How Did Middle America Become Addicted to Heroin? Sam Quinones Has an Answer.

Sam Quinones’ Dream Land marks the timely end of heroin’s romanticism. Where you once imagined the netherworld of junk through ‘50s jazz musicians and the literati shooting up in the Bowery, you now have cheerleaders and football players who have “shape-shifted into lying, thieving slaves to an unseen molecule,” writes Quinones.

In Dream Land, a vast, ultra-modern, interdependent web of painkillers, Mexican heroin, aggressive marketing, pain, pill mills and dirty doctors, hangs in a time of cultural excess amidst economic depression, resulting in what we see today, which is a heroin revolution.

How this happened is always asked next. Some people blame doctors for overprescribing. Others blame cheap heroin infiltrating the posh suburbs where kids have time, cash, and no responsibility. But these arguments, while both valid, in isolation do not explain the obscene rise in use, abuse, and mortality prevalent in America’s youth today. In Dream Land, much like the real world, everything is connected and irreducible.

Coming to Quinones as an ex-heroin user, or humble poster-child of the phenomenon he exhaustively covered in his new book, I called him over the phone and below is our conversation which has been slightly edited for space.

So there is this very entrepreneurial network of Mexican heroin traffickers, the Xalisco Boys, pushing their product North, up and along the West Coast. All the while Big Pharma’s pain pill campaign is making a mess out of the East. The heroin traffic moves independently, yet simultaneously, east. What happens is these two forces collide to create a massive opiate epidemic.

This was all coincidence? Like, there isn’t some gigantic narco-conspiracy to get everyone doped up?

Quite coincidental, there is no conspiracy theory at work. I really begin this with pain specialists who are trying to right what they see as the historic lack of use, or reluctant use, of opioids to manage pain. They viewed this as inhumane and indecent and, to some extent, they were right.

For many years there was a real reluctance to use [opioids] for terminal cancer patients and that’s crazy. People were dying indecently and there were pills which could have helped them. Who really cares if the last six months of your life you’re an addict so long as you’re living with some amount of comfort?

That line was picked up by Purdue Pharma, which began to fund, in a variety of ways, these pain specialists as well as Continued Medical Education (CME). At sponsored seminars and conventions, these specialists would speak of data which showed that opiates were not addictive.

And this “data” that was cited all over, turned out to be some obscure paragraph in a 1979 issue of a medical journal?

Exactly. It was actually a letter to the editor, which is not a study, not a report, not even really an article, but a 101-word letter. The proper interpretation of that letter, considering it was using data from the years where opiates were very restricted in their use, is that when you use opiates in a hospital and you’re being very closely overseen, then you can expect few people to become addicted to them.

So Purdue begins to market in areas, I think, where they knew doctors were most liberally prescribing drugs and this was mostly in Appalachia and the Rust Belt. They’re busy doing that for two years and then there are the Xalisco Boys. One guy I talked to was kind of the perfect person to figure this pill market out. In 1998, he arrives first to Indianapolis and then to Dayton and finally to Columbus, where he stayed.

Aside from the Xalisco Boys cornering the pill market, there was/is a culture that allowed heroin to flourish. This atmosphere becomes one of the large macro-factors that contributed to the opiate use we see today. And it’s this culture that becomes “Dream Land.” It’s not a place but more of a concept. Would you elaborate on that?

Absolutely. It all comes back to one theme for me, and that’s the destruction of community. In Portsmouth, Ohio—a place that eventually became the Petri dish for the pill mill—you had this town that had really good jobs and there was this stunning community pool that was almost literally the center of life. All of that gets destroyed along with the girding that held life together. Eventually, the people leave, jobs leave, Main Street empties out and Walmart comes. The pool also closes and what you’re left with is a town that turns in on itself: people no longer go out, people don’t get to know each other.

In that situation, then, you have this drug that turns everybody into the most narcissistic, self-absorbed, hyper-consumer.

The question always is: what is it that Portsmouth, Ohio, has in common with other towns like Charlotte, N.C., where it is very affluent? And my feeling is, that our age of excess has also done a lot to destroy communities, particularly in wealthy areas. People are now indoors, they don’t go out, the houses are too big and the gadgets are too accessible. People don’t have connections with each other. On the contrary, the kids get cellphones, cars, private bedrooms, and a lot of money. Those are all the things that add up to easy access to heroin particularly when the Xalisco Boys are in town. And my feeling is, and this is kind of a hunch, but what Charlotte and Portsmouth both have in common (besides a heroin problem) is a lack of community.

At the same time, of course, you have massive prescribing going on. Every time you go in for surgery, you take home 60 Vicodin or OxyContin

So where I grew up is probably not unlike Charlotte, where there is excess and little community. Around 2007, I started to do 80mg OxyContins, once the source dried up and I was supremely addicted, the switch to heroin was a no-brainer.

That’s what I saw. It happens among kids who you wouldn’t think have a need for a drug that numbs pain. It appears these kids have everything. In Portsmouth, Ohio, you might understand the pain, but suburban Charlotte? Not at all, there is no pain in these communities unless you dig. What you’ll find is that the kids are often alone and the parents are overworked or divorced.

The book is about heroin, but only superficially. It’s really about the end result of the Reagan Revolution. The Reagan Revolution was about the exaltation of the consumer, of the individual, and of the free market. This served to destroy what we did not know to be very, very valuable until we lost it.

The result of this revolution is a drug that turns everybody into a hyper-consumer.

In my early 20s, I felt a kind of extreme dread where nothing was real. I had no meaningful connection to or anchoring in the world I lived in. All the while I’m doing massive quantities of heroin, which I thought was the utility by which I can say “fuck you unreal world” and keep to the fringe. In the end, though, it’s all a story. In the end, it’s totally conformist and thoughtless. It’s a sad trap, really.

You’re right on the money. You had Charlie Parker, Sid Vicious, Lou Reed, and Burroughs and then what this opiate epidemic has shown is that heroin is about the most middlebrow, conformist thing in American culture. It’s about commerce, business, selling, consuming, and that’s it. All the romantic outsider stuff, those guys I mentioned who allowed the romantic ideas to advance, were just victims of it. But now we’re seeing the truth about heroin: it’s all about consumption.

I want to talk about an implicit Drug War criticism I picked up on with respect to policing the Xalisco Boys’ network. There are huge busts spanning across several cities all the way down to Mexico. Hundreds get arrested or deported and the very next day there are new drivers zooming around selling product. It all seems so futile to me.

That is true, and I began to feel sorry for the police. The police are standing in the sea trying to keep back the tide. What do you do if you’re a police officer, arrest these guys or not? In either case, you’re not doing much.

And this is the problem: we’re asking the police to just stand in the place of where doctors, public health officials, politicians, and even all of us in the community, ought to be standing in. "Why aren’t you arresting these guys so they stop? Well, because every time I turn around there are 10 more addicts because they’re taking these pills." On top of that, there is a big labor force of Xalisco Boys back home who are raising their hand to serve.

Cops can do one of two things, arrest in these big operations and investigations or don’t. And my feeling is, given the problems they face, that they have to arrest. But the problem is this is not a police or criminally caused problem. This really came out of modern medicine. Because there are so many more doctors across America than there are ever going to be drug traffickers, that means this problem is all over the country. To say that the police are in charge of dealing with it is a cop out.

And it’s really deeper than that. It’s us, as in Americans, as in medical patients, saying we will find other ways to treat our own pain. We will make better life choices. We will not smoke, we will walk more and eat less crap. That is part of the solution.

You touch on this in one of the later chapters called “The Treatment is You,” which I especially enjoyed. Because it’s saying, "Look, doctors might be great at curing diseases but when it comes to complex human problems, they’re not so good at treating those, and you have to take up yourself as a concern, you have to care about your own health."

We are Americans and a crucial part of our system of government and society is accountability. And here, I believe, American patients have held everybody accountable except themselves. I think that’s true in a lot of ways. People are out there saying, "Why hasn’t the doctor fixed my pain?" or "Why don’t the cops do more?" Well, why don’t you learn what’s in your medicine cabinet? Why don’t you ask the doctor, "Why? Why are you giving me this? Why are you giving me 60 of this? Why should I take these home?"

I want to be really clear that there are people who do need opiates and that these drugs do help them. It’s crucial for them to regain their lives because they have been mangled by pain.

There are a lot of us out there who want to find someone to blame. Law enforcement and doctors need to be held accountable, that’s very important, but it’s also important to point the finger of blame back at ourselves.

Lastly, in your coverage, what did recovery look like for ex-opiate users? What did you see working and what did you see that wasn’t working?

That’s actually a topic I don’t have much of an opinion on, which may sound strange. We tried to deal with pain with one solution, which was with pills. What we need is a wide panoply of options that can be adapted for the enormous variety of human beings that exist.

People are different. We tried to treat pain one way and that didn’t have a good result. I don’t believe that one way to treat addiction is going to be any more successful. What those ways are—I’m a layman. I’ve never been addicted except to nicotine and I kicked it on my own, cold turkey. I’m sure people can kick heroin the same way, while others cannot.

Zachary Siegel, is a regular contributor to The Fix. He recently interviewed Ethan Nadelmann and wrote about how "he" didn't quit heroin. Follow him on twitter.