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Dreamland: The True Tale of America's Opiate Epidemic

Sam Quinones · 8 HN comments
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Winner of the NBCC Award for General Nonfiction Named on Amazon's Best Books of the Year 2015--Michael Botticelli, U.S. Drug Czar ( Politico) Favorite Book of the Year--Angus Deaton, Nobel Prize Economics ( Bloomberg / WSJ) Best Books of 2015--Matt Bevin, Governor of Kentucky ( WSJ) Books of the's 10 Best Books of 2015-- Entertainment Weekly 's 10 Best Books of 2015 --Buzzfeed's 19 Best Nonfiction Books of 2015--The Daily Beast's Best Big Idea Books of 2015-- Seattle Times ' Best Books of 2015-- Boston Globe 's Best Books of 2015-- St. Louis Post-Dispatch 's Best Books of 2015-- The Guardian 's The Best Book We Read All Year--Audible's Best Books of 2015-- Texas Observer 's Five Books We Loved in 2015--Chicago Public Library's Best Nonfiction Books of 2015 From a small town in Mexico to the boardrooms of Big Pharma to main streets nationwide, an explosive and shocking account of addiction in the heartland of America. In 1929, in the blue-collar city of Portsmouth, Ohio, a company built a swimming pool the size of a football field; named Dreamland, it became the vital center of the community. Now, addiction has devastated Portsmouth, as it has hundreds of small rural towns and suburbs across America--addiction like no other the country has ever faced. How that happened is the riveting story of Dreamland. With a great reporter's narrative skill and the storytelling ability of a novelist, acclaimed journalist Sam Quinones weaves together two classic tales of capitalism run amok whose unintentional collision has been catastrophic. The unfettered prescribing of pain medications during the 1990s reached its peak in Purdue Pharma's campaign to market OxyContin, its new, expensive--extremely addictive--miracle painkiller. Meanwhile, a massive influx of black tar heroin--cheap, potent, and originating from one small county on Mexico's west coast, independent of any drug cartel--assaulted small town and mid-sized cities across the country, driven by a brilliant, almost unbeatable marketing and distribution system. Together these phenomena continue to lay waste to communities from Tennessee to Oregon, Indiana to New Mexico. Introducing a memorable cast of characters--pharma pioneers, young Mexican entrepreneurs, narcotics investigators, survivors, and parents--Quinones shows how these tales fit together. Dreamland is a revelatory account of the corrosive threat facing America and its heartland.
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You shouldn’t skim the article and assume things and down vote stuff you don’t know about. Sam is a friend of mine and one of the leading experts about this crisis. You should read his book dream land and not jump to conclusions. He’s dedicated a lot to this story.
Why are you angry with me for downvoting something? How would you know that? Sorry for not reading your friend's book. Never claimed to be a drug expert.
The book to read about the opioid crisis is Dreamland by Sam Quinones.

It is really well written and researched and lays out the several separate events and trends that converged to make this perfect storm happen when and where it did:

One of the big drivers in this has been the quadrupling in opioid prescriptions in the US since 1999.

Opioid pain prescriptions used to be very limited and carefully monitored because of the perceived risk of addiction. The prevailing wisdom on this danger was changed because of some low quality papers on the risk that were pushed by drug companies.

Another big driver has been a more effective opioid selling due to some Mexican drug sellers. Interestingly, these sellers are much less violent than previous opioid sellers.

These reasons are outlined in the excellent book 'Dreamland'

Long interview podcast (~1hr) with the author to listen to or read the transcript of here:

We can conjecture all we'd like, but Sam Quinones wrote a rather definitive history of the opioid epidemic in America.

Sam ran the podcast circuit awhile back if you want to listen to his story. I found out about it via Russ Roberts' Econ Talk.

The book Dreamland covers this quite a bit, and is a good read on the subject:

My takeaway was that opiates were incorrectly classified as a non-addictive way to treat pain, so doctors started dolling them out far too liberally. Hospitals also started employing pain specialists who's sole job was to treat pain in patients. It's pretty easy to find people in any sort of "pain" if that's all you're looking for.

For those interested in this topic and how the opiate epidemic has stretched across the US, read Dreamland by Sam Quinones (

There are a multitude of reasons to explain how this happened but to quickly sum up an excellent book:

- Purdue created the whole "sell-direct-to-doctor" phenomena that is now the norm in the US medical profession

- One bad study that showed opiates for pain relief are NOT addictive and this study kept being cited by sales people

- Mexican drug dealers from a very tiny area in Mexico importing black tar heroin

- A prevailing idea in the US that people should never be in pain and managing it through lifestyle changes is not acceptable; a quick fix is needed

- economic depression in the Midwest and Appalachia regions

But really, read the book. It's eye opening and well written.

I just finished reading Dreamland which I also thought was good.

This book has more of a focus on American pharma industry but still has lots of interesting insider insights.

Also excellent:

Interesting, but I just listened to Econtalk podcast[1] where the guest, author of the book Dreamland about opioid epidemic[2], claims that all this epidemy only started at first place because researchers at the time claimed that opioid based pain relief medicine was disassociated from addiction (and pharma companies gladly played along).

Except it wasnt.

Very worthy your time listening to this guy if you are interested in the topic.



+1. I found this interview highly informative about the background, scale, root causes, and complexities of opium addictions. This episode talks about -

  * What role the doctors, drug companies, and even government policies play in causing the epidemic
  * How the largest suppliers of heroin came to be, and how they compete based on customer service
  * How drug addictions can be caused by supply as much as demand.
  * In the USA, heroin overdosing now takes more lives than all homocides
EconTalk almost always has engaging discussions, and this interview is no exception.
In the USA, heroin overdosing now takes more lives than all homocides

I'd been hearing about the heroin epidemic for years. I saw articles about needles in Golden Gate park, I saw discarded needles and black-lit[1] restrooms in Vancouver, but it didn't really have weight until I read that 30,092 people died of opioid overdoses in 2015. In the US alone. Over 30,000!

Anyway, I'm just writing this on the off chance that there are others who are still blissfully unaware.

[1] black light makes it difficult to locate a vein for shooting up.

The last section of the article (title "A Dose of Caution") covers exactly this. Shouldn't get too excited just yet.
> researchers at the time claimed that opioid based pain relief medicine was disassociated from addiction

They're mostly right if they're talking about acute pain - post operative pain, for example.

>(and pharma companies gladly paid along).
You have to remember like everything, beliefs around addiction to pain medication ebbs and flows over time.

I can remember back in the late 1990s, there was a huge push from the medical community to be more open about prescribing pain medication. A lot of pain wasn't being adequately treated.

As a result, doctors loosened their reigns over prescribing and things moved drastically in the opposite direction. People were getting strong narcotics for pain that they never would have gotten it for in the past.

As a result, we have a huge upswing in addiction.

My concern is that we're now going to swing back the other way and people will get hurt. There are people out there where narcotics are the only thing that works for their pain. Sometimes they need a lot of them as well, we're talking hundreds of milligrams of morphine per day. They will have physical withdrawal symptoms if they were to stop, but they aren't addicted in the way we think. They don't exhibit "drug seeking" behavior.

I'm worried folks like this will get cutoff and have to live a life in terrible pain. All because other patients get addicted.

My girlfriend is in exactly this situation. She has terminal pain from a Whipple and every step of the way the onus is on her to provide evidence that she isn't a drug-seeker. And there are not clear success criterion. Pharmacists can (and have) arbitrarily decide not to fill her prescription, leaving her without pain meds suddenly and unexpectedly (ie baseline pain returns + withdrawal symptoms).

Illinois won't allow sending pain scripts any more, so we have to go to the hospital to pick it up every month. They won't allow you to fill it more than a single day before you need it, and many pharmacies won't have the total number of pills prescribed in stock. If you accept a partial fill - you forego the remainder. Getting the doctors AND insurance (either of which will likely block it) to understand you had to do a partial fill and thus issue your refill before 30 days is a Sisyphean task.

All this means if the pharmacy at the hospital doesn't have enough Morphine on hand to fill her one month description the day we pick it up - we have 24 hours to play Pharmacy Whack-a-mole trying to find one that both does have enough pills and won't just arbitrarily decide to say no. Even better - while sometimes you can call ahead and ask, often they are afraid you are probing for large supplies with intent to rob them, so they won't always tell you if they have it in stock.

It's a huge pain in the ass with multiple able-bodied family members in her corner. I can't even fucking imagine how torturous this whole process is for someone in her situation without that kind of help.

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