Medical Program: Dreamland: The True Tale of America's Opiate Epidemic

Dr. Russell:
Opiate use and abuse is one of our most pressing epidemics in the United States today.  What factors have led to its start?  Welcome to ReachMD Book Club.  I’m your host, Dr. John Russell, and I’m joined today by author Sam Quinones, discussing his book, Dreamland: The True Story of America’s Opiate Epidemic.  Sam, thanks for joining me on the show today.

Mr. Quinones:
You’re very welcome.  I really appreciate the time.

Dr. Russell:
So, where does the title of your book come from?

Mr. Quinones:
Dreamland comes from a swimming pool that once existed in a small town called Portsmouth, Ohio, on the Ohio River, southern Ohio, which was once a town of great, kind of lithiated, all-American town really and all the steel factory and shoe factories, everybody employed, bustling Main Street, 50,000 population, and kind of at the center of life was this enormous football-field-sized swimming pool we called Dreamland where everybody went.  And it was a place where you kind of grew up in public and everybody watched over all the kids and made sure no one was misbehaving, and it was a place where community was essentially created and recreated over and over and over, for generations really.  And then the town fell apart as the Rust Belt phenomenon took hold, and the steel factory left, the shoe factories began to close, the Main Street couldn’t hold on, it emptied out, and so did the town.  Population cut in half.  Eventually, Dreamland could no longer be sustained, and in 1993 they closed the pool, dug it up, destroyed it, and it is now a big parking lot and a strip mall. But to me, I used it as a metaphor, frankly, to put what I believe is at the root of this whole opiate addiction epidemic, which is really a destruction of community, a destruction of ways in which we come together and be together as neighbors, as community, as townspeople, as people in the same region, what have you.  So, it’s kind of what we’ve done to community across the country is what happened to Dreamland in Portsmouth,Ohio, destroyed it, hadn’t invested in it, allowed it to wither, allowed it to be depleted, a variety of things all across the country, in wealthy areas as well as less-developed areas and poor areas.  It’s not an economic story.  It’s really a story about what we did to community, and that by destroying community, it left us very vulnerable to the most isolating of all the drugs that we know as a species, the opiate class of drugs, and allowed us to more easily be devastated by their spread.  And I chose it as the title because I think this is what we’ve done.  We destroyed Dreamland.  And what you get when you destroy Dreamland, that place where everyone kind of comes together for better or for worse… It’s not perfect, but it’s a place where people come together to commune, and what you get when you destroy that is heroin. 

Dr. Russell:
So, how do opiates show up in Portsmouth?

Mr. Quinones:
This is all part of a much larger story, of course, which has to do with the revolution in pain management that took place.  It seems to be really in the 1980’s, but in the 1990’s is when it really got going and developed enormous momentum in which it was held by pain specialists and pharmaceutical companies that pain killers were now known, by science, to be virtually nonaddictive when used to treat pain.  Actually, science knew nothing of the kind, but that was the claim, that virtually nobody who was a pain patient would get addicted if treated with these drugs.  And what’s more, therefore, a very dangerous corollary grew out of that was that if they’re nonaddictive, then eventually it became—the thought was, “Well, it doesn’t matter how many of these things we prescribe.”  So, an enormous new blast sustained over decades of opiate pain killers was unleashed on the country and from coast to coast because of doctors, in general, who were buying into this idea, either eagerly, as was the case, or very hesitantly and reluctantly.  A lot of doctors had to be pushed to do this.  There was a lot of pressure on doctors to get behind this idea that now patients’ pain needed to be treated very aggressively, and that meant with narcotic pain killers like Vicodin, Percocet, and then later, of course, OxyContin.  Portsmouth is important in this story because that pain revolution created, at its extremes, pain clinics in which there really was no pain diagnosis going on, no pain medicine being practiced.  Really, it was more like just simply a get in line to get a prescription.  They were called pill mills, and the place where the pill mill was literally invented as a business model was in Portsmouth, Ohio, where one doc kind of figured this out.  And they began to hire a bunch of other docs to run the clinics for them, and they began to branch off and eventually form their own clinics, and in time, the pill mill—where people just line up and go through some façade, some charade of pain diagnosis for 2 minutes or 3 minutes at the most and then come away really with what they’re looking for, which is a large, a very long prescription, that they then have to find a pharmacy to fill—that business model began to spread, and it started in Portsmouth.  It spread throughout the Appalachian area, through the rust belt, then to many other parts of the country.  But Portsmouth is important in this story because it was the place where the far extreme of the pain revolution in modern medicine took hold in the form of a pill mill.

Dr. Russell:
So, one of the things that I think was amazing in the book was kind of the New England Journal… So, there was a letter to the editor in the New England Journal that people tried to quote this like it was a study.  I want to talk about that.

Mr. Quinones:
These pain specialists began to make the claim, wanted very much to change doctors’ way of thinking about narcotics and how properly to use narcotics in pain treatment, believing the doctors were way too reluctant to use these pills; and in fact, I think in some regards they were correct.  They certainly were uses to hospice care, dying/terminal cancer patients, and so on where these pills had very, very legitimate uses.  In order to get doctors to get behind these ideas, they began to push the idea that said that these pills were now known to be virtually nonaddictive.  They had no science to back that, no documentation, so they looked about for evidence of any kind that they could possibly find, and one thing they find is that the letter written several years before, 1980, and published in the New England Journal of Medicine, the back of the book in the Letters to the Editor section, in which a doctor in Boston, Dr. Hershel Jick, who runs a database of patient-hospital records said, “I checked my records”— by that time I think it was 300,000 records, roughly—“and I found that of all of the patients, 11,000 of those patients received narcotics while in hospital, and 4 of those 11,000+ got addicted.”  And they published this…  He writes this letter.  It’s a hundred words long.  It’s just a paragraph is all it is, no study, nothing of the kind, just as kind of a FYI—by the way, this is what we noticed.  And he turns that and they publish it in the New England Journal of Medicine early in January 1980 under the heading, “Addiction Rare in Patients Treated with Narcotics.”  Unfortunately, as far as a headline, it makes no mention of the fact that these are all patients in hospital, that no one has taken big, big bottles of these pills home with them.  But, nevertheless, this is taken as gospel, as evidence at first that this might be the case, that maybe we don’t need to be as scared of these little pills as we have been.  And then in time though it gets quoted and requoted and footnoted.  Nobody actually reads it. Nevertheless, it’s quoted in the scientific press first as a report and then a study, and then it’s a landmark point, and eventually, it becomes transformed into a landmark…  Time Magazine in 2001 called it, “A landmark study that does much to change what we know about pain pill addiction,” da-da-da-da-da, total nonsense.  It was totally taken out of context, because Dr. Jick was correct.  If you use these pills in a very controlled setting, as was the case with the people in his hospital records where the doctor is overseeing the administration of this pill to this one patient, and then maybe a day later the patient would get another one, but nobody’s taking any of these pills home, there’s strict scrutiny and control, then yes—when the supply is deeply, deeply controlled, then yes, you will not get lots of addiction.  But it was misinterpreted to mean it doesn’t matter now.  We now know, “Oh, everything’s fine.”  And, of course, the pharmaceutical companies use this in all their promotions.  Purdue Pharma, which makes OxyContin, used the message of what this letter was taken to mean, which was, again, a misinterpretation completely, and ran with it and used it in all their promotions and stuff.  “Oh, finally we know when used to treat pain, these pills will not create addiction.” And the result of all of this was catastrophic because, first of all, people do get addicted the longer they are exposed to these pills, so if it’s 30 days, 60, 90 days, after a while the risk of serious addiction grows, but also what grows from that is that, as I said, this idea that we could therefore get away with prescribing these pills wantonly, indiscriminately.  And the enormous new supply that grows out of the idea that it doesn’t matter how many of these pills you prescribe because we now know that they’re virtually nonaddictive when used to treat pain creates an enormous supply and creates with it a big black market and creates huge amounts of addiction, catastrophic amounts of addiction across the country, based on what really was a letter to the editor.

Dr. Russell:
If you’re just tuning in, welcome to ReachMD Book Club.  I’m joined today by author Sam Quinones of the national book award-winning Dreamland:  The True Tale of America’s Opiate Epidemic. I thought it was very interesting when you talked about opiates becoming a currency in parts of the middle part of the country that people were—I would get some diapers for an Oxy, and people kind of trading back and forth.

Mr. Quinones:
Yes, that happened in Portsmouth, particularly.  It happened because in those towns, Rust Belt towns, towns that were really suffering economically had been kind of shredded.  This feeling of community had been shredded.  The jobs had gone.  Half the population had gone.  Buildings were abandoned.  There was this feeling of dread like you never knew what was coming next, and everyone kind of retreated indoors.  People were not outside.  And these pills, indeed, proved to be perfect currency, particularly because they were in areas where the supply—the money supply, if you like—was unstinting.  It was provided by the pill mills, and so you had this huge amount of pills circulating, and these pills proved to be almost as good as metallic currency in that they don’t dissolve, they don’t lose their value, they all have on the pills marked the denomination, so 5 mg, 10 mg, 20, 40, 80, whatever it happens to be; and meanwhile, you have lots and lots of people getting addicted, and that means the only value that you really have… Cash doesn’t have much value, only in the extent in which it can get you your dope for the day, and so the pills became currency. Along with that… Very important to understand though that along with that, addicts really had a very limited choice in what they could do to get their daily habit.  You could deal dope, and a lot of them did.  You could steal from family, and a lot of them did, but that lasted a very short period of time until the family got wise.  But a lot of people used Walmart.  Walmart had taken—sucked up all of Main Street in town after town after town, and all that stuff that used to be sold on Main Street, which were meat, shoes, hardware, on and on, things like that, all of that was sucked up and regurgitated onto the floor of Walmart in kind of a very easy one-stop shopping.  Buy pretty much anything you need for life at Walmart.  But that also meant that one-stop shopping meant also one-stop shoplifting, and particularly easy to do when you have employees who really are not that wedded to their job because they’re paid pretty poorly, 9 bucks an hour.  Some of those greeters are like 70 years old, and these are young addicts stealing stuff.  And so, Walmart provided the stuff, the things that you could steal that you could then sell or trade, frequently trade for pills.  And so the whole thing created this economy of OxyContin economy where you could trade pills, live basically on pills and buy things that you needed with pills, and that’s largely because of how the towns had been denuded in that area.  I’m referring to not across the country but in that area you found places that just didn’t have many other retail opportunities, didn’t have many other economic opportunities, so Walmart became it.

Dr. Russell:
So, it set up a perfect storm for heroin to show up, correct?

Mr. Quinones:
Yes, correct, Most of our heroin used to come from the Far East, used to come, therefore, across 2 continents, would get to New York.  New York, it would funnel out to other parts of the country.  Virtually, most of the Eastern United States would get it from New York.  Mexico was providing some but at relatively limited amounts into the Western United States.  But nevertheless, most of our heroin was coming from the Far East and was getting here very expensive and very weak because it had a long way to go, changed a lot of hands, had to cross an ocean, etc., etc. Well, in the 1980s, all of that changed.  The Columbian cartels, the Mexicans were coming up.  They weren’t quite good with script medication Columbians but they were getting there, and these 2 groups brought in other drugs:  marijuana, cocaine, but along with that they brought heroin. That’s a big part of the book Dreamland that I wrote, is talking about this one group coming in who figures this out.  The reason I write about this one group from a town of Jalisco, Nayarit, is not because they’re the only heroin traffickers from Mexico, but really because they have this very wild system of selling heroin retail—which rarely do you find Mexican trafficking groups involved in; it’s mostly wholesale—delivering it like pizza, kind of, in a very convenient-oriented system.  

Dr. Russell:
The delivery system was really amazing.  So, in the 1970s, if you wanted to get heroin, you went to the bad part of town in some city.  You were getting heroin that maybe came through the Mafia and things like that.  And suddenly it changes that someone’s meeting you in the Walmart parking lot, correct?

Mr. Quinones:
Yes, heroin is, in fact, one of the easiest things for cops to bust because heroin dealers tended to be stationary, so you’d be in a bar or a motel room or a house or skid row, none of the places where you, as a buyer, would want to ever go, but you had to every day.  But it’s very easy to bust you there and bust the dealer too, because it just was a drug thatdid not havea lot of innovation applied to it, honestly.  And then these guys come along with a system in which you have… It worked because it provided addicts something very, very crucial in the addict market, which is a reliability.  The biggest question the addict has every day is:  Where am I going to get my dope today?  And if it’s as easy as calling a number and then driving a half mile to the Burger King parking lot and waiting, it’s a whole lot easier than going to some seedy motel, some guy you don’t know if he is going to rip you off, don’t know what the quality is.  These guys provided reliability, they provided convenience, and they provided accountability, so if you got ripped off or your driver was way late or the dope was bad, primarily if the dope was bad, you had also a customer service number you could call. 

Dr. Russell:
So, we’re some years later, and hopefully we in medicine are a little bit smarter about what we’re writing prescriptions for.  I think we’re talking about 3-5 days before someone can start developing some addiction, so I think, probably, hopefully the medicines that are coming from medicine are decreasing, but I think we’re only seeing kind of deaths increasing as more and more people are turning to heroin, correct?

Mr. Quinones:
Exactly.  No, what’s happened is doctors have become more—let’s use the term judicious, I would say.  I think that‘s probably the case.  In some cases it’s more than judicious.  In some cases it’s saying, “I’m not prescribing anymore.”  See, that to me is also a huge mistake.  We have a lot of people out there, first of all, who do have chronic pain.  They may need these pills.  They may not need as much as they’re taking, but they need to be worked with.  And also, that’s where insurance companies come in.  They need to be… Now, one of the most important things to confront this problem is that insurance companies, once again, need to get onboard and start reimbursing for pain strategies and therapies that do not involve narcotics—because doctors increasingly have 2 choices.  It’s a very, very bad choice.  A person whose dose is elevated to 6– 8–, 900 mg a day comes in.  The doctor’s choice is:  I could cut you off, which means that patient could go right to the black market, very dangerous, very cruel, completely counterproductive from a societal standpoint, of course, because you’re feeding the black market, or I can keep on giving you all these pills. Instead, what I believe needs to happen is we need to see insurance companies lobbied, pressured, pushed to once again, as a class, reimburse for pain strategies so that the doctor actually says, “Well, we can continue you on this for a bit, but I’ve got a bunch of other things I’d like to start trying with you: marital counseling, job therapy, physical therapy, swimming, diet, acupuncture, Tai Chi, on and on and on and on.  All of those things need tried before on one patient and a kind of a recipe, a kind of a smorgasbord idea—like we’ll try all these different things together on 1 patient.  All of that went the way of the dinosaurs.  I mean, these are the turn...  It’s actually a very effective way of long-term treating chronic pain. But over and over you’re seeing, yes, hospitals, health systems, doctors in general, questioning how many of these pills, particularly, I would say, after surgery.  Routine surgeries, I believe it’s something on the order of 50 million routine surgeries in America every year.  People were naturally just given 30 days’ worth of pain pills—in my case, for an appendix operation say.  Pain of the appendix operation cutting me open was going to last 3, maybe 4 days.  I got 30 days’ worth of pills.  I have no doubt that I could have had, if I asked for it, a refill and maybe 2 refills, so that would be 90 days’ worth of very addictive narcotics for a pain that lasts 3 days.  That’s insane, and that’s what we need to get away from in a big way.  We need to reassess how we prescribe and to whom and in what quantity following a routine surgery. I would say one of the biggest problems honestly right now is—in an anecdotal sense I’ll say—I’ve heard over and over is wisdom tooth extraction.  My God, the number of people, mostly young people, getting their wisdom teeth out…  Five million people get their wisdom teeth out every year according to the American Dental Association.  Well, most of those folks are coming home with big bottles, 30 days, 60 days, whatever it happens to be.  It’s just a ridiculous amount of pills for pain that probably… I’m no dentist.  I try to be humble when it comes to this stuff, but I’ve heard too many people say, “Ibuprofen was enough for me.”

Dr. Russell:
And the book is Dreamland: The True Tale of America’s Opiate Epidemic, I think a must-read for anyone who is practicing medicine in the United States today.  Sam, thank you so much for being on the show.

Mr. Quinones:
Great to be with you.  Thanks so much for taking the time.  I really appreciate it.

Dr. Russell:
This is Dr. John Russell. You’ve been listening to ReachMD Book Club.  To download this program or others in this series, please visit ReachMD.com.  Thanks again for listening.