I decided to read Sam Quinones’ Dreamland after coming across Spotted Toad’s post on it (which links to a review by sociologist Gabriel Rossman that people should read for a better overview than mine). Toad characterizes the epidemic as resembling a free-market economist’s dream, and there’s a passage within the book where Quinones writes something similar, which he has repeated in interviews:

And—this is my bigger point—what we are seeing is the end result of 35 years of exalting the free market, exalting the private sector, exalting the consumer and the individual, despising government, despising the public sector, despising the community assets that the public sector can and should provide. The end result of that is heroin—a drug that turns people into narcissistic, self-absorbed, intensely individualistic hyperconsumers. That is the point.

At the time I started this blog I identified as a libertarian who was particularly incensed by the war on drugs. I wasn’t some hippy who wanted to decriminalize soft drugs like pot because I or people I knew used them recreationally (I’m just a boring beer drinker); I knew that the War on Drugs was primarily waged against the dealers of hard drugs. I had heard arguments that the laws were supplements to laws against crimes with real victims (something I reviewed William Stuntz discussing more recently), but rejected the conclusion that the laws should remain on the books. Over the years I have taken my libertarian leanings in a more meta/decentralist direction and decided that identifying with an ideology like libertarianism doesn’t pay epistemic rent and serves as a motivation to selectively evaluate evidence in a way that a more agnostic identity like consequentialist does not (leaving me free to lean libertarian to the extent that the lessons I learned earlier still hold). And as a consequentialist, it’s hard to look at this huge rise in deaths from overdoses and just shrug it off as the result of the free-will of all those individuals, assign them the responsibility (I won’t say “moral blame” because I gave up belief in objective morality even when I was still a libertarian). I still have too many issues with paternalism to embrace it, but I can see that certain drugs are novel enough for us to lack evolutionary adaptations to them (like certain populations with alcohol), and thus for pessimism to be warranted about free access to them.

All this throat-clearing aside about my own views, I should address the actual contents of the book:

Dreamland looks at America’s opioid epidemic from many angles, including not only familiar types like the medical system which developed, prescribed & provided prescription drugs and treated addiction (along with the addicts themselves and the cops who have to deal with them), but also the relatively unique delivery system in the “Xalisco boys”. My view had long been that the prohibition on drugs created problems by leaving the market to criminals who fought over territory, and sold a dangerously unreliable product that was frequently mixed with undesirable substances. The Xalisco boys somehow avoided all that to deliver better customer service than many legitimate establishments. They’re scared of indigenous American street gangs and try to avoid them, they all know each other (and are willing to supply each other) because they’re all from the same small state of Nayarit and would like to live in peace amongst each other when they go back (I’m not sure why they weren’t segmented into hostile families while working in the US like many are in Mexico), their drivers (who respond to phone calls from customers rather than waiting on corners) are paid on salary rather than making their own money from each sale (so they have no incentive to try to sell more individually, which would usually involve cutting the heroin with other substances), they don’t carry guns which would result in higher criminal penalties and police attention, they compete enough to bring prices down very low and standards (including purity) very high, and their response to other cells is never to try to claim territory as theirs exclusively but instead to keep spreading out to new ones. Drivers only carry small quantities of heroin in balloons in their mouths, so when arrested they don’t have serious charges (and are only deported & quickly replaced by more farmboys who’d rather not harvest sugarcane). The drivers look down on heroin users and wouldn’t touch the stuff themselves, instead just indulging in beer (and if they’re flush when they’re back home, cocaine). There’s a lot of emphasis on the small “retail” quantities of drugs being dealt and the just-in-time supplies which further reduced the likelihood of big busts, but there was relatively little discussion of how wholesale quantities of the drug were being smuggled into the US and then later across state lines. There’s a few mentions of drugs hidden aside a doll or some FedExed ovens, but given the large scale eventually achieved by this network I thought there was a lot more to talk about than the little guys. I also found it odd that a non-Nayarit Mexican-American addict who got connected to the Xalisco boys once they’d already pioneered their M.O was given nearly as prominent place in the book as Xalisco cell leaders who preceded him, and he’s given the moniker of “The Man”. To me he was just one of many men behind this giant web.

Just there I have spent a considerable amount of time on one angle I found distinctive in the book, but another thing I thought was notable (relative to other non-fiction books) was how quickly it jumped around. The chapters tended to be very short, just a few pages each, with a descriptive title and usually a location for a subtitle. Then it would go to a different place with different people in different roles and often at a different time (though the main focus is on the early 90s up through and especially in the 2000s). I couldn’t always keep track of all these people’s names, but with many of them I didn’t need to and if someone was revisited there was often a reminder of who they were. This made it relatively easy to get through without feeling overwhelmed by a huge mass of information. That’s one possible benefit of having a journalist rather than an academic for an author. The downside is that there wasn’t necessarily a lot of rigor near the end when Quinones finds hope in activists increasing awareness of addicts seeking treatment. If Mark Kleiman had been writing the book there definitely would have been more focus on evidence that anything is actually improving.

For all this talk of the villains of the book, it’s easy to overlook the genuinely good intentions behind the revolution in medical attitudes toward treating pain with opioids. The initial push began by observing people dying of cancer in hospitals, for whom the risk of addiction seems beside the point. Observing the relief in the suffering, doctors treating chronic pain patients, whom I found just as sympathetic when treated like criminals as Radley Balko did in the midst of this revolution, naturally wanted to provide the only thing that seemed to work. One of the most cited pieces of evidence behind the idea that patients were unlikely to be addicted was from a doctor who wasn’t to his own knowledge part of that push but instead just reporting one of a number of findings from a hospital database (which he never thought would be generalized to outpatients whose usage wouldn’t be monitored). The search for a “holy grail” of painkiller which wouldn’t be addictive after morphine & heroin actually had some successes even if they weren’t perfect. Compared to all the problems of heroin, methadone really does appear to lack the euphoric highs & crashing lows that lead to an escalating addictive cycle & inability to function normally, but unfortunately it wound up being implicated in the recent epidemic. The Xalisco boys specifically sought ought methadone clinics to find addicts who weren’t quite satiated with their daily dose*, and these (well-compensated with heroin) addicts served as advertisers & guides to new cities that did yeoman’s work in spreading heroin addiction. Later on when opioid overdoses started becoming a larger problem, some doctors mistakenly tried prescribing methadone for pain, which is a terrible idea because its persistence in the body makes overdoses even more likely when taken as a response to pain (which it isn’t that effective at treating) rather than at a regular interval. The surge in overdoses doctors observed were largely coming from Oxycontin, where the “contin” in the name refers to the continual release of the drug over time which is intended to similarly prevent those highs & lows. This made it safer to give people one large dose infrequently which was automatically doled out over time rather than people taking multiple small doses throughout the day. Oxycontin also had another advantage over some common painkillers in that it lacked ingredients which damaged the liver, a side effect that had served as an imperfect deterrent to the abuse of those other drugs. Unfortunately, people taking the drug without supervision were able to process the pills into a relatively pure high-quantity dose of opioid that could give addicts the euphoric surge they craved, and many elderly patients without any inclination to abuse the pills themselves had no qualms about selling their surplus and many people who would have been wary of heroin (and particularly anything requiring needles) found it easy to start with pills, only to later switch when they were thoroughly addicted and found pills more expensive than cheap Mexican black tar. Years into an epidemic of escalating prescriptions, addiction & overdoses, the formula was changed again and appears to successfully deter processing into a more abusable form. Unfortunately by this time heroin had grown enough off the back of pill usage that all of the shortfall in deaths from Oxycontin were offset by an increase in those from heroin. When reading the medical section you want to go back in a time machine to yell a warning at the doctors and head them off from the road they’re about to go on, and it doesn’t even get into the more recent problem of super-potent fentanyl being mixed into drugs and causing the surge of overdoses we’re seeing today. Spotted Toad has more directly indicted the ACA for increasing the opioid epidemic, but even before then the book makes clear that the part of the safety net intended for the unwell was deeply implicated in abetting what became our leading cause of death.
*Quinones writes that two competing visions of methadone treatment are to either have a high dose which the addict takes forever without trying to get off, or a more holistic treatment program which gradually weans the addict off dependence. In practice the common approach was low doses at a high markup and little in the way of reducing dependence.

I don’t think anything I write can do justice to the book. It’s a well-written & informative history of one of the biggest problems of our time. Read it.