While the µ receptor and its agonists have crossed paths for centuries, social and cultural phenomena have occasionally interacted with the biologic to create a catastrophic mixture. Dreamland: The True Tale of America’s Opiate Epidemic takes a detailed look at the people and institutions that led to development of widespread opioid addiction over the past 25 years. In that time, opioid-related deaths surpassed vehicle deaths as the principal cause of accidental mortality, totaling over 30,000 per year in the United States, with millions more socially and functionally incapacitated.
As anesthesiologists, we are familiar with some of the factors underlying this opioid crisis: ascendance of opioids from the treatment of end-stage conditions to the default treatment for most pain, the construing of pain control as a patient right with various academic societies and regulatory agencies enforcing this idea, and an economic and regulatory environment that allowed the distortion of clinical evidence by the pharmaceutical industry.
In addition to an increased supply of prescription opioids, Dreamland describes how the epidemic was also rooted in a social context that included increases in unemployment and disability, problems with prescription drug regulation, and a shift to Medicaid funding of drugs rather than comprehensive rehabilitation services for patients with injuries and chronic pain. And then there was heroin. A new, more potent form, Mexican black tar heroin (heroin acetate), spread to locations previously not associated with the drug, and by a novel marketing and distribution scheme that took law enforcement agencies years to decipher.
Dreamland gets its name from a community pool and park in Portsmouth, OH, which was once the gathering point of a community that enjoyed stable income and employment. The book is not a medical textbook or academic monograph, but a piece of modern history intended for the lay public. While generally chronological, covering the mid-1990s to around 2010, the narrative is presented as a handful of concurrent storylines that update and evolve during this time. Many of the storylines pass through Portsmouth, which, in contrast to its idyllic past, turned out to be a magnet for all that could go wrong. The title is sadly ironic, as one sees the American dream once enjoyed in rural Ohio consumed by the external costs of other dreams: dreams of huge corporate profits, heroin traffickers dreaming of a better existence, and the right to live life free of any pain.
The chapters are generally short, each adding a small piece to the puzzle as the crisis unfolds. Some of the subjects are familiar, such as the rise and diversification of prescription opioids, and the enforcement of pain control by the Joint Commission and patient satisfaction surveys. The reader will probably be most fascinated by some of the less familiar players in the disaster, such as the Xalisco Boys, traffickers from a small county in Mexico who worked in the most prolific distribution network of black tar heroin, and the unscrupulous physicians who plied their trade-in “pill mills,” a troublesome form of retail medicine for which a couple hundred dollars in cash would buy Xanax and OxyContin prescriptions without the inconvenience of a history and physical exam. The struggles of local police, Drug Enforcement Agency agents, and state epidemiologists investigating opioid use are quite suspenseful, as the reader sees each working through epiphenomena of the crisis before eventually seeing the whole picture. The creation of OxyContin and its unabashed promotion by Purdue Pharma (Stamford, CT) is developed over a number of chapters and is enhanced with some background on the history of direct marketing and physician detailing. The reader will find the scale of OxyContin marketing compared to previous campaigns shocking. Finally, the center of the crisis is how a population primed by OxyContin was handed over to heroin. The nuances of the Xalisco drug trade and its adaptation to a new clientele is a theory convincingly presented in this book.
The Greek translation of epidemic is something that is over or upon the people, yet the most compelling aspect of this book is the fact that it is a story about the people contributing to or affected by the epidemic and is told in their words and through their perspectives. The author covers the topic with a reporter’s desire to understand the subjects’ motivations and social contexts. And of course, he follows the money. A particular strength of the book is the author’s understanding of rural Mexican “rancho” cultures and their interesting evolution. His previous experience as a Los Angeles Times reporter covering Mexican immigrant life provided him the insight into rancho life that unlocks an important part of the story.
The breadth of topics covered and the scholarship involved in developing these storylines is impressive. While the writing is largely conversational, most statements of fact make reference to source documents and attributed conversations. The few sections dealing with pharmacology and neurobiology that will be familiar to physicians are highly accurate and reinforce the credibility of the entire work.
As detailed in Dreamland, the opioid crises can be viewed as a historical convergence of forces in specific regions of the country that markedly increased their susceptibility to opioid addiction and death. At the same time, it does not ignore the influence of American institutions and beliefs that probably increased the magnitude and duration of the crisis. Accordingly, this is a tale of capitalism and the profit motive, a medical establishment that took too long to evaluate its own practices and assumptions regarding opioids, and the general image of the “typical” heroin user that made it difficult to acknowledge the presence of the drug and its risks when it came to white suburbia.
Dreamland is an engaging and fast-moving account of a tragedy that we are still living. The book is of high importance and will undoubtedly be enjoyed and appreciated by readers interested in American culture and history. Physicians, and especially anesthesiologists, will not only read a well-told story but also may reflect upon their own views and practice patterns regarding opioids and where they may have come from. It may be overly optimistic to hope that understanding the evolution of the opioid epidemic may promote a vigilance that could prevent a similar crisis from occurring, but Dreamland should at least prompt physicians to question the evidence underlying new policies or products that make big, sweeping claims.
Geoffrey K. Lighthall, MD, PhD
Department of Anesthesiology, Perioperative and Pain
Stanford University School of Medicine