Last Updated September 5, 2023.
Dreamland: The True Tale of America's Opiate Epidemic was written by Sam Quinones. Quinones, an investigative journalist, interviewed a wide range of people with direct connections to the opioid crisis, including incarcerated heroin dealers, addicts and their families, healthcare workers, police officers, and government workers. Dreamland shows that the opioid crisis began with the overprescription of opiates. This overprescription, with very little medical supervision, led many patients to become addicted to opiates and gave people who were not being prescribed opiates access to the drugs. As people became addicted, their tolerance grew, and consequently, these addicts needed cheaper and larger amounts of opiates. Around the same time, a network of dealers from Xalisco, in southwestern Mexico, began producing and distributing a cheap form of heroin known as “black tar.” This group strategically moved into areas where addiction was running rampant, including affluent mid-sized towns and suburbs as well as some parts of Appalachia. These areas’ pre-existing prescription opiate addictions combined with access to cheap opiates to contribute to an epidemic that has resulted in the addiction and death of millions of Americans.
A Crisis Fueled by Financial Gain
In Dreamland, Quinones explains how the opioid crisis was fueled by financial motives. Quinones consistently notes that many different groups of people reaped enormous financial benefits from the crisis. At the highest levels, big pharmaceutical companies profited tremendously from the reckless prescription of opiates. For instance, Purdue Pharma, the producer of OxyContin®—the main drug that was overprescribed and led to addictions—more than quadrupled their revenue in a matter of years. They engaged in an aggressive marketing campaign, urging physicians to prescribe the drug. Quinones writes that Phillip Prior, a doctor in Ohio, stated about heroin addicts, “I’ve yet to find one who didn’t start with OxyContin®.” Prior continued,
They [drug dealers] wouldn’t be selling this quantity of heroin on the street right now if they [Purdue Pharma] hadn’t made these decisions in the boardroom.
Many doctors began spreading the message that opiates like OxyContin® were a safe way to deal with pain. While some doctors truly wanted to help patients, others were motivated by greed. Quinones notes that the result was that, within a few years, “opiate use in medicine had been destigmatized by crusading doctors.” Many unscrupulous doctors began to charge cash for opioids. Others prescribed opiates in order to assist patients in committing fraud in order to obtain social security disability benefits. Many of these patients lived in regions that had suffered huge economic losses and offered few, if any, jobs. Therefore, disability benefits were seen as a means to survive. Some pharmaceutical companies were aware of this desperation and capitalized on it. For instance, Purdue Pharma routinely guided sales reps to focus on physicians in areas where opioid prescriptions were being issued to aid disability cases.
With this abundance of pills circulating and numerous addicts in need, a middleman market arose, through which many people sold opiates at inflated prices, seemingly unbothered by the devastating harm the pills caused. Finally, as the addiction grew increasingly rampant, drug dealers from Xalisco, in an attempt to escape the poverty of that region of Mexico, began to exploit the addiction crisis by dealing black tar heroin in these communities. Quinones writes,
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.
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one Xalisco immigrant said to another, “I can supply all the dope you need. We could get rich like you wouldn’t believe.”
A New Kind of Epidemic
Quinones details the ways in which the opioid epidemic spread in a very different way than past drug influxes and addictions spread in the United States, allowing the crisis to fester and grow—unchecked by law enforcement—for years. First, the addiction epidemic started with legal prescriptions. Second, the most flagrantly illegal part of the crisis, the influx of cheap heroin, was managed in a different way from other drugs. These drugs were sold in very small quantities. The Xalisco dealers used what Quinones refers to as a “pizza-delivery” style; these dealers did not operate out of seedy, crime-infested locations, but rather delivered their goods to their customers. Quinones writes,
The operator would take phone orders from addicts, and drivers would then deliver black tar to the addicts at prearranged meeting points. The “Xalisco boys” completely eschewed violence, drove unremarkable cars, kept their heroin supplies small, and were paid a wage by the cell manager. With this system, they long remained under the radar of law enforcement.
Xalisco traffickers avoided large cities and other areas where heroin was historically sold. They had also found a new market: affluent white customers. For instance, in Tennessee, Quinones writes,
Most of the new Tennessee junkies come from the white middle and upper-middle classes, and from the state’s white rural heartland—people who vote for, donate to, live near, do business with, or are related to the majority of Tennessee legislators.
These groups of people had not traditionally been the focus of drug investigations, so for years, they were able to carry out their drug purchases without attracting police attention.
The Role of Youth in Opioid Addiction
Dreamland explores how young many opioid addicts are, and Quinones suggests that some elements of the crisis may be directly linked to the relative youth and naivete of the addicts. Quinones writes,
Black tar, once it came to an area where OxyContin® had already tenderized the terrain, sold not to tapped-out old junkies but to younger kids, many from the suburbs, most of whom had money and all of whom were white.
Quinones explains that black tar dealers envisioned correctly that these addicts would easily transition from OxyContin® to heroin. Quinones explains how these users’ youth contributes in part to their susceptibility. One teenage addict told him, “You’re as much addicted to going and buying it as to going and using it.” The adventure of purchasing the drug and interacting with people they might not have normally met was a source of excitement for these young people.
Quinones notes that young athletes were also swept up in the epidemic as they tried to reach their athletic goals. Many high school and college football players in opioid crisis hotbeds initially started using prescription opiates to help them play through injuries without fully appreciating the enormous risk they were taking. Many of these young athletes quickly transitioned to heroin, and unfortunately, a large number of them died.
Reflecting on the role youth plays in the ubiquity of the crisis, Quinones writes,
The front of the brain has to develop through mistakes. But the first reaction of the addicted person is to head back to the family: “Will you rescue me?” Whatever the person’s rescued from, there’s no learning. There’s no experiences, no frontal brain development. They’re doing well and then some idea comes into their head and they’re off a cliff. It may not be a decision to use. Most relapse comes not from the craving for the drug. It comes from this whole other level of unmanageability, putting myself in compromising situations, or being dishonest, being lazy—being a fifteen-year-old.