Dreamland: The true tale of America's opiate epidemic

Abstract

Especially newsworthy has been the "surprising" demographics of new opiate users (Whites, middle-aged women, teenagers from "good families"). [...]whereas heroin use was once concentrated in major coastal cities, its availability, use, and overdose rates have swelled in smaller interior cities, towns, and rural hinterlands. First the shoe factories closed; followed by the steel, brickyard, atomic energy and Coca-Cola plants; and of course, the swimming pool.

Quinones, S. (2015). Dreamland: The true tale of America's opiate epidemic. New York: Bloombury Press.

To say that the United States is in the midst of an opiate epidemic seems cliché at this point. In 2014, there were nearly 30,000 deaths related to prescription painkillers and heroin, representing a four-fold increase since 1999 (National Institute on Drug Abuse, 2015). Over the past two years, thousands of media articles have been written about it, numerous television and radio news sources have run profiles on addicts, nearly all U.S. states and counties have held public hearings, Congress passed new laws, and President Obama pledged funding and action to address the crisis. Especially newsworthy has been the "surprising" demographics of new opiate users (Whites, middle-aged women, teenagers from "good families"). Moreover, whereas heroin use was once concentrated in major coastal cities, its availability, use, and overdose rates have swelled in smaller interior cities, towns, and rural hinterlands.

To many, this "epidemic" seems to have come out of nowhere, but as Sam Quinones demonstrates in his bestselling book, Dreamland: The True Tale of America's Opiate Epidemic, heroin did not just appear in small-town and rural America overnight. Instead, the U.S. opiate problem was driven by a complex interplay of globalization, industrial restructuring, poverty and affluence, neoliberal policy regimes, and changing medical and pharmaceutical institution ideologies and practices.

This was not new; it had been happening for fifteen years. And there was more to it than drugs. This scourge was ... connected to the conflation of big forces: economics and marketing, poverty and prosperity. (p. 304) Forgotten places of America acted like the canaries in those now-shuttered Appalachian coal mines. Just no one in the country listened much until more respectable types sounded the same alarm. (p. 201)

Quinones, a journalist and nonfiction storyteller, uses interviews with addicts and their family members, public health nurses, epidemiologists, defense attorneys, doctors, counselors, pain specialists, local cops, prosecutors, DEA and FBI agents, and imprisoned Mexican heroin traffickers, along with transcripts from drug indictments and trials, pharmaceutical company marketing materials, and newspaper articles, to weave together classic tales of capitalism-how aggressive pharmaceutical company marketing, unfettered pain medication prescribing, and poor rural Mexican sugarcane farm boys trafficking heroin collided to form the perfect opiate storm.

Readers may find it hard to believe that Quinones is not a sociologist. Whereas the overwhelming majority of media and political attention ignores the global macroeconomic drivers of the U.S. opiate epidemic, Dreamland emphasizes these structural forces. Although Quinones includes several stories about addicts and dealers, including a middle-aged man who lost both legs to frostbite when he fell asleep outside in an Illinois snowstorm and a young Mexican farm boy who knew he had finally made it when he was able to purchase a pair of Levi 501s with his heroin income, his analysis is not user- or dealer-centric. Instead, Quinones' reporting makes it very clear that unchecked opioid prescribing and the subsequent influx of potent and cheap Mexican heroin into the United States were the spark, and global economic restructuring, rising inequality, and the United States' "quick-fix" culture were the kindling that produced this out-of-control fire.

Dreamland is structured as a series of overlapping revelations about America's pain revolution, Purdue Pharma's aggressive marketing of OxyContin® in the late 1990s, the appearance of the first pain clinics (a.k.a. "pill mills") in Appalachia, the small industrial cities and mining towns left behind in the new economy, poor sugarcane farm boys from rural Mexico who came to the United States to sell heroin like pizza, and the law enforcement officers trying to stop them. Below I summarize three major threads. First, Quinones describes how the opiate epidemic was kicked off by legal drugs-prescription opioids (e.g., oxycodone, hydrocodone), which are opium derivatives virtually identical to heroin. The introduction to the market of time-released OxyContin® in 1996 changed the game. The manufacturer, Purdue Pharma, claimed OxyContin® was less addictive than other opioid products and did not provoke withdrawal symptoms because its time-release formula allowed for delayed drug absorption. This assertion made physicians comfortable in prescribing it for a wide range of chronic ailments from back pain to headaches. However, not only was OxyContin® far more potent than other painkillers, but addicts quickly learned they could crush, liquefy, and inject the tablets to experience the full dose at once. Overdose deaths quadrupled between 1996 and 2010, and so did OxyContin® sales, going from $45 million in 1996 to $3.1 billion by 2010. Important to the story is that Purdue Pharma instructed its sales representatives to target physicians in parts of the United States where opioid prescribing and social security/disability receipt was already high: Appalachia.

This story connects us to blue-collar Portsmouth, Ohio, home to the book's namesake, Dreamland-a swimming pool that was the vital center of the community during the city's pre-1970s industrial golden age. Here, Quinones describes the consequences of economic restructuring with which sociologists are so familiar (Brown & Swanson 2003; Smith & Tickamyer 2011). First the shoe factories closed; followed by the steel, brickyard, atomic energy and Coca-Cola plants; and of course, the swimming pool. In place of retreated businesses, there were Walmart, checkcashing and rent-to-own services, pawnshops, scrapyards, and the nation's first large pain clinic-where doctors doled out prescription for OxyContin® like ATMs, often without much diagnosis or follow-up. These clinics spread across Appalachia like fast-food franchises. By the late 2000s, pain pills were ubiquitous in central Ohio, Tennessee, Kentucky, and West Virginia and were killing more people than car accidents.

Local dealers regarded pills as a grassroots response to economic catastrophe-the way some poor Mexican villagers view drug trafficking. Dealers who could not have found a legitimate job in moribund Portsmouth bartered pills to support themselves and feed their kids.... Down in Xalisco, black tar heroin lifted sugarcane farmers to the status of local merchants (p. 218).

This phenomenon brings us to the third major piece of the system: small cells of sugarcane farm boys from the tiny Mexican town of Xalisco, Nayarit, who sold black tar heroin in tiny uninflated balloons that they carried in their mouths to U.S. addicts. As Quinones explains, the first "Xalisco Boys" of the early 1980s sold heroin predominantly in California. But the same global economic forces that led to the Rust Belt's decline also prompted the dispersion of Hispanics to new destinations across the United States in the 1990s (Kandel & Parrado 2005), allowing the Xalisco Boys to blend in and expand to small cities like Nashville, Columbus, Charlotte, and Omaha. Poverty, the desire to escape grueling farm labor, and dreams of prosperity were what brought these young rancheros to the United States in the first place. Quinones describes how inequality in Mexico was perpetuated by schools where teachers awarded affluent students with candy and restricted poor students from using the restroom. Selling heroin allowed these young men a life of their own, away from the fields. As policymakers began to catch on to painkiller addiction and pill mill shenanigans, prescription opioids became more expensive and difficult to obtain. Enter heroin. Recognizing the demand created by reductions in painkiller supplies, the Xalisco Boys headed east to take advantage of the very populations made vulnerable by OxyContin® in places ravaged by economic turbulence.

Although Dreamland is not explicitly about rural education, it is clear that rural educational opportunities (or lack thereof), perceived low returns to education in Mexico, and failure to talk about teen drug use in rural America contributed to the opiate epidemic. Prescription painkiller abuse is more prevalent among rural vs. urban teens, and rural teens view substance abuse as less risky (Monnat & Rigg 2016). Quinones' stories about rural high school football players who popped pain pills to push through injuries reminded me of scenes in the movie, Varsity Blues, where the athletic trainer injects the star quarterback with a painkiller in his knee so he can keep playing, and when Coach Kilmer tells his team: "Never show weakness. The only pain that matters is the pain you inflict." Small towns across the United States from Maine to Washington are losing teens to painkiller and heroin overdoses. The number of schools carrying the opiate reversal drug naloxone (Narcan®) has increased exponentially over the past year. I recently asked my undergraduate students to raise their hands if they personally knew someone who was using heroin in their high school. Three-quarters of them raised their hands. For rural educators and education researchers who want to understand the prevalence and roots of this problem so they can play a role in helping to reverse it, Dreamland is an essential read.

Sidebar

Citation: Monnat, S. M. (2015). Book review "Dreamland: The true tale of America's opiate epidemic." Journal of Research in Rural Education, 31(4), 1-3.

References

References

Brown, D. L, & Swanson, L. E. (Eds.). (2003). Challenges for rural America in the twenty-first century. University Park: Penn State University Press.

Kandel, W., & Parrado, E. A. (2005). Restructuring of the US meat processing industry and new Hispanic migrant destinations. Population and Development Review, 31, 447-471. doi:10.1111/j.1728-4457.2005.00079.x

Monnat, S. M., & Rigg, K. K. (2016). Examining rural/ urban differences in prescription opioid abuse among US adolescents. Journal of Rural Health, 32, 204-218. doi:10.1111/jrh.12141

National Institute on Drug Abuse. (2015). Overdose death rates. Retrieved from https://www.drugabuse.gov/ related-topics/trends-statistics/overdose-death-rates

Smith, K., & Tickamyer, A. (2011.) Economic restructuring and family well-being in rural America. University Park: Penn State University Press.