Dreamland: The True Tale of America's Opiate Epidemic

The United States of America is in the midst of a widespread opiate epidemic that has devastated hundreds of small rural towns and suburbs across the country. The captivating story of exactly how this came to be is expertly told in acclaimed journalist Sam Quinones' fantastic book, "Dreamland: The True Tale of America's Opiate Epidemic", which was published in 2015. In "Dreamland", Quinones magnificently blends together two seemingly-independent narratives: the overly generous prescription of pain medications during the 1990s (including Purdue Pharma's ambitious campaign to aggressively market and sell OxyContin) and the unforeseen—and unprecedented—arrival of cheap, consistent, high quality black tar heroin from one small county in Mexico. According to Quinones, these developments joined forces in a dangerous synergy that ultimately resulted in America's modern-day opiate epidemic. The book opens with a ridiculously thorough timeline that begins with the distillation of morphine in 1804, moves on to the invention of the hypodermic syringe in 1853 (did you know that the inventor's wife was the first to die of injected drug overdose?), glances at the release of OxyContin in 1996, and ends with the FDA's 2014 approval of Targiniq ER, which combined timed-release oxycodone with naloxone. This timeline, which provides plenty of insight into what went on in between those four events, sets the stage for the book's narrative and successfully primes the reader for the information that follows. And the actual book doesn't disappoint, either—as the dust-jacket blurb states, it introduces "a memorable cast of characters—pharma pioneers, young Mexican entrepreneurs, narcotics investigators, survivors, and parents, and Quinones shows how these tales fit together." Sure enough, about midway through "Dreamland", the reader begins to see the sophisticated web that was woven by several groups of people who were simply following the capitalist dream (operating in their own best interest in an attempt to make as much money as possible), and the once-hidden connections between the people and places involved become as clear as crystal. When it comes down to it, "Dreamland" is the best book that I've read so far this year. The story is compelling and unfolds beautifully, in a masterful manner that constantly tempts the reader to read the next chapter. The level of detail that is crammed into each page is truly impressive, but never overwhelming. Simply put—I enjoyed every single word. The topic isn't necessarily the most popular (for the average reader), so I'm not sure that I would recommend this book to someone unless they're already interested in America's opiate epidemic. However, if you are at all intrigued by the topic, then I wholeheartedly recommend this book to you. It will likely take a while to read, because it is packed so densely, but it will be worth your investment of money, time, and energy. And I will keep an eye out for any future books and articles by Quinones, as his writing is an absolute joy to read.

"Dreamland" is a critical book that charts the epidemic of opiate addiction that has run rampant across the United States over the last 20 years. Quinones does a commendable job of weaving several converging narratives together that collectively gave rise to the scourge that resulted. Quinones focuses a great deal of the story on Portsmouth, Ohio, an epicenter of the destructiveness when these forces collide and a microcosm for what played out across so many places across America. Multiple factors came together to create this epidemic. One key factor was the changing view of pain management in the medical profession. Many medical professionals began viewing and talking about pain as a "fifth vital sign" that required treatment and management like other vital signs such as blood pressure. While there had been more holistic approaches to pain management used given the concern around opiate addiction, a small study was about have a dramatic impact. Since the advent of opioids, pharmacologists and drug companies were looking for ways for a "miracle" formula that took advantage of the pain "numbing" nature of opioids while diminishing or eliminating their addictive nature. Then a study was published in a pain journal (ultimately highly distorted and taken out of context) that provided doctors, drug companies and others the impetus to expand prescribing the drugs as treatment because they could now fall back and cite research that stated these drugs were not addictive. Suddenly, a new drug, Oxycontin, in highly concentrated dosages, combined with aggressive marketing by the drug maker directly to doctor with the pitch of a miracle "cure" --- pain relief without addiction --- created an explosion in the dispensing of pills to treat any and all forms of pain. On the distribution side, Quinones charts the rise of a network of heroin dealers from a small city of Mexico, Xalisco, in the state of Nayarit. They began producing a highly pure form of heroin, black tar, and running drug operations that were completely different from anything police or others had seen previously, especially in major American cities like NY and LA. They essentially built a retail operation selling small, very cheap, but potent heroin, to white suburban kids in second tier suburbs of cities like Columbus, Portland, Salt Lake City and Denver. Unlike the cartels who sold impure drugs on street corners and relied on the stereotypical junkies as their "customers", the "Xalisco Boys" focused on hand delivering highly cheap and pure drugs to suburban kids who had started out using pills and now finding dealers bringing them even cheaper drugs that provided them an ever quicker and more powerful high to feed their habit. Finally, there are the pill mills, unscrupulous doctors many unfit to practice medicine now opening sham clinics to dispense prescriptions for Oxy and other opiates for cash. These pill mills had customers lining up, "zombies" as Quinones calls them, to get their vast quantities to both use and sell to feed their growing addiction costs and could operate unfettered given lax databases within and across states All of this creates an incredibly frightening and depressing story engulfing the country. However, there were a couple of aspects that prevented "Dreamland" from being even more powerful. First, there was a lot of repetition throughout the book. At times, Quinones repeated the same phrases or conclusions multiple times in the same chapter. These points were accurate, but they were already clear from the narrative and began to feel belabored. He probably could have saved 30-40 pages through judicious editing to remove redundancy. Second, this would have provided him more opportunity to focus on the changing nature of the traditionally "tough on crime/drug" crowd that was beginning to rethink crime and punishment for drug use. While Quinones does note changing perspectives among many who focused on mandatory sentencing and get tough policies against mostly minorities, there was plenty of further exploration about attitudes of leniency and treatment for drug offenders now that white America was at the center of opiate addiction epidemic. Even with those critiques, "Dreamland" is an important work about the power and destructiveness of opiates and the recovery much of our country is undergoing as a result.

Eugene O’Neill won the Nobel Prize for literature in 1936. His most famous play, “Long Day’s Journey into the Night,” is set on just one day in August 1912. Mary Tyrone, 54, is a central character, stricken by rheumatism, stricken by grief after the death of her second son. The helpful family doctor, back when they carried little black leather bags and made house calls, prescribes morphine to comfort. Mary would become hooked, and would later say: “It hides you from the world and the world from you. You feel that everything has changed, and nothing is what it seemed to be. No one can find or touch you anymore.” Denial is the addict’s crutch, as Mary proclaims: “Now I have to lie, especially to myself.” Just over a century after the setting of this play, on New Year’s Day, 2013, Sam Quinnones, a former reporter for the Los Angeles Times, sat in a café in Covington, Kentucky, as he commenced full-time work on this remarkable book. He never mentions O’Neill in his work, but he does mention Bruce Springsteen. I’ve read two other serious works on the human and social devastation that have been wrought by the outsourcing of jobs overseas and the “comfort” that the humans who have been placed on the discard pile have sought through the use of drugs, often opioids. “Dopesick” was written by Beth Macy, a reporter with the “Roanoke Times,” who had covered, for two decades “marginalized families,” as the expression has it, and focused on the trial of Purdue Pharma, and its corporate leadership. The “Ghosts of Tom Joad – A Story of the 99%” was written by Peter Van Buren. In my idiosyncratic rating system, I rated both books 6-stars. Van Buren also mentioned Springsteen; in fact, both Quinnones and Van Buren reference the same line from Springsteen’s lament, “The River,”: “They bring you up to do like your daddy done.” Quinnones starts in the Ohio River valley, in the town of Portsmouth, Ohio. In his preface he provides a profoundly moving elegy for “the way things were,” when in 1929, the town opened a massive swimming pool that would be the community center for decades, where first loves were consummated. It was called “Dreamland.” Again, Springsteen’s lines would resonate: “Her body tan and wet down at the reservoir.” Portsmouth would become the epicenter for the “pill mill” revolution. Imagine obtaining your medical care from a doctor who dressed like Liberace! The author describes (Dr.) David Proctor in this manner. No physical exam, no diagnosis. “You ache, here, take this pill, all will be resolved. Two-fifty, please.” Proctor would be the godfather of the “pill mill,” and would do serious prison time, before being deported to Canada. A true strength of Quinnones’ reportage is that he moved far beyond the Ohio River Valley and Appalachia, the locales of the other two books. He speaks Spanish, lived in Mexico for a decade and understands the rural areas as well as any “gringo” can. All the black tar heroin sold in the United States comes from Xalisco, in the sixth smallest state of Mexico: Nayarit. They control it all, using basic free market principles, emphasizing customer satisfaction, with interchangeable drivers that deliver the goods. An internet for drug distribution. Poor farm boys, escaping the sugar cane fields, so they can buy Levi 501’s, and be the “big man” when they return to Xalisco… at least for a week or two. Quinnones nails the motivation perfectly. A quiet subtext of his account is how easily these farm boys turned heroin merchants, as well as their merchandise, transit the border between the United States and Mexico, after a very simple phone call. They and their merchandise arrive faster than an Amazon Prime two-day package. “You can run, but you can’t hide.” I grew up at the commencement of the Ohio River, but serendipity lead me NOT to do what my daddy done, which was work in a steel mill. Quinnones repeatedly visits many places in California, as well as Portland Oregon and Boise Idaho. He devotes two entire chapters to two towns in my late-in-life new home in the Land of Enchantment, specifically the village of Chimayo, with its 4000 somewhat tarnished souls, a place dubbed the “Lourdes of America,” as well as Santa Fe. Nary a mention of the Opera House in the chapter on the latter; rather, he notes that when the drug bust came that nailed the director of the funeral home, who also had a habit, who used his name to register all the cars and apartments for the drug delivery boys, that the supply of heroin in the town was disrupted for ONE DAY. The 24th richest family in America, per Forbes, the Sacklers, became obscenely rich by pushing heroin, labeled as Oxycontin. Poor farm boys from Xalisco did not grow as rich, but did obtain designer clothes, nice homes with running water, and pick-ups. Quite a few would do prison time, as they managed to replace the higher priced Oxycontin with black-tar heroin, where a user could get his daily fix for about the price of a 6-pack of beer. Much of this social devastation has occurred because, as a nation, which certainly includes US attorney’s offices, follow the path blazed by the fictional Mary Tyrone, of over a century ago: “Now I have to lie, especially to myself.” Quinnone has provided an excellent account of how this all occurred, with many pithy observations and phrases, like “the vinegar for a crucified region.” Who amongst us has not been affected? Two weeks ago my wife and I toasted, remotely, a “celebration of life” for one of our daughter’s friends, who “slipped in the shower” at the age of 32, in San Francisco. Meanwhile, three days ago, the local newspaper announced the death of the University of New Mexico defensive lineman, Nahje Flowers, age 21. UNM refused to disclose the cause of death. Indeed, we have to lie, especially to ourselves. 6-stars for Quinnone’s seminal work.

One of the MOST important and riveting books I've read in a long time - and that is not an exaggeration! I rarely give 5 stars but this one deserves it. An incredible journey and comprehensive telling by perhaps one of our best living journalists of what went wrong leading to the opiate-heroin-drug-overdose-death epidemic in America, how easily opiates evolved into a heroin epidemic, ravaged small town America and then spread well beyond into comfortable communities of privilege. I came upon this book delving into trying to understand what has been going on in this country (starting with Hillbilly Elegy), and why despite reading broadly than most, I was so taken aback by the Nov'16 election outcome. The factors are myriad - and that journey continues - but what became obvious to me was that the opiate crisis particularly in places like Portsmouth Ohio or the Appalachia created much of the senseless destruction that contributed to it. It's only when that crisis reached "us" with the death of people like Philip Hoffman Seymour in 2014 did we even begin to pay attention. But it was too late. Given the garbage heap of non-essentials that the media shoves at us they largely missed the urgency of this story. Death due to drug overdoses exceeded those from car crashes as early as 2007!!! YES you read that right - 2007 - nearly a decade before we paid attention. How broadly was that publicized, and how deeply investigated? Thankfully for us there are journalists out there like Sam Quinones who researched it for 5 years and then wrote this tome. Besides being a great read because of his fantastic narrative style and passion for getting to the bottom of it, Quinones brings together a complete picture of all that played here. The opiate-heroin crisis resulted from a PERFECT STORM of varied factors coming together - -- the drastic swing in the pain management pendulum with a change towards prescribing opiates starting in the '90's willy-nilly to one and all under the misguided - and to some extent deliberate - notion that they are not addictive when prescribed for pain "pain soaks up the euphoria"! There was no "data" or "study", instead a small paragraph in a letter to an editor of a medical journal that set this off. No one asked questions or asked to see the source! The man who wrote the paragraph had no intention nor data to support what was inferred. -- unethical companies like Purdue Pharma taking advantage of this new fad, pushing their drug(s) esp. OxyContin on anyone with ANY pain creating drug addicts who would never have gotten there. Purdue knew the "data" was faulty and that new addicts were being created everyday yet they pushed it hard until the end, -- unethical, often "quack" pill doctors who appeared at mushrooming "pain clinics" everywhere to provide willing Rx for OxyContin; they only took $250 in cash per visit! -- unlimited and unchecked Medicaid card, SSI, disability benefits that funded the pills; a medicaid card enabled you to get pills with a $3 copay that you could resell for thousands of dollars. One reason for the millions who are not employed nor looking for work... -- the appearance of black tar heroin from Mexico for which OxyContin happened to be the perfect gateway drug a lot cheaper and better quality (high potency) than the white powder; OxyContin traveled west and black tar heroin traveled east and the invasion was complete! -- a new business model for selling heroin via near unbreakable Mexican drug dealing cells where the heroin is delivered like pizza to customers along with great service by salaried drivers! Yes that's how crazy it got -- and we are only now beginning to understand and unravel let along address! Read on for an amazing book and incredible journey of learning.

Purdue Pharma peddling OxyContin and Mexican heroin dealers both ended up destroying America for profit. The only difference is that the board of directors and executive staff of Purdue aren't serving time. Welcome to American addiction. What a wonderful, informative and depressing book. What I learned was that Opioid deaths have skyrocketed as five things changed. First, the medical profession embraced "pain as the fifth vital sign". With very little evidence doctors convinced themselves that prescribing opioids for pain had a minimal chance of causing addition. They were very, very wrong. Second, dealers in the town of Xalisco in Mexico pioneered a "cut-out-the-middleman" strategy for delivering 80% pure heroin directly to a customer just by dialing a number. And they targeted non-urban (read "white") customers. As the author describes it turned buying heroin from scoring in a dark alley to as easy as having Pizza delivered. Third, Purdue Pharma developed a pill - Oxycontin - which was essentially legal time-release heroin. They then marketed it to patients and doctors for every-day pain relief (bad backs, torn ligiments, etc) promising that it wasn't addictive. Fourth, insurance companies refused to reimburse pain managment clinics - those that recognized that pain could be better controlled via diet, exercise, therapy, etc. Instead insurance found pills to be an easy short-term reimbursable answer. Fifth, some doctors became drug dealers as they set up "pill mills" and they dispensed millions of pills solely for profit. The book also raises a few more questions for me. Where was the American Medical Association? Rather than policing their own profession or at least owning up to and shaming the small number who have turned into drug dealers, and even after 60,000 people died from opioids, in a mind-blowing statement in 2017 the American Medical Association Opioids Task Force said, "it has always been that the decision about a specific treatment alternative is best left to the physician and their patient." The government failed its citizens. If there was ever a case for the role of government in protecting our citizens this was it. (More people died from opioids-related deaths in 2016 then died during the entire Vietnam War.) Yet each institution that could have slowed this epidemic lacked the moral and political courage to do so. First and foremost, the nation's drug safety watchdog, the Food and Drug Administration (FDA). Buckling under political pressure (from both parties as drug companies now pay for almost half the FDA budget,) they approved OxyContin in 1995 and continued to approve its every increasing dosages. And in 2013, after 18 years of creating an epidemic, the FDA was still approving new extended release opioids (Zohydro.) . And it just wasn't the FDA. The Centers for Disease Control (CDC) didn't issue opioid prescription guidelines until 2017. And for 15 years the Federal Trade Commission (FTC) sounded like crickets as drug manufacturers, distributors, and pharmacies advertised opioids as non-addictive pain relief. And even as, hard-working Drug Enforcement Agency (DEA) field agents were trying to break up Mexican heroin rings, their senior leadership let the cases against drug distributors, manufacturers, pharmacies and doctors drop. While the DEA was trying to break up the dealer network I'm surprised the author never asked, "Given all the money the DEA has pumped into drug eradication programs in Mexico how come the Mexican government hasn't destroyed the opium fields?" It's not like we don't know where they are. Hyperspectral scanners on UAV's, aircraft and satellites can find these fields. If the DEA is frustrated by corruption in Mexico that refuses to take out the growers, at least they could put the fields up on their web site and let the public see what our neighbor is protecting. A real eye-opener of a book. Well worth the read.

The four stars that I gave this book are for the story itself & for the content & what I learned from it. The actual writing & editing of the book left alot to be desired. Which is a shame because I thought the book was so informative & I loved how it read like a story & not just a bunch of boring, dry, facts. If the author had an editor that would go back through & clean up the grammar & remove some of the repetitive sections, this book would be more than a 5 star winner. Despite the lack of polished writing, I have already recommended this book to others because I learned so much from it & it was a fascinating story about big Pharma that few have heard about. So if you're able to overlook the sloppy editing like I did, then I think you'll come away from this book with a newfound knowledge of this deadly opiate epidemic & that knowledge just may end up saving someone you love from being a statistic. My prayers are with all those who have been affected by this tragic epidemic just as my family has been also.

WHAT I LIKED. The book is a wealth of information and research on the narcotics epidemic in the United States. It covers a massive swath of events (some of them rather incidental) that resulted in what we call the "opioid epidemic" and what ravaged not just urban megapolises but also the Heartland of America. Mr. Quinones takes a systematic look from many different angles and the volume of data and histories he collected for it is quite immense. Knowing virtually nothing about it, I learned a lot. WHAT I DIDN'T LIKE. The Author's writing style is rather peculiar. First of all - it jumps around the storylines and timelines, a lot. While it is sometimes an effective writing device, in this particular case it makes the overall narration choppy and quite annoying. Surely, the book covered several narratives, but the way they were presented wasn't helpful. Secondly, the narration gets quite repetitive - a lot, actually. There are probably more than a dozen of long passages where the Author elaborates again and again the technical details of the Xalisco Boys operation. Other storylines get the same treatment with multiple long recaps. This quickly loses novelty and makes the book quite dull to read. More than once I felt that each chapter was originally intended as a separate magazine article. To sum it up, the topic is extremely interesting (and terrifying, actually) and I highly recommend the book. But you might struggle plodding through it.

Dreamland, by Sam Quinones is the story of a nation gone berserk, a harrowing, fear-inducing slog through the small towns and backwater alleys of what was once as American as baseball and apple pie. On the front lines are generations of hard-working Americans, possessed of the values of the people who did make America great and who, sadly, could not forestall the destabilization of that same country in the grips of an opioid epidemic. In 2012, 259 million prescriptions were written for opioids — enough to give everyone in the U.S. their own bottle of pills. The addiction started in the heartland and worked its way outward, like ever-growing tentacles that stretched and squeezed and stretched and squeezed until we had all succumbed. Over 50,000 lives were lost to opioid addiction in 2015 and it all started with the Xalisco boys and a perfect storm of events. Those beginnings were so covert that even the medical profession that aided and abetted it could not foresee such a complete and total coup. Dreamland would be great as a work of fiction — intense, edgy, adrenalin-inducing — if it were only that. Unfortunately, it’s for real. Whether you blame the resilient Mexicans, the ad execs that turned the pharmaceutical industry into a money making machine, the use of the “pain index” as a fifth element in medical treatment, or a sagging American spirit that once fought for rugged individualism, but due to unemployment and loss of manufacturing jobs, among other things, now accepts the status quo like a prison inmate accepts lunch, you still come out in the same place: America likes its opioids more than it has liked any drug before, and throwing addicts in jail as a way to solve the problem is not going to work. Quinones is the quintessential journalist, the type who goes in search of a story rather than one who sits behind a desk and waits for the internet to bring it to him. He spent years investigating the Xalisco Boys, researching, writing, following leads all the way to Mexico and back. It’s no surprise that Big Pharma comes out with egg on its face, having shoved the idea of pain as an indicator down physicians throats, sending forth wave after wave of sales team to rival an invasion and then promising to the moon and back that the oxycontin and oxycodone and other opioids were not addictive “if used properly” (what drug has ever been created that someone didn’t figure out how to use improperly?). Quinones doesn’t blame anyone, just shines a light, but Big Pharma knew, and even in the face of escalating deaths, it’s allowed the ruse to continue. Once an addict, always an addict, just ask anyone who’s ever smoked cigarettes and tried to quit. To this day, I won’t touch one because, despite however much I may cough at first, if I make it through one, there’s a 50/50 chance I’d have another. I know the clarity that nicotine delivers to my brain is better than a pot of coffee and my brain, especially when I’m writing, gets a bit giddy just thinking about recreating that effect. And while addicts are addicted for different reasons, they generally can’t quit for the same one: the beast of desire is a hard one to tame. When a sports injury in high school leads to a life of addiction, and in case after case, death as Quinones describes in the book, then something is wrong with the system, not the child addled because of it. Unfortunately, there’s no easy way forward and we’re not going to get out of it without talking — a lot — because counseling is key and so is patience. But, and it’s a big BUT, that means a groundswell of a shift toward listening, not just locking people up, and in order to listen we need to stop and take a breath, suspend our judgment, and give ourselves the space to hear. Is America ready to listen? Quinones hopes Dreamland will facilitate the conversation. Our kids’ futures depend upon it.

Reading this book arouses a lot of emotions. One usually associates narcotics in the USA with blacks living in the projects. This book tells how drugs are decimating white communities in the rust belt of the United States. I got to learn that India is the largest producer of opium. Millions of elderly Indians die in agony every year because the Indian govt taxes on morphine is so high that only rich people can afford it. Most of the opium grown in India is exported to the developed world. In this new and complex world that we live in many issues require much thought and debate because the stakes are very high and the gap between the winners and losers is every widening. This book shows how Mexicans from one small town start selling heroin in America the way McDonald's sells hamburgers. they have amazing success. This book is very much about the effects of globalisation as it is about substance abuse. And what happens in USA today will most likely happen in other parts of the world ten years later.

Stop reading everything in the news. Stop blaming Trump for this epidemic. Educate yourself a little bit so you can be in the "know" rather than voicing opinions you have no idea about. I am American living in Spain, and it turns me red when i read opinions about this subject. If you have never lived in the United States, then don't voice your opinion on a subject you haven't seen with your own two eyes. Read this book and maybe, just maybe, you'll realize that there is always some cause and effect. Deja de leer todo en las noticias. Deja de culpar a Trump por esta epidemia. Eduque a sí mismo un poco para que pueda estar en el "saber" en lugar de expresar opiniones que no tienen ni idea. Soy americana viviendo en España, y me vuelve rojo cuando leo opiniones sobre este tema. Si usted nunca ha vivido en los Estados Unidos, entonces no exprese su opinión sobre un tema que no ha visto con sus propios ojos. Lea este libro y tal vez, tal vez, usted se dará cuenta de que siempre hay alguna causa y efecto.

Very compelling! Hard to put down. Am a pain physician myself and with that background knowledge even more interesting and shocking as well. Would recommend it for every physician who treats patients with chronic pain disease.

Mesmo para quem, como eu, atua nessa área de estudos há décadas, o livro informa e mesmo surpreende, pois o jornalista que o escreveu realizou um trabalho notável de investigação, além de escrever de forma claríssima, de modo que a gigantesca investigação jornalística que se transformou em um livro que vem colecionando prêmios pode ser lida com prazer tanto pelos especialistas como pelo público em geral. Não é necessário qualquer conhecimento prévio sobre a dramática situação dos opioides/opiáceos nos EUA, pois o texto é 100% auto-explicativo.

A well written, researched investigation into the over prescribing of legal opiate medications leading to the explosion of black tar heroin in heartland US