Dreamland: The True Tale of America’s Opiate Epidemic

Quinones opens this section with a description of a young Mexican named Enrique who used a fake US ID to cross into Arizona, miles away from a childhood of poverty in a Mexican village in the state of Nayarit. Enrique’s route out of this poverty was heroin trafficking. From here, Quinones moves on to describe a doctor named Hershel Jick at Boston University, who in 1979 began a database recording the number of people prescribed painkillers who became addicted to the drugs. His findings were simple: “of almost twelve thousand patients treated with opiates while in a hospital before 1979, and whose records were in the Boston database, only four had grown addicted” (16).

Having set up these two contrasting players in the opiate epidemic, Quinones describes another setting, a small, declining West Virginia town called Huntington, which had shrunk and grown poorer in the 21st century. With low immigration and few jobs, the town’s Mexican population was small; therefore, Mexican drug traffickers did not operate in town. That leaves Quinones asking how to explain the presence of Mexican black tar heroin in Huntington, an outbreak that led to several overdose deaths in 2007. This question leads Quinones to discover a Ranchero—a term to describe isolated Mexican villages where residents mostly focus on one trade—that produced traffickers of black tar heroin who had spread across the United States. Specifically, they were from a town called Xalisco. As a police officer named Danny Chavez tells Quinones, this successful system had spread across the United States. Chavez says, “I call them the Xalisco Boys […] They’re nationwide” (46). One of these boys is Enrique, who we met at the beginning of the section. With his uncle’s help, Enrique crossed the border to traffic black tar heroin in Los Angeles.

In this section Quinones also describes the arrival of Dr. David Procter in South Shore, across the Ohio River from Portsmouth. Procter’s arrival coincided with the decline of Portsmouth, as factories and other industrial sites closed and families moved elsewhere. Procter processed worker’s compensation paperwork for many people in the area and helped them get disability; he also wrote many prescriptions for opiates. Quinones traces the popularity of these opiates back to Arthur Sackler, who pioneered direct pharmaceutical advertising to doctors to encourage them to write prescriptions. One of these drugs was a tranquilizer called Valium, “the industry’s first billion-dollar drug” (31). Decades later, his company Purdue would use the same strategy to market opiates.

This section opens with a description of the poppy, which was known to humans as far back as the ancient Sumerian civilization. The ancient Egyptians were the first to use opium, which is made from the poppy, as a drug, while in the 19th century, the soporific element in opium was isolated and named morphine. Nineteenth-century wars led to thousands of morphine-addicted soldiers; meanwhile, patent medicines containing opium were marketed to the public, including for children. The addictive properties of morphine led researchers to search for alternatives, which led to the development of heroin in the late 19th century. Though initially prescribed for everything from diarrhea to menstrual cramps, it was soon outlawed, and addicts were stigmatized. Gangs, in turn, formed to sell heroin, which they marketed to differentiate their product from rival gangs. The fact that addicts had no choice about whether to use heroin made it an ideal commodity around which gangs could build their business models.

With black tar heroin, the gang was the Xalisco Boys, many of whom were from the Tejeda clan, whose parents had farmed sugarcane and were wealthy by Xalisco standards, but who were looking for an easier way to make a living. Xalisco Boys like David Tejeda started selling black tar heroin in Los Angeles and quickly expanded across the US. In this expansion they were helped by addicts themselves, who aided them in setting up markets in towns where the Xalisco Boys had no existing connections. These addicts also helped the Xalisco Boys navigate methadone clinics, which were established in the 1970s to help people struggling with addiction to opiates, but which had become, through mismanagement, a source of a population vulnerable to the lure of street heroin. The Xalisco Boys “discovered that methadone clinics were, in effect, game preserves” (64). Gang members hung around clinics looking for potential clients and then used these clients to drum up more business.

Quinones then describes, through the experience of Allan Levine, a heroin addict who spent much of his life in Portland, another way in which the Xalisco Boys cultivated customers. Unlike Levine’s prior experience of having to hobble on prosthetic limbs to find drugs, the Xalisco Boys brought potent heroin to his door. This approach prompted Levine to reflect that the Xalisco Boys’ solicitous approach to customers was part of their successful marketing scheme.

Quinones closes this section with another description of Enrique who, having failed to make headway with his uncles in the San Fernando Valley, returned home to Nayarit and was working in the sugar cane fields, despairing at ever having another chance to leave.

Quinones introduces the Federal Medical Centre, otherwise known as the Narcotic Farm, a prison and treatment center that opened in 1935 and hosted famous writers and musicians like William Burroughs and Chet Baker as well as thousands of addicts who were convicted of crimes. The Narcotic Farm also had an important role in history for another reason: It was the testing ground in scientists’ search for the holy grail of pain research, a nonaddictive painkiller that could replace heroin. The treatment center was eventually shut down without the grail being found, but results of research at that facility spurred researchers’ hopes that they’d find it someday.

Meanwhile, doctors’ attitudes toward treating pain were evolving as well. In the United States the history of morphine and heroin had made doctors wary of opiates. But these fears were assuaged by organizations like the World Health Organization (WHO), which developed a pain-management ladder to guide practitioners in providing opiates for pain that nonopiates did not assuage. WHO also proclaimed freedom from pain as a human right; as a result, opiate use rose “thirtyfold between 1980 and 2011” (82). Morphine use climbed most in developed countries, as it was used not just for pain following surgery or disease but also for everyday suffering such as bad backs and knees.

Against this pharmaceutical model, Quinones contrasts the pain clinics started by anesthesiologist John Bonica in the mid-20th century. These clinics brought together specialists from as many as 14 disciplines to treat pain, including with exercise and diet. These strategies did not completely relieve pain, and much of the work had to be done by the patient—an approach that some patients resisted. Insurance companies were also unwilling to provide funding, with the result that “doctors were increasingly deprived of some crucial tools to treat pain just as patients were taught to believe that they had a right to pain relief” (88). Meanwhile, doctors in the 1980s and ’90s, buoyed by new medications—and a belief that pain limited the euphoric effects of opiates, making them less addictive—doctors began to treat pain as “the fifth vital sign” and started using opiates to treat what people were seeing as a pain epidemic in America. As this shift was happening, doctors’ caseloads also increased due to changes in billing structures; as a result, many relied on quick-fix options for pain management, such as opiates.

Underlying all of this was the confidence—despite paltry evidence—that opiates used to treat chronic pain were not addictive.

As a revolution in pain treatment was shaking up the medical world in the 1980s and ’90s, another revolution was taking place in drug trafficking in the United States. The Xalisco system of selling black tar heroin through small cells, rather than a cartel, allowed traffickers to serve markets of middle- and upper-middle-class white people who were transitioning from OxyContin to heroin, while largely evading law enforcement. One cell in Boise, Idaho, was run by a man named Cesar Garcia-Langarica, or Polla, an early pioneer from Xalisco. Eventually, Polla acquired competition in Boise, from other men from Xalisco seeking to get in on the market and to make enough money to buy Levi’s 501s and other consumer goods with which to impress friends and family back home. Despite this competition, the cells were unusually cooperative compared to other drug gangs like the Bloods and the Crips in Los Angeles, as they deliberately avoided any violence that might draw attention to them—moreover, because their product was so addictive, they didn’t need to compete.

One of the young men enriched by this system was Enrique, who found his way back to the United States and worked up to a management position in a cell in Arizona. That work allowed Enrique to have the glorious homecoming he’d dreamed of, bearing gifts and touring the home he’d asked his family to start building with the money he was making. But in time, Enrique realized the money was not enough for all he wanted to do, and he started looking to Albuquerque, New Mexico, and new markets for black tar heroin.

Meanwhile, this section explores how the pharmaceutical side of this equation grew out of the letter to the editor published by Dr. Hershel Jick, mentioned at the beginning of Part 1, on how less than 1% of patients given narcotics became addicted. Despite only being a letter to the editor, this research became gospel in the 1980s and ’90s. This message was furthered by influential doctors like Russell Portenoy, who promoted pain management—the easiest route to which was pills. Conventional wisdom came to dictate that a patient seeking higher doses of opiates wasn’t being prescribed enough and that “there was conceivably no limit to the amount of opiates a patient might need” (110).

This section opens on a Portland advocacy group of recovering heroin addicts called the Recovery Association Project (RAP). In the face of rising numbers of overdoses from black tar heroin sold by the Xalisco Boys, recovering addicts demanded more services from the government. Meanwhile, in the 1990s, a researcher named Gary Oxman began looking into these statistics; though at first he didn’t find large numbers of deaths, he soon realized this was because the language used to describe overdose deaths was inconsistent. He discovered that “the numbers had been growing steadily, hidden in the tall weeds of inconsistent language” (119). Through his research, Oxman realized deaths had increased since the early 1990s, without anyone noticing, spiking by 1,000% in eight years. Spurred by his discovery, Oxman had an advertising firm launch a campaign aimed at reducing overdose deaths. With RAP’s help, this campaign worked—for a time.

This spike in deaths was enabled by the Xalisco Boys’ disciplined, decentralized structure, where dealers were employees of family-owned cells—reducing the incentive to dilute heroin, as they were paid no matter what they sold. The drugs were produced in the mountains of Nayarit, generating about $100,000 in profit per kilo of heroin, even with dealers selling it cheaply.

Quinones then introduces OxyContin, a drug produced by Purdue that is molecularly similar to heroin. Despite being a strong opiate, OxyContin was prescribed freely by physicians who were newly concerned with America’s epidemic of untreated pain. With its timed-release formula, OxyContin was seen as the holy grail—a nonaddictive painkiller. Because of this formula, the FDA allowed Purdue to label its drug as having a lower potential for abuse than other similar products, and Purdue salespeople were instructed to pitch the drug to physicians as “virtually non-addicting.” This direct marketing to healthcare practitioners was a key part of Purdue’s strategy for selling OxyContin—and was echoed by other pharmaceutical companies in the 1990s. In return, Purdue reps made huge bonuses, relative to those offered at other drug companies. Quinones notes, “They bore instead a striking similarity to the kinds of profits made in the drug underworld.” (134).

At Continuing Medical Education conferences, part of doctors’ ongoing training, Purdue sponsored seminars on pain treatment focused on OxyContin, featuring speakers such as Russell Portenoy. Purdue also funded videos about OxyContin, websites promoting treatment for pain—namely, OxyContin—and pain patient organizations that promoted opiate use.

By the end of the ’90s, OxyContin’s addictive properties were clear, supported by media reports of drug rehab clinics filling with OxyContin addicts. Despite these warnings, Purdue continued its aggressive marketing of the drug, which had come to form 90% of its revenue.

This section begins with a description of Xalisco, seen through the eyes of the Man, the black tar heroin dealer encountered several times in Part 1. In early August, Xalisco hosts a town fair that doubles as “a kind of convention for tar heroin traffickers in the United States,” given Xalisco’s role as the epicenter of black tar heroin trafficking (141). Though the Man had established a home in Xalisco, he kept an eye open for expansion into new markets in the United States. He eventually settled on Columbus, Ohio, with its large white population and opportunities for further expansion into the economically depressed region of Appalachia.

In Columbus, the Man sold black tar heroin, starting in 1998, to a market used to the much weaker powdered heroin brought in from New York City. His dealers quickly found a market among the white population of Columbus and the surrounding area for “the most powerful heroin anyone had tried” (164). As the Man expanded further into the Rust Belt, his territory overlapped with areas where opiate addiction was rising due to doctors’ prescribing practices.

One of the areas where this was the case was Portsmouth, which had become “ground zero of an almost viral explosion of opiate use and abuse” (147). Much of this was driven by pill mills—pain clinics run by doctors that churned out huge numbers of opiate prescriptions. The owner of one such clinic, Dr. David Procter, was a rich man by Portsmouth standards, with a mansion and several luxury cars. Though Procter had started his career trying to encourage a more holistic approach to managing pain, by the 1990s, he was prescribing opiates with little diagnosis or suggestions for alternatives. To continue receiving these pills—which are Schedule II drugs, with restrictions—patients had to get a new prescription every month, at $250 a visit.

Despite the widespread acceptance of opiates for pain treatment at the time, Dr. David Procter’s practice attracted attention. Eventually, Procter relinquished his Kentucky medical license and hired other doctors to staff his clinic; many of these doctors went on to start pill mills of their own. A DEA investigation eventually jailed Procter, but his business model continued. In turn, this drove the market for black tar heroin, which was cheaper and more potent than pills.

Part 1 closes with a description of the law officers on the trail of black tar heroin. From Chimayo, a New Mexico valley community dominated by a handful of heroin clans, DEA and FBI agents built a case against the clans from the stories of families who’d lost loved ones to heroin overdoses. During their investigation, agents realized the heroin was coming from somewhere else: the Xalisco Boys, particularly Enrique, who by the late ’90s had set up a black tar heroin cell in Santa Fe, New Mexico. Efforts to investigate the Xalisco Boys soon evolved into a large operation involving federal agents from the FBI and DEA and police from 22 cities; the operation was called Operation Tar Pit. In June 2000 this culminated in an operation to arrest 182 players, including Enrique, in cities across the United States. Despite the success of the operation—the largest the DEA and FBI had ever mounted jointly—agents realized that employees at all levels of these cells could be endlessly replaced with more young men from Nayarit, making it almost impossible to shut down cells.