On the subject of narcotics, American public discourse is prone to alarmism, but it is not an exaggeration to say that the United States is currently experiencing an epidemic of opiate addiction. To be exact, we are in the grip of two related epidemics: one involving legal, regulated prescription painkillers, and the other involving black market heroin. Chemically, these two types of drugs have a great deal in common, and both are devastatingly addictive. But the rise in pill addiction and the rise in heroin addiction are linked on a deeper causal level, as well.
Drug overdoses now kill more Americans than car accidents, and most of those overdoses are from opiates. Heroin-related deaths have quadrupled since 2000, leading to what the New York Times has suggested may be “the worst drug overdose epidemic in United States history.” Former attorney general Eric Holder described the rise in heroin addiction as a “public health crisis,” with heroin overdoses leading to 10,574 deaths in 2014 (see Figure 1).
But in fact, the spike in heroin abuse is an outgrowth of a much broader and in some ways more pernicious problem—the widespread addiction to prescription painkillers. Pharmaceutical opioid overdoses have also quadrupled since 2000, leading to 18,893 deaths in 2014 (see Figure 2)—almost double the number of heroin overdoses for the same year. The suppliers of these drugs are not street-corner dealers, but ostensibly respectable physicians, and behind them, multibillion-dollar pharmaceutical companies, with squadrons of lawyers and lobbyists.
According to the Centers for Disease Control (CDC), in 2012, American health care providers issued 259 million prescriptions for opioid painkillers, the equivalent of a bottle of pills for every single adult in the country. According to the journalist Sam Quinones, a hundred million Americans suffer from chronic pain, and most of them receive prescription opiates. Quinones has written a book, Dreamland: The True Tale of America’s Opiate Epidemic, which is a landmark work of reporting and storytelling that brings together the licit and illicit strands of this story and illustrates, in vivid detail, how pharmaceutical painkillers and heroin from Mexico are linked on a continuum of addiction.
As a longtime reporter for the Los Angeles Times, Quinones has decades of experience on America’s southwest border and in Mexico. The most arresting and unfamiliar parts of Dreamland are the chapters that chronicle a generation of young heroin dealers who hail from the same small corner of Mexico, a rural area around the town of Xalisco, in the western state of Nayarit. The “Xalisco Boys,” as Quinones calls them, pioneered an unusual business model.
Most Mexican drug cartels are in the business of producing and exporting narcotics like marijuana or methamphetamine, or smuggling cocaine from the Andes. As such, they tend not to play a major role in retail distribution inside the United States, preferring to sell to regional wholesalers who then assume the risks and exposure of dealing with gangs and with a strung-out, unreliable clientele in local drug distribution networks. But the Xalisco Boys were vertically integrated “from the farm to the arm,” as drug agents sometimes say: they produced their own heroin in Mexico, shipped it across the border, and then operated retail distribution cells that sold directly to addicts in communities across the United States.
By interviewing Xalisco Boys, the customers they sold to, and the cops who pursued them, Quinones is able to elucidate their unusual methods in unusually vivid detail:
Each heroin cell or franchise has an owner in Xalisco, Nayarit, who supplies the cell with heroin. The owner doesn’t often come to the United States. He communicates only with the cell manager, who . . . runs the business for him. Beneath the cell manager is a telephone operator. . . . The operator stays in an apartment all day and takes calls. The calls come from addicts, ordering their dope. Under the operator are several drivers, paid a weekly wage and given housing and food. Their job is to drive the city with their mouths full of little uninflated balloons of black tar heroin, twenty-five or thirty at a time in one mouth. They look like chipmunks. They have a bottle of water at the ready so if police pull them over, they swig the water and swallow the balloons.
The Xalisco Boys are purely a delivery operation: like any other retail business, they discovered that there can be distinct advantages to foregoing a brick-and-mortar storefront. Rather than assume the risk of keeping heroin at a single house where junkies (or the cops) will know where to find it, the Xalisco Boys come to the customer. Each driver hits the streets with a small enough volume of heroin in his car that if the authorities pull him over, they will not be able to make a major case (because criminal charges in these cases are generally tied to the volume of product the dealer is arrested with).
The Xalisco Boys tend to be young and clean cut, Quinones explains. They drive anonymous sedans, and after working in a given market for a few months, they cycle out of the country and return to their home village in Mexico, with a small fortune in earnings. Each departing driver is replaced by a new anonymous face, with no criminal record, which further compounds the challenges for law enforcement officers trying to make a case.
Whereas retail distribution of illegal drugs is often characterized by violent turf wars, the Xalisco Boys never carried guns. They competed among themselves, driving down prices, but did not engage in bloody gang wars. During the 1990s, they targeted small and mid-sized cities in the American heartland, avoiding large cities such as New York where there was already an entrenched hierarchy of heroin suppliers. According to Quinones, they tended as a rule to avoid doing business with African Americans, preferring to sell to whites. “Guys from Xalisco figured out what white people—especially middle-class white kids—want most is service, convenience,” he writes. At any hour of the day, an addict could telephone a number and know that within thirty minutes, a polite driver would meet them in a nearby parking lot or show up at their door, ready to make a sale.
When the Xalisco Boys set up shop in a new area, they would identify potential customers through a devilish but ingenious device: they would target methadone clinics, where they were sure to find people coping with heroin addiction, and offer them free samples. Most of these dealers lacked much formal education, but they proved remarkably adept at marketing their product, and at developing relationships with customers. Quinones relates harrowing stories of addicts summoning the strength to quit the drug and informing their dealers that they were done with heroin, only to have the dealers arrive at their house, minutes later, to express support for the decision—and to offer one last hit, for free.
Gradually, as Dreamland relates, the Xalisco Boys expanded from Southern California to cities and towns across America. The type of heroin produced in Mexico—black tar heroin, known as such because it has more impurities than white powder heroin, but is just as addictive—was originally found only on the West Coast, but eventually it began to appear east of the Mississippi, with increasing regularity.
You might think that the fact that heroin is typically injected would pose a challenge for dealers looking to attract new customers. Many people have a phobia of needles. But as the Xalisco Boys continued to expand, they found out that this did not seem to be a problem—because someone had prepared the territory ahead of them, creating a vast marketplace of opiate consumers, hungry for more.
For most of their history in American, opiates were typically prescribed only for short-term pain, or for chronic pain associated with terminal illnesses. But in the last decades of the twentieth century, a myth took hold in the medical community that these drugs were not addictive, and doctors began prescribing them much more widely. By the 1990s, Quinones writes, there was “a new conventional wisdom that science had advanced and now knew that opiates wouldn’t addict a pain patient.” This was completely untrue, based more on wishful thinking (and nakedly self-interested marketing campaigns by drug companies) than on actual medical science. But it was embraced as a new orthodoxy.
The 1990s were the decade of the blockbuster drug, and, in 1996, the company Purdue Pharma introduced a new pill, OxyContin, that was intended to revolutionize the treatment of pain. To that end, OxyContin was an astonishing success, though not, perhaps, in precisely the manner that its parent company had predicted.
OxyContin was designed with a hard shell, intended to operate on a “delayed release” mechanism, calibrating the diffusion of the drug into the bloodstream in a way that might prevent the dramatic highs and lows that can often lead to addiction. In practice, however, the hard shell did little to prevent OxyContin from becoming habit forming.
Furthermore, in the first decade of the twenty-first century, Purdue and other pharmaceutical companies pushed aggressively to have doctors prescribe pharmaceutical painkillers for more and more conditions. Bad back? Sore knee? Football injury? Toothache? OxyContin was frequently the answer. “This was a vast new market for an opiate painkiller,” Quinones writes, and the market was vast indeed: if roughly one-third of the American population can be said to suffer from some sort of chronic pain, then the potential for sales growth was astronomical. Pharmaceutical reps received big bonuses for pushing their products with doctors. Drug companies furnished physicians with notepads that featured product names, so that every time the doctors took a phone call and jotted a note, their pain pills might come to mind.
One extraordinary dividend of Quinones’ decision to tell the story of both white collar pharmaceutical executives and black market drug pushers is the uncanny similarities that emerge in their approaches. Like the Xalisco Boys loitering outside the methadone clinic, the pharma companies liked to offer free samples:
Purdue offered OxyContin coupons to physicians, who could in turn give them to patients for a onetime free prescription at a participating pharmacy. By the time Purdue discontinued the program, thirty-four thousand coupons had been redeemed.
The result of this corporate push was the democratization of opiate addiction. Military veterans. Housewives. Athletes. (Quinones suggests that “football was almost a gateway to addiction.”) One addict and dealer describes coming out of jail in 2007 to find a completely changed landscape. In the past, opiate abuse was prevalent only in “a certain group of people,” he tells Quinones. Now, “it was a certain group of people plus everybody else. Cops’ kids. Poor kids, rich kids, smart kids, dumb kids.”
As the use of prescription opioids deepened and spread, an increasing number of people began to use these drugs in a manner that was obviously nonmedical—and a new cadre of unscrupulous doctors proved all too willing to furnish these customers with prescriptions. Quinones pinpoints the small city of Portsmouth, Ohio, as the home of the original “pill mill.” He profiles a doctor, David Proctor, who was so prolific with his prescription pad and so influential on the younger doctors he hired and trained that one law enforcement officer gave Proctor the nickname “Ray Kroc”—after the businessman who built McDonalds into a national chain.
Like the Mexican drug peddlers, the doctors and pharma executives could count on the peculiar susceptibility that the American people have to addiction. The United States consumes 83 percent of the world’s oxycodone (the opiate in OxyContin) and 99 percent of the world’s hydrocodone (the opiate in Vicodin). In fact, drugs containing hydrocodone are the most prescribed medications in the country, according to Quinones—136 million prescriptions a year. Sales of oxycodone increased almost tenfold between 1999 and 2010—and during that same period, tens of millions of Americans began using prescription pills non-medically.
As opioid use exploded, the pharmaceutical companies paid lip service to the idea of taking potential abuse seriously, but the reality is that they were conspicuously slow to acknowledge the addictive properties of their products. More to the point, addiction and abuse were good for their bottom line: today, sales of opioid painkillers generate over $9 billion a year. (In 2007, Purdue, the maker of OxyContin, paid over $600 million in fines for misleading the public about the drug’s risks.)
The logic of addiction is one of escalation. A patient taking pain pills on a certain schedule may start to take them more frequently—because the pain returns faster. If the dosage effectiveness wanes, she can suck on the time-release coating, dissolving it and creating a more immediate and intense high. She may begin to crush the pills and snort them. (Quinones points out that a sticker on bottles of OxyContin which advised consumers not to grind the pills may have functioned as a warning label for some users, but it was an instruction manual for others.)
With tolerance for the drug growing, an addict is always seeking to recreate the intensity of that first high, which may mean that after snorting OxyContin in powder form, she will start dissolving the pills and shooting them directly into her bloodstream with a needle. Addicts who have exhausted their doctors’ largesse can rely on a robust black market for painkillers, but with a street value of $1 per milligram for OxyContin, addiction can get expensive, and this is where the transition to heroin occurs: black tar heroin is cheaper, and easier to procure—through the kind of customer-oriented delivery service offered by the Xalisco Boys—than black market OxyContin. As a result, it becomes simple, even logical, for large numbers of pill addicts to graduate to heroin, and this is the actual explanation for the rise in heroin addiction and overdoses.
According to Quinones, many of the Xalisco Boys did not even realize that they had stumbled onto a market that was already primed for them—a country full of addicts who have been prepared for heroin by our own legal pharmaceutical industry, in the name of pain management.
While the challenges associated with the crisis of opiate addiction are formidable, one sign of promise is that the country seems to be waking up to the gravity of this issue. Until fairly recently, news stories and political speeches tended to address either the rise in heroin overdoses or the quiet scourge of painkiller addiction. But thanks to the work of Quinones and others, it is becoming increasingly untenable to tell one story without the other.
On the 2016 campaign trail, presidential candidates from both parties have been encouragingly forthright in discussing the problem and committing to take it on. Hillary Clinton recently announced a $10 billion plan to combat drug addiction. Jeb Bush has publicly recounted how his daughter struggled with prescription pills and was jailed twice. Carly Fiorina has related the story of how her own step-daughter died in 2009 after a battle with prescription drugs, saying, “I buried a child to addiction.”
In fact, in Dreamland, Quinones observes that one potentially hopeful development to emerge from this devastating sequence of trends may be a slightly gentler national approach to addiction, in which families are pushing to treat addiction not as a crime but as a public health problem. This change in tone is a reflection, at least in part, of shifting demographics. Heroin use is climbing in all groups, but the most pronounced growth is in the white population: nearly 90 percent of those who tried heroin for the first time in the last decade were white. A recent headline in the New York Times captures the stark racial dynamics of this change of heart: “In Heroin Crisis, White Families Seek Gentler War on Drugs.” Some of the very same political constituencies that in the past demanded a “zero tolerance” approach to drug crimes are now appealing for a reconsideration.
The irony is not lost on Quinones:
[C]oincidentally or not, this change of heart was happening among conservatives just as opiate addiction was spreading among both rural and middle-class white kids across the country, though perhaps most notably in the deepest red counties and states. Drug enslavement and death, so close at hand, were touching the lives, and softening the hearts, of many Republican lawmakers and constituents. I’ll count this as a national moment of Christian forgiveness. But I also know that it was a forgiveness that many of these lawmakers didn’t warm to when urban crack users were the defendants.
But whatever the provenance of this revised philosophy of criminal justice, it may end up representing a welcome and durable improvement in this country’s fraught policy stance toward addiction and narcotics. If the country begins to perceive drug addicts as sick people in need of treatment, rather than marginal criminals who should be relegated indefinitely to the prison system, that will be a major shift in outlook, and a promising development for addicts and their families and communities—and for our over-subscribed prison system, as well.
But that would be a gradual tectonic shift. More surprising are the near-term, common-sense solutions that are—or are not—being employed. One tool currently used is prescription monitoring databases, which physicians can consult in order to make sure that patients are not receiving multiple prescriptions from different doctors. These databases now exist in nearly every state. Yet some doctors refuse to use them.
The CDC has also developed a set of nonbinding guidelines to advise physicians on how they should prescribe opioid painkillers. The draft guidelines counsel doctors to prescribe these drugs only as a last resort for chronic pain, after trying other drugs or physical therapy. The CDC would also advise doctors to prescribe the smallest amount of the drugs, and the shortest course of treatment for acute pain. Yet the guidelines have met with intense, organized opposition from the pharmaceutical lobby, which has argued that even though the advice is nonbinding, if it were adopted by insurers or hospitals, it might block patient access to medications. Of course, there may be entirely justifiable grounds for tinkering with the draft guidelines, but in the nature of the federal bureaucracy, sometimes postponing a reform is all that is required to kill it.
It is impossible to read a book like Dreamland and not come to the conclusion that Purdue and the other companies that manufactured and marketed prescription painkillers share a considerable degree of moral culpability for the current opiate epidemic. You might think, in light of their role in causing all this sickness and death, that company executives would feel some compunction about fighting reforms designed to curb addiction.
Patrick Radden Keefe is a senior fellow at The Century Foundation and a staff writer at The New Yorker magazine. He has written several investigative pieces tied to the war on drugs in America and abroad, including articles on the capture of key players in the Mexican drug trade and the policy challenges of developing a legal marijuana economy in Washington State. Keefe’s “The Hunt for El Chapo,” which documented the capture of one of the world’s most notorious drug lords, was a finalist for a 2015 National Magazine Award and received a citation from the Overseas Press Club for Best Magazine Reporting on an International Story.