Midget Faded Rattlesnake (View Comment):

    Kozak (View Comment):
    I blame a lot of the opiate epidemic on the academics who pushed the “ you don’t need to worry about your patients getting addicted to narcotics” , coupled with the JCAHO ” pain is the 5 th vital sign” campaign that along with the “customer service model” of medicine pushed us to prescribe way way more narcotics then we used to.

    You’re obviously not alone in blaming these academics – Quinones does, too, on the grounds that they should have noticed sooner how their studies were being (mis)interpreted, especially by infomercial material (including “Pain is the 5th vital sign!”) Purdue Pharma sponsored (one reason Quinones blames Purdue so much).

    “carefully controlled hospital settings” doesn’t include released patients who are given the left over pills or generous prescriptions”  The system is deeply flawed and not at all controlled and that is where the addiction probably really gets under way.    We just went though this and were given enough left over pills to addict an elephant.  They didn’t want to take them back because of the paper work and were ready to prescribe more for therapy.  One told us to just flush them down the toilet.    Then we got a call after being released asking if we had any oxycotin we wanted to sell.   The patient still not functioning well and still under medication didn’t jump on it to set up a sting.  Finally I took them to the pharmacy where a cop visits periodically to pick this stuff up.

    • #23
  24. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    I Walton (View Comment):
    The way to study and understand the business of harmful narcotics is not through a moral lens of why an individual finds himself addicted, or open to addiction, or willingly destroys people’s lives to make a quick buck, or murders competition, or exploits a person already addicted or almost addicted through medical treatment etc. but as a business with incentive, elasticities, costs and benefits, risk takers and consumers, some of whom come willingly others are roped in. And the battle against it must be based on an understanding of the business. Individuals caught up in it, addicted, or driving while drugged raise medical, legal and moral issues and once we get the anti drug policy right, we can focus on those things but we can’t start there.

    Dreamland ambitiously attempts to synthesize a story combining all these things at once – the moral, medical, and legal issues, the economic issues. We know why journalists do this – only a few geeks like us find economics alone a compelling story. I agree that, while there’s some impressive economic reporting in Dreamland, some distance between the analysis and the moralizing would be helpful. Quinones’s description of the pharmaceutical action of opiates was similarly moralized, and suffered factually as a result:

    Quinones claimed “the morphine molecule” is unique among drugs in not breaking down into mere glucose (which is false: many perfectly non-recreational drugs also contain, for example, at least one nitrogen molecule and thus can’t break down into mere glucose, either). Moreover, he describes “the morphine molecule” as uniquely rebellious because it refuses to leave the body, which contradicts his own reporting on how quickly addicts crash after their high, and again, is just factually false: morphine’s half-life in the body is 2-3 hours; many other drugs have half-lives longer than that, with some much longer (amiodarone’s is two months!).

    It’s narratively attractive to describe a molecule as resembling “a spoiled lover, throwing a tantrum as it left”, but problematic when reporting on what the chemistry really is and does is distorted to match such romantic moralizing.

    • #24
  25. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    I Walton (View Comment):
    “carefully controlled hospital settings” doesn’t include released patients who are given the left over pills or generous prescriptions

    Exactly!

    • #25
  26. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    I Walton (View Comment):
    We just went though this and were given enough left over pills to addict an elephant… One told us to just flush them down the toilet… Finally I took them to the pharmacy where a cop visits periodically to pick this stuff up.

    I admit, in our family, we carefully save these extras, for use in small doses over the course of years (if we were given that much). But we also don’t have someone who’d use them excessively, and if we did, we’d have to flush or find a return mechanism, too.

    • #26
  27. MarciN Member
    MarciN
    @MarciN

    I have to really disagree with some of the assumptions here. I have yet to meet a doctor who thinks that opiates are wonderful. If they prescribe them, they are considering the context of the pain. If the pain is something that needs to be worked through so that the patient can ultimately get better, then the opiates are helping considerably. Movement is the key to almost all healing.

    My daughter, now a veterinarian, spent a few years working with a veterinarian, John Sherman, in North Carolina who achieved some fame for rehabilitating dogs, some were racing dogs, and I think he treated some horses too. My daughter was his vet tech. He achieved tremendous results.

    One reason for his interest in rehabilitation and success with it, my daughter told me at the time, was that Dr. Sherman had had back surgery, and the surgery was not done well, and he ended up in chronic pain. He passed away a few years ago, sadly. He was a much-loved doctor.

    At any rate, what made him unique in his field was that he said you’ve got to treat the pain.

    And having recovered from surgery and couple of other bad things, I would agree with him. You need good sleep, and you need to be able to move around. Without moving around, patients are at risk for deadly upper respiratory infections. And atrophy elsewhere in the body. And depression.

    Furthermore, most people cannot take time from work these days for “bed rest.” What a joke.

    I don’t think doctors are wrong to prescribe these medications. The doctors and the painkillers have saved lives.

     

    • #27
  28. Arahant Member
    Arahant
    @Arahant

    When I broke my back, of course they were treating the pain with some powerful stuff. I broke it on Saturday and got out of the hospital on Thursday. My wife, without my permission, went ahead and filled the three prescriptions the doctor had given. I don’t remember the specifics, but the painkiller was some sort of opiate. (The other two were a stool softener, because of the opiate, and a high-dose vitamin D for the bones.) I took the opiate on Friday, and decided enough was enough on that stuff. (I was also using an electronic device, a TENS stimulator, so did not need the additional pain control.)

    At the next follow-up visit, I brought the pills and asked, “What do I do with these?”

    Doctor: “Keep them. You’ll have some bad days.”

    Me: “I don’t think you understand, Doc, I’m not going to use these things. I took them for one day, and wouldn’t have even filled the prescription were it up to me. Now, what do I do with them?”

    Doctor: “Just keep them. Trust me, you’ll have bad days.”

    I finally asked my brother, who at the time was on a drug task force, how to get rid of them.

    • #28
  29. Midget Faded Rattlesnake Contributor
    Midget Faded Rattlesnake
    @Midge

    MarciN (View Comment):
    I have to really disagree with some of the assumptions here. I have yet to meet a doctor who thinks that opiates are wonderful.

    We are probably lucky enough to a) have never visited a genuine pill mill and b) have some freedom to avoid doctors who, while they don’t think opiates are wonderful, are so pressed for time that they write us a narcotic scrip because it’s quicker than advising us how to treat the pain in other ways.

    If they prescribe them, they are considering the context of the pain. If the pain is something that needs to be worked through so that the patient can ultimately get better, then the opiates are helping considerably. Movement is the key to almost all healing.

    Yes, opiates can help considerably with helping people endure healthily aggressive physical rehabilitation. Doctors should consider the context of the pain, and many do (mine do, yours do – I bet a lot of the Ricoverse seeks out doctors who do). Regrettably, some don’t.

    My daughter, now a veterinarian, spent a few years working with a veterinarian, John Sherman, in North Carolina who achieved some fame for rehabilitating dogs, some were racing dogs, and I think he treated some horses too. My daughter was his vet tech. He achieved tremendous results.

    One reason for his interest in rehabilitation and success with it, my daughter told me at the time, was that Dr. Sherman had had back surgery, and the surgery was not done well, and he ended up in chronic pain. He passed away a few years ago, sadly. He was a much-loved doctor.

    At any rate, what made him unique in his field was that he said you’ve got to treat the pain.

    And having recovered from surgery and couple of other bad things, I would agree with him. You need good sleep, and you need to be able to move around. Without moving around, patients are at risk for deadly upper respiratory infections. And atrophy elsewhere in the body. And depression.

    Yes, you need good sleep and to be able to move around.

    Furthermore, most people cannot take time from work these days for “bed rest.” What a joke.

    I don’t think doctors are wrong to prescribe these medications. The doctors and the painkillers have saved lives.

    I don’t think it’s wrong for doctors to prescribe these medications, either. There does seem to be a “right way” (even if it involves some luck) to prescribe them, just as there seems to be a “right way” (also seeming to involve some luck) for patients to treat these medications once they have them in their homes. But enough patients have been doing it the wrong way, with their doctors’ apparent blessing (if only because the doctor was too harried to pay more attention, or was afraid of getting bad patient reviews), that it’s become a problem – a problem bad enough that many of our fellow citizens are willing to impede the right ways, too, if they think it will stop the wrong ways.

    • #29
  30. MarciN Member
    MarciN
    @MarciN

    Midget Faded Rattlesnake (View Comment):
    a problem bad enough that many of our fellow citizens are willing to impede the right ways, too, if they think it will stop the wrong ways.

    This is what I’m worried about.

    I’ve seen the medical field go to extremes at times, and I’m worried that’s what they are going to do now with prescribing painkillers. I know the feds are monitoring doctors for this. Good lord. We will be creating a country in which people are in pain and suicidal from it.

    I live in an anti-opiate state, for sure. The doctors I’ve had worry constantly about the addiction-possibility side effect. I certainly understand the concern. But opiates can as often prevent permanent disability as cause it.

    And as to the number of people turning to SSDI–this is a problem with readily available solutions. I say that based on years of hanging around Social Security offices in the course of caring for someone who was permanently disabled. We don’t give SSDI counselors enough resources for them to prevent people from dropping out of life and living on SSDI forever. It has always troubled me. No one wants to live that way. Of that I am sure.

    First of all, the counselors need flexibility. They need something like long-term disability insurance. It should be easy to get on and off SSDI. That would help a lot. And we need to look seriously at rehabilitation, which there often isn’t money for, at least not that the SSDI counselors are aware of. And we need to do better job help for disabled people. What is disability exactly? It’s not being able to find work within the limits of your physical issues. With a more creative employment office, we could help people live better. I visited the Massachusetts unemployment office once, and I don’t think I’ve ever seen a group of more depressed people in my entire life. The staff was as depressed as the clients. Finding a job requires some optimism. I saw none among the staff. How can they help anyone?

    Sigh.

    • #30
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