Sam Quinones’ Dreamland

Like many people, I was vaguely aware that America was in the midst of an opiate crisis, but the scope of the problem eluded me until I read Andrew Sullivan’s excellent New York Magazine exposé, “The Poison We Pick,” which begins with a punch:

More than 2 million Americans are now hooked on some kind of opioid, and drug overdoses — from heroin and fentanyl in particular — claimed more American lives last year than were lost in the entire Vietnam War. Overdose deaths are higher than in the peak year of AIDS and far higher than fatalities from car crashes. The poppy, through its many offshoots, has now been responsible for a decline in life spans in America for two years in a row, a decline that isn’t happening in any other developed nation. According to the best estimates, opioids will kill another 52,000 Americans this year alone — and up to half a million in the next decade.

Part of Sullivan’s contention, in that piece, is that there has been a mysterious dearth of coverage of the crisis and the lives it has claimed. The AIDS epidemic of the 1980s went largely ignored for the obvious reason that America had not yet come to terms with – let alone accepted – homosexuality, and was shamefully content to overlook the suffering and death of gay men. The opiate crisis is different. It began by afflicting white working class men and women, in America’s heartland, and has gradually begun to claim the lives of younger and younger victims: college and even high school students. My curiosity about the crisis brought me to Sam Quinones, an American journalist who has specialized on Mexico and Mexican immigration into America, and his award-winning book Dreamland: The True Tale of America’s Opiate Epidemic, a sprawling, episodic investigation into the crisis: its origins, the nature of the drugs involved, and the people both pushing and using these powerful narcotics.

Part of the brilliance of this book is its ability to weave together disparate narratives to tell a single story – a necessary skill, as it turns out, since the opiate epidemic has multiple origins. One of those beginnings belongs to the morphine molecule itself, a powerful analgesic derived from the opium poppy, known to mankind for thousands of years for its ability to alleviate pain.

What gave the morphine molecule its immense power […] was that it evolved somehow to fit, key in lock, into the receptors that mammals, especially humans, have in their brains and spines. The so-called mu-opioid receptors – designed to create pleasure sensations when they receive endorphins the body naturally produces – were especially welcoming to the morphine molecule. The receptor combines with endorphins to give us those glowing feelings at, say, the sight of an infant or the feel of a furry puppy. The morphine molecule overwhelms the receptor, creating a far more intense euphoria than anything we come by internally. It also produces drowsiness, constipation, and an end to physical pain. Aspirin had a limit to the amount of pain it could calm. But the more morphine you took, […] the more pain was dulled.

The study of the poppy flower gave birth to our modern understanding of anaesthetics, without which we would still be suffering terribly from even the mildest of surgeries or battlefield wounds. But the poppy has also bequeathed to us opium and, after its first synthesis in 1874, heroin – both powerfully addictive drugs, notorious for turning their users into mindless zombies who will stop at nothing to achieve their next fix. Still, neither opium nor heroin use had risen to epidemic levels; something changed, within the last few decades, to make their use far more common. “Worldwide morphine consumption began to climb,” Quinones tells us, “rising thirtyfold between 1980 and 2011.” But this sentence is misleading, for, according to Quinones, 90% of the world’s morphine was consumed within the world’s wealthiest countries, with just 20% of the world population.

Quinones blames a philosophical shift in the medical community, given most direct expression by the World Health Organization, which, in 1980, convened a panel of 16 experts on pain to outline and standardize an approach to combatting and managing pain symptoms, particularly in terminal cancer patients. They produced a book, translated into 20 languages, that outlined what came to be known as the WHO Ladder, the series of escalating treatments to be used to mitigate human suffering, culminating in the prescription of powerful opiates. But as such organizations are wont to do, the WHO panel went too far, declaring freedom from pain a “human right.” Their stance dovetailed with one taken by the American Pain Society, a group whose legitimacy as an unbiased medical organization was compromised, from the beginning, by their funding from the pharmaceutical industry, which had lately developed a series of powerful pain killers (Oxycodone and Vicodin, in particular). The American Pain Society successfully lobbied to have pain elevated to the status of a vital sign, together with body temperature, pulse, respiration rate, and blood pressure, but unlike these four staples, pain cannot be measured objectively. Instead, physicians were encouraged to take their patient’s subjective assessment of their own pain into consideration, and seek to treat that pain – with prescription drugs.

At the same time as the medical community was undergoing this tidal shift in its approach to pain treatment, the illegal drug trade changed dramatically. Heroin, long supplied to America from poppies grown in Afghanistan and shipped through Europe, began to arrive from Mexico, and the proximity of the delivery system allowed for both a cheaper and more potent drug. Not only that, but the control of the drug trade was temporarily in the hands of poor Mexican rancheros, who learned from the mistakes of the inner city heroin dealers. Rather than distribute their drugs conspicuously, from street corners, they employed illegal immigrants as delivery men, taking orders for heroin in the same way that you might order a pizza. They did not carry guns, and understood American drug laws well enough to know exactly how much heroin they could possess, on their persons, without incurring jail time for a first offence. The result was an underground network of illegal immigrants offering a level of customer satisfaction and a quality of product without precedent. They did one other clever thing: they deliberately avoided the usual heroin markets, in New York and Los Angeles, for example, in favour of smaller towns and cities in the Rust Belt. Not only did this help them allude DEA detection for years, but it kept them from being in direct competition with the established gangs of these cities, who were known for killing their competition. This decision brought heroin to an entirely new, untapped market: white, working class men and women, whose industrial towns had long been abandoned by American industry, and who were disproportionately likely to have been prescribed a painkiller for lingering physical injuries.

Quinones spins a compelling – and depressing – tale of medical malpractice, pharmaceutical malfeasance and criminal entrepreneurialism, centred on what he rightly recognizes to be a philosophical question: why are men and women in the wealthiest country in the world self-medicating with powerful painkillers? His answer also points the way to a possible antidote, since the successful treatment of opiate addiction relies on more than just rebalancing the addict’s brain. Communities have disintegrated and jobs have been lost, and with them the pathway to a dignified, meaningful existence. A great many Americans are, indeed, experiencing pain, a terrible and existential pain, but not one that admits of a medical or pharmaceutical solution.