Dreamland

by Sam Quinones  [2015]

This book provides a brief history of the opioid crisis in the US and describes how an illegal heroin operation in the US was run.

The Timeline of the Opioid Epidemic

In 1979, a doctor at Boston University’s School of Medicine, Hershel Jick studied the hospital’s patient database and found that out of 12,000 patients who had been treated with narcotics, only 4 became addicted.  He wrote a short paragraph describing his findings and submitted it to the New England Journal of Medicine.  The NEJM published it in the letters-to-the-editor section.  This was significant, as we’ll see later.

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.

The pill was highly successful and in 1996 Purdue released a similar drug, OxyContin.  Instead of morphine, Oxycontin’s active ingredient was oxycodone, an opium derivative similar to heroin.  It also had the time-release coating.

In 1995, the FDA had approved OxyContin largely on Purdue’s claims that because of the time-release coating, less than 1% of patients would become addicted.  What the FDA failed to notice was that this was true only in the carefully controlled hospital conditions.  But Purdue aggressively marketed the pill to doctors outside of hospitals.

By 2003, OxyContin was predominantly being prescribed by primary care physicians with very little pain management training.

Adding fuel to the fire was that, suddenly, people were citing Hershel Jick’s 1979 paragraph as gospel science.  Scientific American labelled it an “extensive study”.  Time referred to it as a “landmark study”.  The small study that Jick and a graduate student had conducted about weak narcotics used in controlled environments was now being used as evidence that way more powerful narcotics (e.g. OxyContin) were safe for prescription use.

So when patients asked for higher doses of opioid painkillers, it was taken as an indicator that the treatment wasn’t working.  And that meant that the dosage prescribed was simply too low.  [Editor’s note:  Some medical professionals now understand that most or all patients who take opioids for chronic pain will predictably ask for higher doses because their bodies become desensitized to opioids over time and they need higher doses just to get the same relief].

Another problem: the time-release coating that was meant to suppress addiction was easily defeated, just by sucking on it.

The Evolution of the Black Market for Opioids

In the 1990s many factories closed and many jobs were lost, particularly in the Rust Belt.  With jobs being hard to find and narcotics prescriptions easy to get, a new black market emerged.  Pill mills were clinics where doctors did little else than write prescriptions.  Drug dealers would make regular visits to pill mills where they could stock up on OxyContin.  Selling the OxyContin to addicts was a way to make a living.

While Oxy use was on the rise in the Rust Belt, migrants from Xalisco, Mexico started selling heroin in the San Fernando Valley.  They went by the name of the Xalisco Boys and their success was remarkable.  Here’s what made them different than the competition:

• Their logistics and organization were professional and efficient
• They sold un-cut heroin whereas their competitors sold much weaker product
• They expanded by basically franchising their operations
• They paid their delivery drivers salaries, so they had less incentive to rip off addicts or start cutting the heroin
• Their customer service was considered superior to many legitimate retailers
• Their drivers carried very little heroin at any time and didn’t carry weapons; this meant they weren’t violent and served little jail time if caught

Within about a year, a “franchise” could make $15,000 a day.  The Xalisco Boys network had become monstrous.

Finally, in 2000, the FBI and DEA launched Operation Tar Pit into the Xalisco Boys, the largest drug investigation in the country’s history.  There were busts in 27 cities across 22 states.  However, the vacuum left behind by the Xalisco busts was filled by new suppliers.  The new suppliers were smaller and had to be more competitive, so they lowered their prices and actually increased the supply of black tar heroin in the US.

A US Attorney Fights Back

By the 2000s, the US had 100 million chronic pain sufferers taking opiates.  The country was consuming 86% of the world’s oxycodone, as well as 99% of its hydrocodone, another popular opiate.  In fact, hydrocodone has since become the US’s most prescribed individual drug, with 136 million prescriptions each year.  [Editor’s note: part of the reason we dominate the world in the use of opiates is that most of the rest of the world has banned them for treatment of chronic pain].

In 2001, John Brownlee became a US attorney and began investigating Purdue.

In 2006, Brownlee brought a suit against Purdue accusing them of criminal misbranding.  Despite their ads, they had given the FDA no proof that OxyContin was less addictive than other painkillers.  Also, their sales reps made claims that patients using up to 60mg of OxyContin a day could stop using without withdrawal symptoms.  The company knew that wasn’t true.

Purdue lost the case and paid a $634 million fine to avoid prison time for its executives.

Brownlee continued bringing case after case, and winning.  He got Pfizer to pay a $3 billion fine for false advertising related to several drugs.

Epilogue

Opioid overdoses have been the nation’s leading cause of accidental deaths since 2008 (surpassing car accidents).  Purdue has made $3 billion a year from the sale of OxyContin.