Dreamland Book Summary - Dreamland Book explained in key points

Dreamland summary

Name: Dreamland
Rating: 4.4 (25 reviews)
Author: Sam Quinones

Sam Quinones

The True Tale of America’s Opiate Epidemic

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4.4 (25 ratings)

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What is Dreamland about?

Dreamland (2015) tells the story of how the opiate crisis in the United States went from being a problem only among social outcasts and the urban poor to one of the leading causes of accidental deaths in the country. The background and science of the crisis are rooted in socioeconomic factors that are distinctly American.

About the Author

Sam Quinones is an American journalist and author, known for his work at the LA Times, as well as his books on Mexico, which include True Tales from Another Mexico and Antonio's Gun and Delfino's Dream.

Table of Contents

Key idea 1 of 12

A tiny pill has played a major role in the current opiate crisis.

The opiate crisis is being felt all over the United States – but it didn’t come out of nowhere. It’s a been a slow process, the foundations of which were laid back in the early 1980s.

In 1984, the drug company Purdue released a new product called MS Contin. It was a time-release morphine pill designed for treating pain in patients who were dying or who had just been released from surgery.

It was highly successful, so much so that the company released a similar drug in 1996. This new drug had oxycodone as its active ingredient, rather than MS Contin’s morphine. Oxycodone is an opium derivative not dissimilar to heroin, and once more Purdue used its time-release coating formula. The name of this pill was OxyContin.

The FDA approved OxyContin in 1995, as they believed Purdue’s big claim about the pill: supposedly, their time-release coating would limit addiction by preventing the sorts of rapid highs and lows usually associated with opiates.

The consequences of this decision were serious: now Purdue could market OxyContin with a unique safety label that stated the drug had less potential for abuse than other painkilling drugs on the market.

It was this claim that became the cornerstone of OxyContin’s marketing. This wonder drug would purportedly be the only painkiller a doctor would ever need to prescribe. It was to be an almost risk-free solution to chronic pain; unlike other opiates doctors had been prescribing for pain, this new drug had been shown to be addictive in less than 1 percent of patients.

But there was a very specific reason these rates of addiction were so low: MS Contin was being used in carefully controlled hospital conditions. Conversely, OxyContin was marketed to doctors outside hospitals. And these doctors were used to dealing with chronic pain in their patients by prescribing opiates.

Now, these old opiates were quite weak, their dosages were small, and they contained agents such as acetaminophen or Tylenol designed to prevent abuse.

Oxycontin was different. It contained large doses of oxycodone and was only deemed safe because of the special time-release coating designed to supply the active ingredient over a long period.

Purdue soon began pushing its new product. Its representatives visited doctors several times a year and took them out to lavish lunches, attempting to drive home the merits of the time-release coating and how it ensured addiction was not an issue.

It didn’t stop there: mountains of OxyContin merchandise and medical seminars at luxurious resorts were quite the norm.

And it was a success: Purdue’s sales tripled. In fact, bonuses for sales rose from $1 million in 1996 to a whopping $40 million in 2001. By 2003, OxyContin was predominantly being prescribed by primary care doctors with very little pain management training. Purdue had successfully transformed the entire industry: prescribing for pain had become the norm, not the exception.

The history of morphine goes back a long way.

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.

Starting in the 1980s, the concept of treating pain underwent a revolution in America.

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.

In the 1990s, pill mills spread rapidly across the American Rust Belt.

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.

The tiny Mexican village of Xalisco has had a huge impact on millions of American lives.

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 Xalisco Boys soon expanded into new markets across the United States.

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.

The Xalisco Boys’ approach to marketing was key to their success.

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.

The pain revolution left opiates triumphant – prescription was the norm.

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.

Eventually, a few people noticed the increasing opiate abuse, and a backlash against opiate prescriptions followed soon after.

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.

The first major criminal case against the opiate manufacturers was brought forward in Virginia.

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.

It took time, but victims of the opiate epidemic finally began speaking out.

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.

The pain revolution has been shown to be misguided – now the recovery has begun.

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.

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Who should read Dreamland

Non-Americans left nonplussed by the United States’ opiate problem
Health care professionals
Policy wonks

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Dreamland summary

Listen to the first key idea

What is Dreamland about?

About the Author

A tiny pill has played a major role in the current opiate crisis.

The history of morphine goes back a long way.

Starting in the 1980s, the concept of treating pain underwent a revolution in America.

In the 1990s, pill mills spread rapidly across the American Rust Belt.

The tiny Mexican village of Xalisco has had a huge impact on millions of American lives.

The Xalisco Boys soon expanded into new markets across the United States.

The Xalisco Boys’ approach to marketing was key to their success.

The pain revolution left opiates triumphant – prescription was the norm.

Eventually, a few people noticed the increasing opiate abuse, and a backlash against opiate prescriptions followed soon after.

The first major criminal case against the opiate manufacturers was brought forward in Virginia.

It took time, but victims of the opiate epidemic finally began speaking out.

The pain revolution has been shown to be misguided – now the recovery has begun.

Key ideas in Dreamland

A tiny pill has played a major role in the current opiate crisis.

The history of morphine goes back a long way.

Starting in the 1980s, the concept of treating pain underwent a revolution in America.

In the 1990s, pill mills spread rapidly across the American Rust Belt.

The tiny Mexican village of Xalisco has had a huge impact on millions of American lives.

The Xalisco Boys soon expanded into new markets across the United States.

The Xalisco Boys’ approach to marketing was key to their success.

The pain revolution left opiates triumphant – prescription was the norm.

Eventually, a few people noticed the increasing opiate abuse, and a backlash against opiate prescriptions followed soon after.

The first major criminal case against the opiate manufacturers was brought forward in Virginia.

It took time, but victims of the opiate epidemic finally began speaking out.

The pain revolution has been shown to be misguided – now the recovery has begun.

Who should read Dreamland

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