Sam Quinones -- Dreamland
===========================

Several themes in this book:

- Stories of individual drug addicts: how they got started on drugs
  and why, their attempts at rehab, in some cases their overdose.

- Accounts of how the heroin distribution system run by the families
  from Nayarit, Mexico worked, why it worked so well, why it was so
  resistant to attempts to shut it down.

- Stories of the pill mills and the doctors and others who ran them.
  How they supplied the pills, OxyContin in particular, how users
  obtained their pills, how they used some and sold the rest.

- Explanations of how the pharmaceutical companies, Purdue Pharma in
  particular, flooded the region with pills.

- Descriptions of the societal conditions and influences that helped
  produce the boom in opioid use and the epidemic of addiction.

In between his main story lines, there is also an account about how
attitudes about the treatment of pain have changed over the last
half century.  That's not something that I was aware of and it helps
a good deal in trying to understand Quinones's explanation of the
progression of the flood of opioid users.  It seems that it is not
*just* that doctors have started proscribing pain medication more
liberally; it's that doctors and others have encouraged those with
pain or even merely discomfort to take heavy duty drugs in order to
deal with it.  And, often, there is no attempt to help someone to
deal with their pain in any other way, e.g. with exercise, massage,
or meditation.  Often, doctors do not have the time, and insurance
does not cover those alternative forms of treatment.  Those with
pain may not have the time.  They need to get back to work; athletes
want to get back out on the field; and their bosses and coaches want
them to, also.  This is part of a culture where we have learned to
expect a chemical fix or a technical fix for each and every one of
our problems.

A good deal of Quinones's reporting is about Portsmouth, Ohio and
the region around it.  That region is interesting and significant
for reasons beyond drug abuse.  The flow of people from distressed
areas (Portsmouth and areas south and east of it) seeking work in
factories in northern Ohio went through Portsmouth.  Listen to
"Readin', Rightin', Rt. 23", by Dwight Yoakam on YouTube.com.
Portsmouth is on Route 23.  And, books like "Hillbilly elegy", by
J. D. Vance talk about a similar migration.

The region around Portsmouth to the south and Chillicothe, Ohio to
the north is also interesting because it was the center of the
ancient Hopewell culture which built huge mounds and wall,
apparently for ceremonial purpuses, although there is some doubt
about their purpose.  That culture flourished from 200 BC until 500
AD.

Modernity is a recent development, at least *our* form of modernity
is.  And, in some ways, we in the U.S.A. have been backward until
very recently.  So, perhaps we are still learning how to deal with
this variety of modernity, specifically a culture that provides a
kind of pill or medical treatment for so many ills and discomforts,
that makes those medical treatments so readily available.  The
availability of those medical treatments is a recent thing, and we
have not yet learned, apparently, the danger and the damage from
uncontrolled and unwise use of those medicines and chemicals and
other technical advances as well.

Why is it that some people seem so much more susceptible to
addictive substances.  I wish that Quinones had spent more time and
space on trying to understand that in "Dreamland".  Perhaps he does
give it more attention in his blog.  I think about this for rather
selfish reasons: I worry that I am or may become susceptible to
addition of some kind.  Quinones does give some clues and hints on
this: (1) depression, (2) job loss, (3) poverty, (4) injuries that
caused chronic pain for which a doctor prescribed pain medication and
then repeatedly increase the dose, (5) a culture in a local area
where drug use was common and accepted and facilitated, (6) drug
companies that promoted dangerous medications relentlessly and
irresponsibly, and (7) an efficient supply system that produced
significant profits and that attracted numerous actors who were
willing to sacrifice users and help them destroy themselves.  But,
at the end of all that attempt at explanation for this epidemic, it
seems that some of us are only left with thinking: "there but for
the grace of god go I".  And, another question, why did it happen to
such an extreme extend in some geographical locations rather than
others.

Quinones describes how and why it is so difficult  to try to
formulate effective policies and actions that would help to deal
with these issues, in particular those related to the supply chain.
For example, when there is so much profit to be made destroying the
lives of addictive people, blocking unscrupulous people willing to
do harm is extremely difficult.

Couple that with the fact that end users were so willing to
cooperate.  And, then, it seems, we have to ask *why* they were
willing users.  With so many lives being destroyed in this region of
the country (southern Ohio, northeastern Kentucky, western West
Virginia), surely they must have known the danger and damage that
these drugs would cause.  One explanation that Quinones gives is
that shame caused those who used and those related to users from
talking about it openly.  Perhaps many of those lured into use of
these damaging drugs really did not know how dangerous they were.

And then we get to the seemingly impossibly difficult task of trying
to formulate and enact measures that might fix some of this problem
for some people, at least.  Start with the fact that those in the
Federal government with the information to recognize the opiate
crisis and the power to act on it refused for a number of years to
act on it.  See "American overdose", by Chris McGreal for more on
this.  Apparently, pressure from the pharmaceutical industry and
their lobbying efforts were strong enough to encourage a, likely,
willful blindness and a refusal to act until the number of opiate
overdose deaths had become so large that it could not be ignored.
Next, there are conflicts about what to do to reduce the flow and
supply of opioids even in the most severely effected regions, for
example West Virginia and southeastern Ohio.  For one, efforts to
reduce the supply of opioids were interpreted by some as an attempt
to deny pain medication from those who were genuinely suffering.
For another, no effective system was in place to monitor the amount
of drugs and opiates being prescribed or even to detect when those
receiving the prescriptions were shopping around for doctors who
would, knowingly or unknowingly, give them multiple prescriptions.
But, perhaps even worse, just reducing the prescriptions to
reasonably legitimate ones likely would still allow enough opiates
to become available so as to facilitate plenty of abuse.  And,
finally, or maybe not finally, since there are plenty of other
barriers to solutions, reducing the supply of opioid such as
OxyContin would encourage users to search for another chemical, and
heroin, both black tar heroin, which is what Quinones discusses, and
white heroin seem to be cheaper than OxyContin and perhaps easier to
obtain.

And, that is why Quinones's explanation about how users initially
get addicted to OxyContin, then transition to heroin is an important
part of this story.  He explains how heroin was made cheap and easy
to obtain and reliably obtainable by suppliers from Nayarit, Mexico.

To a significant extent, this is a story about product delivery and
sales.  It's about how efficient the suppliers from Nayarit, Mexico
were at delivering black tar heroin, about how well they supplied
their clients and kept them coming back, and about how they
delivered that product to their customers and a low cost.  It's also
about the delivery system for OxyContin, and about how well Purdue
Pharma ran the system that encouraged doctors to introduce future
customers to OxyContin, and about the pill mills that enabled users
to obtain large amounts so easily.  In the case of OxyContin, the
supply chain did not stop there, but extended to resale and to users
who shared rides to the pill mills, shared the driving costs, paying
in OxyContin pills, and distributing some of their supply.  In fact,
Quinones describes how the supply of OxyContin became so prevalent
that OxyContin pills, with their markings as to the number of
milligrams in each pill, became a denominated currency in some
geographic areas.

With a system that is so rational, that has been so rationalized,
that has had the inefficiencies so well worked out and eliminated,
it is hard to imagine how delivery could be stopped.  Trying to stop
it means that you are going against the desires and brains of both
suppliers and consumers.

Quinones describes how those who had SSDI (Social Security
Disability Insurance), and apparently there was some significant
number of these in a region where many had worked at hard and
abusive labor in the coal mines, could use that to obtain OxyContin
pills and resell them for a large profit, possibly feeling that they
were just trying to support a decent standard of living for
themselves and their family.  As coal mining transitioned from deep
mines to strip mining and surface mines, there were likely fewer
injuries, but also fewer jobs and more unemployment.  That increased
the pressure to obtain income in other ways and also drove the
OxyContin pill resale model.  Shoplifting at Walmart and Lowe's
became a way of converting (OxyContin) pills into usable, needed
goods.  Quinones even reports on how some people stole merchandise
from a store, then returned the stolen goods for a gift card, and
then traded the gift card for OxyContin pills.  It was a system, as
horrid as it's consequences were, that worked efficiently.

Add to this story the significant amount of job loss in the region
and the pressure that the resulting loss of employment put on many
to find an alternative means of obtaining income for themselves and
their families.  Soon, a drug based economy becomes part of the
local culture.  It becomes a small-time business model, in which
word of mouth becomes a way of connecting sellers to buyers.  Once
it becomes that pervasive, once so many people support it, stopping
that system or even slowing it down becomes *very* difficult.
Quinones describes just how well that system worked and how
difficult slowing it down was.

Plus, many hid the damage that was being done, even when those
harmed were close loved ones.  Often they did so because of the
shame and stigma that they feared would come from admitting that a
member of their family had died of a drug overdose.  

Another thing that made reducing the damage so difficult was the
delivery of black tar heroin was done by a decentralized system.
There are no single choke points that can be attacked and disabled.
And, according to Quinones, if you arrest individuals who drive cars
and deliver to the end user, or even capture a cell leader, they are
soon replaced.

Quinones does spend a good deal of time describing law enforcement
efforts to stop the supply of illegal drugs, but that task is a huge
and difficult one.  That task is made so difficult when there is a
huge demand, when there were drug companies that were eager to flood
the region with pain pills, when there are unscrupulous doctors
willing to prescribe OxyContin for pay, and when there is such an
efficient supply of heroin when OxyContin becomes too expensive.  It
is also made more difficult by a culture in which we have been
raised to believe that there should be a pill for every medical
problem, even unhappiness, where it seems acceptable to give high
school athletes pain medication so that they can continue to
compete, and where parents have enough pain medication in unlocked
medicine cabinets to get their children started on drugs.

Quinones makes a good case that it is immaturity and pampering of
teenage kids that helped drive this epidemic.

By the way, there are multiple classes and types of people who are
trapped and harmed or destroyed by this delivery system, for
example, those in poverty and out of work, (2) pampered teenagers in
affluent families, (3) those who have genuine, often chronic pain,
and even (4) in one chapter, children of Russian immigrants whose
strict parents provided the motivation to rebel.  These stories all
are interesting and also very sad.

Those who began abusing the system started searching for pill mills
farther from home that provided better access.  This was especially
true in states farther from Kentucky and West Virginia where at
first there was no monitoring system to prevent someone from going
to multiple doctors and obtaining multiple prescriptions for
OxyContin.  And, another step towards increasing and facilitating
the supply of OxyContin was ride sharing: someone willing to provide
the vehicle would give others a ride in exchange for a share of
their prescription.

Dealing with the addicted was also problematic, in part because
insurance companies are selective and somewhat rigid about what
kinds of treatments they will reimburse.  So, for example, they
apparently will pay for medicinal treatment, but not counselling or
help with lifestyle changes and support for those attempting to
re-enter the workforce, etc.  Often, support with dealing with
social dysfunction is the help that is needed most.

One small positive, one slightly positive thing to come out of this
epidemic is that it has encouraged more of us to think of addictive
drugs as a problem for which treatment is needed rather than prison
and incarceration.  But, it is sad and shameful that white addicts
had to start suffering and dying rather than black ones before this
shift in attitudes happened.  We do live in a racist country after
all.

But, any hope of solving this problem merely by putting more money
into treatment programs is likely just a dream.  Treatment and
rehabilitation for someone who has been on heroin for any
significant length of time can take years and multiple attempts.
These drugs cause physical changes to your body that cannot be
reversed for years.

One question that I'd like to be able to ask Quinones is how the
supply chain for black tar heroin works, in particular, how heroin
is transported from Mexico into and through the U.S.A.  With all our
talk and conflict currently about building a wall on the U.S.A. and
Mexico border in part to keep bad things out, I'd like to know
whether President Trump's proposed wall would have any affect on the
supply of black tar heroin.

Be sure to read the last page of this book.  Quinones does try to
give the story and us readers a lift and a glimpse of a happy ending.

These are other books in the same topic area:

- "Dopesick: Dealers, Doctors, and the Drug Company that Addicted
  America", by Beth Macy

- "Methland: The Death and Life of an American Small Town", by Nick
  Reding

- "American Overdose: The Opioid Tragedy in Three Acts",  by Chris
  McGreal

02/01/2019

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