A Brief Book Review of “Dreamland: The True Tale of America’s Opiate Epidemic” by Sam Quinones
From The New York Times:
“Over the past two decades, more than 200,000 people have died in the United States from overdoses involving prescription opioids, according to the Centers for Disease Control and Prevention. About 200,000 more have died from overdoses involving illegal opioids, like heroin.”
From Dr. Nathaniel Katz, a pain specialist in Boston:
“My instructors told me that when you take opioids for pain you can’t become addicted because pain absorbs the euphoria. That was at Harvard Medical School. It was all rubbish, we all know now. Why do we listen to those messages? Because we wanted them to be true.”
In a book filled with powerful, tragic stories, there’s one story in particular at the core of crime reporter Sam Quinones’s book Dreamland (2015) that might elicit some of the deepest, most frustrating sighs. It goes something like this: In 1980, the prestigious New England Journal of Medicine (NEJM) published a one-paragraph letter to the editor from a doctor at Boston University named Hershel Jick. In the decade prior, Dr. Jick grew highly interested in using statistical data to track the effects of various drugs on patients at area hospitals. Technologically illiterate, he would hire computer technicians to run his studies. Out of the many studies he ran, one in particular took on a monstrous influence far beyond his wildest nightmares. With the help of a graduate student named Jane Porter, Jick investigated the number of people who had developed addictions after being given narcotic prescriptions while hospitalized. Findings in hand, Dr. Jick wrote a paragraph in longhand and gave it to his secretary to type. It stated that of the 12,000 or so patients treated with opioids while in area hospitals before 1979, and who had records in his database, only four had grown addicted. On page 123 of the January 10, 1980, edition of the NEJM, the findings of Porter and Jick were published. The paragraph was soon forgotten by the authors themselves.
Four out of 12,000. It would be remarkable if generally true, and if widely applicable. Sadly, it was neither generally true nor widely applicable. As Quinones writes in a blog entry on “the findings of Porter and Jick” published after the book was released:
“Remember this was data taken from the 1960s and 1970s, a time when narcotic painkillers were rigorously controlled, and never given to patients to take home with them. So it stands to reason that patients, under such strict controls and administered the drugs only in hospital, would rarely develop addictions – as the letter’s headline in the journal read when it was published: Addiction Rare in Patients Treated With Narcotics.
“They simply didn’t have access to large supplies of narcotics, and especially drugs to take home with them, as patients routinely do today. Hence they didn’t run much risk of addiction. (The whole thing, btw, helped change my mind about what ignites a scourge of addiction, which I now believe is not demand, but supply. Supply first sparks demand.)
“The problem came not with how the letter was written, but how it was interpreted, then used, by others.”
In the two decades that followed, the innovative marketers-cum-entrepreneurs-cum-scientists-cum-corporate-drug-dealers the Sackler family, their company Purdue Pharma, and their army of well-incentivized sales reps used Porter and Jick to ignite a revolution in how hospitals treated pain, how pharmaceutical drugs were marketed, and how Americans consumed opioids. This little paragraph in an elite publication, forgotten by the authors themselves, was used continuously to buttress the idea that prescription opioids were safe and non-addictive. Ignored was the reality that the study was only about patients in controlled situations. Ignored was the reality that this wasn’t some rigorous study but a throwaway paragraph about initial findings. The findings of Porter and Jick were published in a time before the NEJM digitized and made easily searchable its records; moreover, doctors on the receiving end of marketing messages that opioids are safe didn’t have the time, access, or incentives to check paper publications on this much cited research to see it was largely meaningless. Today, we know the hypothesis that opioids are not addictive is false. There is a time and place for opioids in medical care. It's just not what's been marketed the last thirty years.
In the process of using a tiny paragraph as a cornerstone to build deceptive and destructive marketing messages, the Sackler family amassed a wealth of over $14 billion. They became world-renowned philanthropists, using their dirty money to buy museum wings and access to elite institutions like Ivy League universities. U.S. attorneys general are trying to claw back some of that money today. In the process, the Sacklers aggressively introduced millions of Americans to what Quinones calls “the morphine molecule,” setting the stage for the other epidemic that followed in its wake.
Given how expensive prescription opioids are, it was no surprise that once addicted to them, addicts, pulled largely from the white middle and upper class, turned to something cheaper and stronger. They found that in black tar heroin. Quinones does a remarkable job showing the parallels between networks of corrupt doctors and “pill mills” in places like southern Ohio, Appalachia, and Oregon who distributed the creations of the Sackler family and the Xalisco Boys (Ha-LEES-koh), a network of a families from a small state in Mexico that similarly revolutionized the illegal opiate trade. Using industry innovations such as novel branding, premium service, sales discounts, and decentralized management, the Xalisco Boys did for heroin what Walmart did for almost everything else. Reading their story felt like reading a bizarro version of Sam Walton’s great memoir Sam Walton: Made in America (1992).
Quinones here clearly holds special contempt for the Sacklers but does not demonize the small-time heroin traffickers who benefited from the addiction frenzy the Sacklers created. Nor does he demonize the addicts whose brain chemistry fell victim to these drugs. But he does raise interesting questions. Why do we usually demonize the street dealer but not the corporate drug dealer executive? The only difference he sees is one can afford better lawyers and posher surroundings. Moreover, America has had other epidemics before this one. Why was the reaction to this one different? (See, Racism). The crack epidemic ravaged inner cities and post-industrial communities that had similarly lost jobs the way Appalachia had. But it was also largely considered an epidemic among black Americans. It was not until the neighbors and children of white legislatures fell prey to addiction through prescription opioids and illegal heroin that the state and media became more interested in rehabilitation versus incarceration, in addiction as a chronic mental illness rather than as a character flaw.
This is a challenging, stimulating book and I think an important one for learning a crucial aspect of American society of the last three decades.