Dreamland: The True Tale of America's Opiate Epidemic, written by investigative journalist Sam Quinones, is an exploration of the causes and impact of the opioid addiction epidemic in the United States. Quinones bases his work on interviews with addicts, health care professionals, and government workers, and he arrives at the conclusion that many local and global issues—including the uniquely addictive nature of opiates, a change in medical culture, increasing economic anxiety, and greed—intermingled to cause the deaths of thousands and the addiction of millions. The following quotes explain important elements of Quinones's thesis.

Like no other particle on earth, the morphine molecule seemed to possess heaven and hell. It allowed for modern surgery, saving and improving too many lives to count. It stunted and ended too many lives to count with addiction and overdose. Discussing it, you could invoke some of humankind’s greatest cultural creations and deepest questions: Faust, Dr. Jekyll and Mr. Hyde, discussions on the fundamental nature of man and human behavior, of free will and slavery, of God and evolution. Studying the molecule you naturally wandered into questions like, Can mankind achieve happiness without pain? Would that happiness even be worth it? Can we have it all?

Quinones explains that much of the opioid crisis began with the prescription of legal opiates by licensed health care providers. Legal opiates, including oxycodone and hydrocodone, have tremendous medical value, but the active ingredient in these opiates is morphine. Though the human body can convert most drugs into glucose and then rid the body of them, Quinones notes that morphine does not function the same way: “alone in nature, the morphine molecule rebelled. It resisted being turned into glucose and it stayed in the body.” This means that many legal opiates are chemically similar to heroin and are thus very addictive. Quinones quotes a doctor he interviewed, writing,

What gave the morphine molecule its immense power, he said, was that it evolved somehow to fit, key in lock, into the receptors that all 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.

The spiral into widespread opiate addiction intensified in 1996 when Purdue Pharma released a drug named OxyContin®. Purdue Pharma aggressively marketed the drug, assuring doctors that the drug was significantly less addictive than other opioids because it had a time-release formula. But this was not the case, and it soon became clear that OxyContin® was far more potent than other painkillers. What's more, users could circumvent the time-release feature by liquefying and injecting the drug to get the full dose without having to wait. Therefore, as OxyContin® sales grew significantly during 1996 and 2010, so did overdose deaths. Once addicts could no longer afford prescription opiates, they often turned to cheap heroin:

And so it went. OxyContin® first, introduced by reps from Purdue Pharma over steak and dessert and in air-conditioned doctors’ offices. Within a few years, black tar heroin followed in tiny, uninflated balloons held in the mouths of sugarcane farm boys from Xalisco driving old Nissan Sentras to meet-ups in McDonald’s parking lots.

The passages below explore the medical culture that furthered the country’s descent into widespread opioid addiction and opioid-related deaths. Initially, many doctors addressed pain via multidisciplinary clinics through which a wide range of options (including exercise and other life changes) were used to alleviate pain.

Why, after all, was all that effort necessary if pain patients could be given pills with little risk of addiction? Patients, too, were hard to motivate when the treatment required behavior changes, such as more exercise. Pills were an easier solution. Multidisciplinary clinics began to fade. Over a thousand such clinics existed nationwide in 1998; only eighty-five were around seven years later.

However, Quinones notes that patients often held attitudes towards healthcare, in part created and upheld by physicians and Big Pharma, that made opioid over-prescription more likely:

But usually the patient says, "I come to you, the doctor. Fix me." They treat themselves like an automobile. People become believers in the philosophy that all I need is to go to my doctor and my doctor will tell me what the problem is.

Patients no longer wanted to undergo the arduous treatment plans offered by multidisciplinary care providers. Rather, they wanted a simple solution—a pill. The structure and culture of the healthcare system quickly gave way to this expectation: the number of multidisciplinary clinics reduced, and the number of pain clinics increased. This shift was exemplified in Broward County, an opioid crisis hotspot that had "four pain clinics in 2007 and 115 two years later.”

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.

A key point Quinones makes is that much of the American public, including leading politicians often respond to the opioid crisis with surprise. They feel as if the epidemic came out of nowhere. However, Quinones explains that these issues were a long time in the making and that there were many signs that there was a problem with over-prescription of and addiction to opioids in parts of the country.

He points to numerous towns that were devastated by the opioid crisis, becoming hotbeds of addiction and addiction-related deaths. Quinones explains that “the conflation of big forces: economics and marketing, poverty and prosperity” were driving factors behind the growth of the crisis. The conflation of these factors changed the traditional pattern of addiction in the United States. This new drug trade was focused on rural, forgotten areas in the United States, especially places that had been ravaged by economic instability. These communities had limited power and no real voice on the national stage, and so very little attention was paid to the high death toll they experienced.