Dealers and Doctors in ‘Dreamland’: The True Cause of America’s Opioid Epidemic

Sam Quinones’ Dreamland uncovers the misguided values and cultural ideals of America and explores how those values manifested themselves in the medical and pharmaceutical industries unleashing the current opioid crisis America currently finds itself in. Quinones pieces together the evolution of the country’s relationship with the morphine molecule and shows how that relationship changed as a consequence of its commercial and recreational use. He ties together the influence of the medical industry, pharmaceutical industry, and illicit drug market to reveal a broken system fueled by profit that caused a chain reaction resulting in an addiction problem unlike any other before seen in the US. Ultimately Quinones shows that drugs have been a part of our society for years and will continue to be for years to come and that when the institutions set in place to control the relationship between drugs and society are misguided it produces extreme consequences for the rest of the population. That is to make a larger point that the focus of institutions like the medical industry is to solve the underlying issues of the problems we face, not treat the effects for profit.

Quinones continually draws on a shift in opinion on opioids role in pain treatment that occurred in the medical field during the 20 years leading up to the 2000’s as the catalyst of the entire opioid crisis. Originally opioids were only used to treat acute pain such as in cancer patients or patients with other types of terminal illness. It was a ubiquitously held belief that opiate painkillers had significant risk of addiction associated with them and therefore their use should be restricted as much as possible. This all changed when Russel Portenoy and Kathy Foley published a paper based on their observations of opiate treatment in their cancer patients that found that only 2 of 38 patients became addicted, further contending that opiates were not inherently addictive (Quinones 92). They additionally started what would be a major problem with the entire pain crusader movement when they cited a 1980 letter from Dr. Hershel Jick to The New England Journal of Medicine as evidence that less than 1 percent of patients became addicted to opiates after treatment, although it was not research based evidence at all but instead just observations Dr. Jick had made from unofficial data he had gathered from a hospital. At first this idea received heavy pushback but eventually Portenoy started to gain support and gradually the entire medical field began to push a narrative that opioids carried extremely low chances of addiction when treating pain and should be used to treat chronic pains of all kinds, not just acute pain. This concept shifted the entire landscape of American medicine.

The idea that for all this time doctors had been significantly undertreating pain because they lacked the necessary technology to properly treat it took the field by storm and prescription opiates were the revolutionary solution they had been waiting for now that they had ‘evidence’ that they were not addictive. Pain undertreatment became the core focus of medicine going so far as to be “identified as a public health problem”(Quinones 197). It became ‘a fifth vital sign’ in evaluating a patient’s health and doctors were judged based on how well they treated pain which essentially meant forcing them to prescribe opiates. The pain crusade as the movement came to be called was described as “a revolution in medical thought” that was integrated into the entire system with “Interns and residents [being] taught that these drugs were now not addictive, that doctors had a mission, a duty, to use them”, the problem was that entire philosophy was based on absolutely zero credible research or scientific fact (Quinones 95). This was a turning point in the story of opiates in America because as pain came to the forefront of medicine and the population began to believe they had an inherent right to be pain free, the amount of opioids being consumed by Americans skyrocketed while insurance companies simultaneously began to stop funding the other holistic aspects of pain treatment like diet and mental health, essentially making prescription pills the only option for doctors. This created a massive opportunity for the pharmaceutical industry to expand into new markets eventually generating billions in sales revenue across the US they never would have had access to without the shift in pain treatment. A crucial component to that expansion was the fact that these ideas were coming from the top minds in medicine and pain management specialists which gave credibility to the false marketing claims Purdue used to create an empire and cause over 7 million Americans to abuse painkillers along the way.

Looking to bring their new product OxyContin to market, Purdue was quietly funding this new ideological shift on pain management. They provided capital for organizations like the “American Pain Foundation that promoted the use of opiates for both chronic and acute pain” and hosted medical conferences featuring speakers like Robert Portenoy (Quinones 137). All of this allowed them to create incredibly high demand in these new markets, positioning their product as a risk free, cure all option for pain. The major selling point for OxyContin that became the basis of their marketing campaign was that patients only had to take two pills a day instead of one every 4 hours and unlike existing painkillers, OxyContin contained a slow release formula that they said reduced the highs of the euphoria and lows of the depression, making it significantly less likely to be addictive. In a later federal investigation using Purdue documents, investigators proved these to be false claims that Purdue knowingly still marketed.

Despite Purdue management being keenly aware of these flaws, they still drilled into their salesforce during training to go after doctors telling them OxyContin was non-addictive, citing the Jick less than 1 percent ‘research’. “The company aimed to convince doctors to aggressively treat noncancer pain, and prescribe OxyContin for moderate pain lasting for more than a few days.” (Quinones 127). The tactics worked, and OxyContin became the primary prescription for pain management of all levels. However, patients began returning to doctors to refill their prescription well before the scheduled date. This meant that the drug was not lasting its promised 12-hour duration, leaving patients experiencing withdrawal symptoms, now hooked and needing more. Purdue all but publicly supported this addiction, as Quinones points out they preyed upon areas with widespread addiction, heavily marketing to doctors who prescribed the highest number of pills. “Some Purdue reps- particularly in southern Ohio, eastern Kentucky, and other areas first afflicted with rampant addiction—were reported to have made as much as a hundred thousand dollars in bonuses.” (Quinones 134. This theme becomes crucial to understanding the opioid crisis because as Purdue capitalized on addiction in those poor areas they spread OxyContin to wealthier areas to cover the cost of their addictions. Heroin traffickers like the Xalisco boys learned to target heavy pill markets to introduce their product, so as Purdue spread pill addiction in these areas they created a foothold for heroin markets which resulted in an exponential increase of overdoses. Inadvertently, the OxyContin epidemic spread by Purdue caused the country’s problem with black tar heroin.

Following his explanation of OxyContin’s spread, Quinones makes an interesting point talking about Purdue sales reps whose bonuses “bore a striking similarity to the kinds of profits made in the underground” (Quinones 134). He draws a parallel between Purdue and the Xalisco boys through the entirety of the book. By doing this Quinones is shedding light on how differently Americans view a company like Purdue and OxyContin in comparison to heroin and the Mexican dealers. The Xalisco boys were essentially just a smaller competitor in the same market as Purdue. They produce virtually the same product except Purdue makes billions from OxyContin while also marketing and advertising their product to get more people on it. Purdue played an equally responsible if not larger role in the opioid crisis and are just as responsible for the deaths of the people who had to switch to heroin because they got hooked on OxyContin. Yet Purdue’s product is essentially subsidized by the federal government in the form of Medicare, is protected with a federal patent, and is distributed through federally funded clinics in some cases. While the Xalisco’s received the opposite, federal funds used to stop them from selling their product with law enforcement. This is not to make the point that they should be able to sell heroin, they absolutely should not. Rather, it points out an ongoing historical trend of demonizing minority or immigrant groups that in this case took most of the blame for the increase in overdoses in most American’s minds.

What Quinones really helps to understand about drugs in contemporary America through his journalism is that when the association of drugs with minorities, gangs, and violence is taken away, people start to realize that they are not the problem but oftentimes a scapegoat. It is the relationship we have with drugs and the way our institutions approach drugs that is creating a large part of the issue. As a reader, one is forced to question trusting things like the war on drugs when that same government approved and continues to approve a schedule 2 narcotic to be mass distributed.