November 3, 2015
etween the years 2000 and 2012, 39,643 Americans died of overdoses involving heroin. In the same years 154,709—nearly four times as many—died of overdoses involving legally-prescribed opioid analgesics. The weaselly expression “overdoses involving” must be used because people who die of overdoses often have more than one substance coursing through their veins, and certain combinations—opioids or heroin with benzodiazepines such as Valium, for example—are known to be particularly dangerous. Not that this prevents doctors from prescribing such combinations.
The figures above give no aid or comfort to those who think that the problems of drug use arise solely from a drug’s illegality. Legal prescription does not in fact guarantee safe, responsible, or effective prescription, and the story of grossly irresponsible prescribing told by Sam Quinones in Dreamland: The True Tale of America’s Opiate Epidemic reflects poorly on a portion of the American medical profession—to put it very mildly.
Quinones is a journalist. When he attempts a literary effect he falls (if I may be allowed a consciously mixed metaphor) flat on his face. Cars do not “lope hypnotically.” They do not lope at all. Bad sentences abound: ‘Heroin had spread to most corners of the country because the rising sea level of opiates flowed there first.” Because heroin is an opiate, it took me a little while to understand what he meant, which is that heroin spread to many places because doctors had already prescribed opioids incontinently.
One should not have to pause over the meaning of sentences in a journalistic book. And it’s also far too long: half as long would have been twice as good. It is not always wise to turn research (of which Mr Quinones has obviously done a great deal) into pages.
Nonetheless, Dreamland is interesting. It tells two interconnected stories, that of the rise of prescription opioids, and that of a new system of heroin distribution pioneered in Xalisco, a town on the western coast of Mexico. There’s no reason to doubt Quinones’s contention that these two phenomena have had a baleful, synergistic effect on American drug users.
Poppies are grown and processed into heroin near Xalisco. The heroin is smuggled into the United States in small quantities, and distributed by young men from Xalisco who are salaried for the work, which they continue until they have accumulated enough to make a show back home. They carry small bags of heroin in their mouths so that they can swallow them if caught as they drive around American cities. All an addict has to do to initiate a purchase is ring their cellphone as if ordering a pizza. The young distributors neither take heroin nor, being salaried, have any interest in adulterating the drug, so its purity remains more or less constant, unlike that distributed in the more traditional manner. With no large-scale bosses, the system works like EBay: small enterprises that cooperate rather than compete. It is an efficient crime syndicate without a capo dei capi, and an example of how a market can organise itself, provided those in it follow certain rules both spoken and unspoken.
The Xalisco boys, as the author calls them, were so successful because they were able to find thousands of customers for heroin: dispirited whites in grim, de-industrialised towns; and bored, privileged white youths from rich communities. Both groups abused prescription opioids. Corrupt and venal doctors exchanged prescriptions for cash or Medicaid payment from poor users, and resorted to opioids as first-line treatment for rich users’ aches, pains and sports injuries. Astonishing to relate, one- ninth of the population of Ohio was taking prescribed opioids during one three month period. If a prescription is cancelled, or users just want a more frequent high, the Xalisco boys are there to provide a “fallback” fix.
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It is commonly observed (at least by me) that when Calvinists or puritans lose their faith they become ideologically, which is to say Calvinistically or puritanically, hedonist. They evangelize on behalf of pleasure that, paradoxically, is pursued out of duty rather for actual enjoyment. In like fashion, the American medical profession used to deny even those patients near death the benefit of opiates, for fear of addicting them. But once persuaded, on very slight grounds, that people in pain did not grow addicted to such drugs, and once a pharmaceutical company developed an opioid that it claimed was not addictive (as the original manufacturers of heroin, Bayer, had claimed about their product a century before), the profession atoned for its past sins. Instead of denying opiates to those who needed them, many doctors prescribe them for anyone with an ache or a twinge, whether or not they needed or benefited from the drugs. In addition, since doctors are now afraid of patient assessments that can be spread far and wide on the Internet, they become reluctant to deny patients what they want. In poor areas the keepers of little stores used to post a notice: “Please do not ask for credit; refusal often offends.” Now doctors might as well post a notice saying, “I prescribe anything because refusal often offends.” In some of the towns visited by Quinones, ex-criminal or deadbeat doctors did little else but prescribe, and made a fortune from doing so. Moreover, they were often the only doctors in town, so they faced neither competition nor censure.
The author describes the several threads of this story but does not draw them together very artfully. Moreover, he seems to accept uncritically the National Institute on Drug Addiction’s simplistic and possibly mendacious definition of addiction as “a chronic and relapsing brain disease,” when clearly there is much more to it than that. While Quinones does not hesitate to blame (justifiably) both the doctors and the pharmaceutical industry, he is careful to avoid passing any judgment on the addicts. They suffer from a disease, he repeatedly insists. If they suffer as a result of their behaviour, after all, what can they be but victims? It is well known that ordinary people, unlike those in authority and corporations, can do no wrong.
Quinones swallows hook, line, and sinker the mythology of opiate addiction, which has proved all but indestructible since originated by Thomas De Quincey and Samuel Taylor Coleridge at the beginning of the 19th century. He repeatedly uses their imagery of slavery and enslavement: “rebuilding an enslaved person,” for example, or “drug enslavement and death,” or “slaves to a molecule” or “[he] survived decades of enslavement.” Dreamland portrays withdrawal from opiates as if it were a serious medical condition, which it is not, unlike the much less hysterically publicized withdrawal from alcohol.
Not surprisingly, he believes that addiction means that people no longer make choices, but become automata. “He [an addict] was losing all control, manipulating…women for sex.” Surely, manipulating women for sex requires quite a lot of control? “Those Vicodins led to an addiction…that even had [the addict] shooting up.” The addiction, allegedly, taught him how to inject, and where to get the needles and syringes. “He was locked up…for breaking into pharmacies, his addiction out of control.” It was not he who broke into pharmacies—quite a complex action—but his addiction. Quinones quotes “addiction specialist” Dr. Richard Whitney: “Once people get addicted they really lose the power of choice.” I bet the manipulator for sex chose his women quite carefully. If we are to believe this nonsense, in the interaction between man and the molecule it is the molecule that is the agent. The addict’s dishonesty is to Quinones what forgetting is to an Alzheimer’s sufferer: neither can be held responsible for their actions, because neither can choose to act otherwise.
But the book itself provides clear evidence that this is rubbish:
Vitaliy faced a two-year prison term if he failed another probation drug test. Terrified, he turned to God Will Provide [an evangelical congregation] where he felt warmth in church for the first time. He kicked heroin, became a Bible teacher, and…went on a mission.
Berardinelli was given a probation sentence by a judge who threatened him with a long prison sentence if he didn’t get clean. With that, he finally kicked.
Try that approach on someone with acute leukaemia or polycythaemia rubra vera!
Unsurprisingly, Quinones believes that treatment is a necessary condition of “recovery” from the disease. “China,” he says, “cured itself of its opium addiction by relying on former addicts to mentor their dope-sick brothers and sisters.” Even were this true, it would go against the disease concept of addiction; but I am afraid that Mao Zedong used rather more coercive, though also more effective, “curative” methods. Nor does the author mention the studies of Lee Robins on American veterans of the Vietnam war, many thousands of whom addicted themselves to heroin while deployed only to stop without difficulty or assistance once they returned home. Quinones himself provides abundant evidence that the problem of addiction is often one of the meaning or purpose of life, and not one of a chronic, relapsing brain disease. Mr. Berardinelli gave up because he feared prison and his fear was stronger than any pleasure he still derived from his addiction. In other words, human addiction cannot be understood without reference to meaning, and meaning is not a simple matter of a few neurochemicals.
Of course, the availability of drugs has an effect on the rate at which people addict themselves to them. What is so startling in Quinones’s account, and which makes it worth reading, is the stunning incompetence, insouciance, and lack of scruple of so many so-called “pain doctors,” who prescribed drugs in huge volumes without knowing, or caring, what they were doing—in effect, serving as drug dealers. I saw it myself in my own hospital: I watched patients bound up the stairs to the pain clinic and come down again clutching their prescriptions for fentanyl patches. And this in a system of socialized medicine in which the doctors had no commercial interest in the whole absurd but damaging transaction.
No one comes out well in this book: the dealers, the patients, the drug companies, or the drug licensing authorities. The enterprise, efficiency, flexibility, and intelligence of the Xalisco boys would be admirable if directed to some better end. If I had to choose, however, the main villains in Dreamland would be the doctors. Invested with prestige and authority, they acted carelessly, irresponsibly, pusillanimously, and dishonestly. This is a far from glorious page in medical history.