Dreamland: The True Tale of America's Opiate Epidemic

I read Sam Quinones' Dreamland:  The True Tale of America's Opiate Epidemic for a new book club I'm joining.  I have had it on my radar since it came out, but I admit that I was wary of reading it.  I've read a lot about the trials and tribulations facing America's rural and forgotten towns and cities since the election, and I no longer want to read about them in a vacuum.  I would rather read about the country as a whole, finding ways to work together.  I am sick of reading about how every single group feels forgotten and left behind (well, mostly how one group feels left behind just because everyone else is starting to catch up).

What I wanted from Dreamland was a meaty account of the way our country has approached drugs from the past to the present, from procurement to addiction to prosecution to rehabilitation.  I wanted Quinones to look frankly at how drug use and abuse channels into our prison system, but he didn't really touch that at all.  And, honestly, he never implied that he was going to touch it.  The book is about the opiate epidemic, and about how it became an epidemic.  It is not about our law enforcement or prison system.  It is about the drug, what it does to you, and how it became so easy for so many people to get addicted to it.

Which is an important story to tell, absolutely.  But did not feel that different to me than other stories about how drugs come into the country and get people hooked.  And so the story felt fairly repetitive and even within the book, it felt repetitive.

The book also made me feel uncomfortable.  The premise of the book is basically that white, suburban, and fairly well-off Americans are addicted to opiates, and the fact that it's people from "good families" that are addicted that this is a story worth telling.  The phrase "good families" is used multiple times.  The flip side of this, of course, is that people who are not white or suburban or rich but become addicted to drugs are somehow less.  That even within addiction, there is a hierarchy, and these opiate addicts are at the top.  This was particularly frustrating because all of these white people seemed to hardly ever go to prison, or if they went to prison, they soon got out, and then they were at it again.  They seemed to get so many chances whereas many other people who did less never get out.  Quinones never even hints at this disparity.

Most of the "black tar heroin" that people graduate to from prescription painkillers comes from dealers that connect back to a small town in Mexico, Xalisco.  Quinones details their operation in  great detail (fairly repetitively), talking about how the key difference in their approach is to deal with heroin like a business that grows quickly, stretching across America.  They value product integrity and quality, just-in-time inventory, and customer satisfaction.  They work hard to keep their clients (meaning they work hard to ensure no one tries too hard to get clean), and they have a very vast, complicated network.  They are also very polite and well-behaved and don't ever use.  So they aren't like most drug dealers, who are also addicts.  They're just there for the money, and then they want to go home to Mexico and live better lives.  They want to take care of their families and impress their neighbors.  That's why they come to America.

The dealers also don't ever sell to black people.  They only sell to whites.  That's part of the reason why they target the smaller towns and suburbs, not the cities.  They don't go anywhere too white, because they need an immigrant population to blend into.  But they also don't go anywhere near black people.  This is stated unambiguously, and again, Quinones does not go into this.

Quinones does go into the herculean efforts put forth by the pharmaceutical industry to get opiate painkillers on the market and approved for any sort of pain medication, and the (very flawed) study they cited over and over again that claimed opiate painkillers were not addictive.  (Spoiler:  They are.  Very.  Addictive.  For some people.)  These were the most informative sections of the book to me, mostly because they highlight just how unscrupulous people can be when they are incentivized to focus on profit and sales, and when they are given information that aligns with what they want to hear.  It was horrifying to read about the lengths to which companies would go to get doctors to prescribe their drugs, and to ensure that they kept prescribing their drugs, and to combat even the slightest idea that their drugs could have very negative side effects.  It's scary, and the more I read about things like this, the more I want strong government oversight of the free market.  The market may force companies to self-correct when they go too far, but how far can they go, and how many people [from "good families"] have to suffer before they get to the tipping point?  Also, how much money are companies able to make from people suffering overall vs the small amount they then pay out in damages?  Generally, the pay-out is way less than the profit, so... we are not really incentivizing them to do anything different in future.

Quinones also goes into detail about the difficulties the medical profession faces in trying to deal with the guidance first for and now against opiates.  This I found particularly good reading, mostly because my father is in general practice, and he's dealt with a lot of patient demands and these patient satisfaction surveys that are both really useful and really horrible.  It's really hard to be in general practice these days, and it's only getting harder, and people still trust their general practice doctor more than any other doctor, so it's REALLY hard to imagine these poor doctors trying to help alleviate their patients' pain, and then these patients trusting their doctors and getting addicted to painkillers and then to heroin.

There were many things about this book that made me sad and angry.  I don't personally know anyone who has dealt with opiate addiction in their family, so I can only imagine the hurt and bewilderment these families must deal with as they grapple with addiction that starts from something as seemingly innocuous as lower back pain.  Addiction is hard to understand.  Pain is also extremely hard to understand.  Understanding pain and addiction together is really hard.  I think it's very valuable that this book was written to bring these things to light.

But, I also think Quinones could have done much more here in bringing up the disparities in the way we treat addiction in this country.  People in the suburbs who are addicted to heroin that they buy on the street from drug dealers are "suffering a disease" and deserve "treatment."  People in the city who are addicted to anything else are "dangerous criminals" and are locked up.  I feel this book was lacking for missing that whole piece of the puzzle.  Granted, it's a big piece of a huge puzzle and well worth its own book.  But it could at least be acknowledged.