Dreamland summary

When telling the history of the opiate crisis and OxyContin, it’s easy to forget that we’re not just talking about the last 40 years – humans have loved opiates for thousands of years. The ancient Sumerians called opium the “joy plant,” while it was also used in ancient Egypt and classical Greece as well as in India and the Arab empire.

The active molecule in opium is morphine. It’s present in a number of other plants too, but not nearly in the same potency. Morphine was first successfully isolated in the early 1800s, and its use spread in the nineteenth century thanks to its properties as a painkiller. It was also put to use in many wars.

It might seem hard to believe, but a single-paragraph letter published in 1980 changed the course of medical history.

A doctor at Boston University’s School of Medicine, Hershel Jick was asked in the early 1960s to put together a database of the records of patients who’d been hospitalized there.

Portsmouth, Ohio was once a bustling town, built by and for American industry. But globalization hit it hard. Factories closed and jobs disappeared. By the 1990s, this town, like so many other cities in the American Rust Belt, was a shadow of its former self.

It was in places like Portsmouth that a sinister industry emerged. The jobs were hard to come by, but Medicare cards were much easier to find. This new economy was based on pill mills, clinics where doctors did little else other than write up prescriptions.

While Oxy use was on the rise in the Rust Belt in the 1980s, migrants from Xalisco, a small Mexican village, started selling black tar heroin in the San Fernando Valley in the early 1980s. They went by the name of the Xalisco Boys, and they quickly met with success.

Their business strategy was different from the other large heroin dealers. Instead of selling their product wholesale, they sold it retail.

The next part of the story has its roots back in 1947, the year methadone was invented. It was special because, although an opiate, it did not result in addicts constantly having to increase their dosages over time. It was therefore seen as a way that addicts could be treated: they could be supplied with a regular amount of methadone on a periodic basis to stop their addiction becoming worse.

Based on this principle, methadone clinics were founded. They provided an effective way of treating addicts too. However, over time, the idea took hold that methadone should be used to wean addicts off heroin completely. Consequently, for-profit clinics began reducing the amount of methadone they supplied to each addict.

If you want to run a good business, you’ve got to keep your customers happy and you’ve got to ensure that it’s convenient to buy your product. The Xalisco Boys knew this well, and it was this approach that set them apart from other dealers. It also meant they were adept at marketing their product to an important demographic: middle-class white kids.

The Xalisco Boys didn’t just hang around on street corners waiting for their customers to show up, like other heroin dealers. They frequently approached potential new customers with free samples and price breaks.

By the 2000s, the trajectory of the pain revolution was plain for all to see: opiates had emerged as the victors. Now, most of the United States' 100 million chronic pain sufferers were receiving them. The country was consuming 86 percent of the world’s oxycodone, as well as 99 percent of its hydrocodone, another popular opiate.

In fact, hydrocodone has since become the United States’ most prescribed individual drug. There are currently 136 million prescriptions for hydrocodone-related drugs each year, while opiate painkillers are the most prescribed class of drugs.

Opiate abuse in the United States was now getting too big to ignore, and there was increasing pushback against unnecessary opiate prescriptions.

The first lawsuit against the producer of OxyContin, Purdue, was filed by a lawyer named Joe Hale. Hale was a public defender who often worked in an area called the Bottoms, a run-down neighborhood in Lucasville, Ohio, near Portsmouth.

It was becoming increasingly clear that the only way to stop the opiate crisis was to get to the source of the matter. There was no point rearranging the deckchairs – something big had to be done.

John Brownlee was among the first to attempt to face down the opiate epidemic. Brownlee had become a US attorney in 2001 at a time when people across Ohio, Kentucky and Virginia were dying of overdoses.

One reason that it’s critical to look at the effect opiates have had on the United States is that it took so long for the issue to be acknowledged. It had rumbled on and on, and there were now 16,000 fatal overdoses each year, but only a handful of parents' groups had formed with the mission of raising public awareness of the issue.

Jo Anna Krohn was one such parent. Her son had been high on Oxy and shot himself in the head while messing around with a gun.

Two decades after the start of the pain revolution, the tide finally began to turn, and a new consensus has formed as a result. Opiates should no longer be seen as necessary in combating pain. In fact, they can be considered risky at best: up to 24 percent of patients were reporting “aberrant” usage according to one 2007 study.

Purdue eventually acted too, but it was too little too late. In 2010, the company added a new ingredient to OxyContin: an abuse deterrent that made it harder to inject and abuse. If they had done this in 1996, then this story might have been very different indeed.