Dreamland tells the fascinating story of the rise of two related phenomena – an upswing in the frequency of OxyContin prescriptions along with the popularization of high-quality Mexican black tar heroin in smaller cities and large towns in America. Quinones explains how these two trends converged to create a large increase in opioid and opiate addiction among demographic groups previously less exposed to these drugs, mainly white and somewhat more middle class. This has led to some pretty dramatic increases in fatal overdose rates.

These changes were initiated, Quinones argues, by the development of time-release oxycodone in the form of OxyContin in the mid-1990s and a revolution in the guiding philosophies of pain management and the use of opioids for chronic pain. Pharmaceutical companies took advantage of this shift by urging doctors to prescribe opioids for conditions they weren’t previously used for, like chronic back pain, or headaches. The careless repetition of the findings of one very small study was used to establish the “medical fact” that when used for treating chronic pain, opioids had addiction rates of less than 1%. Doctors and patients alike were convinced that the risk of addiction was low and the number of OxyContin prescriptions escalated hugely. Meanwhile, Big Pharma cleaned up.

While this was happening a new drug trafficking and retail network formed in the United States to peddle black tar heroin. Unlike the organized crime groups, cartels, and street gangs that sold powder heroin or other street drugs, these groups were decentralized and eschewed violence. Hailing from the small province of Xalisco on Mexico’s Pacific coast, relatively poor families set up a business transforming locally grown poppies into black tar heroin, smuggling the heroin into the United States in small amounts, and selling it via networks of delivery drivers dispatched via phone orders. Each driver only carried a small amount of heroin at any one time, stored in tiny balloons held in their mouths, so arrests resulted in only short jail stints and deportation. This network started in Southern California but quickly moved to any other markets not already dominated by larger and more dangerous competitors. Thus heroin quickly spread to the Pacific Northwest, the Southwest, and eventually the South and Midwest, to urban areas that had never had much experience with heroin before. Users who had first become addicted to OxyContin then switched to the cheaper black tar heroin. In this way the large increase in heroin addiction was generated.

Quinones weaves this all together, jumping back and forth between narratives focusing on OxyContin and opioid prescription promotion and the formation of Xalisco Boy cells. While there is some redundancy overall, the writing and various narrative strands are fascinating. Quinones is a good writer and an excellent journalist, and this is the definitive account of the rise of opioids and heroin in the first decade of the 21st century.

In the constant background is the question of who is responsible for opioid addiction. In an earlier time when junkies were dismissed as weak, poor and largely non-white, the user was assumed to be responsible for their addiction. But as the socioeconomic and racial profile of opioid and heroin addicts changes, it becomes harder to blame the user, as a greater number of Americans face affected people who are “more like us”. Then we need new culprits. In Dreamland, the culprits are pharmaceutical corporations, doctors, and decentralized Mexican drug retailers. The first two groups got everybody addicted to OxyContin – the CDC has classified prescription drug abuse as an epidemic – and the Mexican Xalisco Boys set up cheap and potent black tar delivery systems throughout small towns and regional cities in the heartland and marketed a high-quality inexpensive product to the burgeoning white user market.

The story really is one of capitalism run amok. The corporate line on OxyContin was based on the purposeful underemphasizing of the risk of addiction. Doctors were encouraged to comply with pain management standards by prescribing strong opioid drugs to patients with a variety of conditions. Unscrupulous doctors opened up pill mills. Pharmaceutical companies made huge profits. Meanwhile, Xalisco’s heroin entrepreneurs made inroads throughout much of the United States by keeping a low profile, using professionalism and high-quality service to market themselves to addicts. The theme throughout is people trying to make a living by selling opioid and opiate drugs, and succeeding.

While the book tells a compelling story of how profits were pursued, it doesn’t tell us exactly why demand skyrocketed, though it makes a few suggestions. Presumably, some of the newly addicted started taking OxyContin or oxycodone for legitimate medical purposes, and became addicted. The connection Quinones asserts between high school athletics teams pushing the painkillers on players and subsequent addiction is troubling. Many others probably tried pills recreationally, for the buzz, liked it, and continued using, then found themselves unable to quit. One gets the feeling that Quinones thinks that doctors, with the medical establishment and Big Pharma behind them, literally pushed OxyContin addiction on people by prescribing it to them unnecessarily. Or that it became so easy to get Oxy that you and your buddies could just go out and party with it more easily than buying a case of beer.

That does seem irresponsible, but then so does incarcerating the Mexican dealers and not the corporate bigwigs at Purdue Pharma. It seems hypocritical to punish some unlucky addicts while overprescribing doctors go on with their lives. Should we put some blame on the schools, since presumably if instead of DARE-based education students were given accurate information about the risks of oxycodone addiction, that might have helped?

Underlying the story is an unspoken question: If your life sucked and people around you were all abusing opioids and opiates, would you do it too? How much control does one have over individual drug-taking and subsequent addiction? If opioids were cheap, legal, ubiquitously accessible, and sold like cigarettes, what would the theoretical ceiling on addiction rates be nationally? 20 percent? 50 percent? It is difficult to measure how many individuals may have used OxyContin – or other opioids and opiates – recreationally and not become addicted. Presumably many people fall into this category; whether it is a very small minority or a very large majority is important. The standard quoted figure for heroin addiction is that 23% of people who try it become addicted, but what does the number look like for oxycodone?

I had one cynical thought as I reached the end of Dreamland. If the increase in numbers of white, middle class opioid users has helped ease punishments for drug-related crime and possession by making opioid abuse a public health problem rather than a law enforcement problem, then maybe that’s a good thing. It’s obviously not a good thing that more people are ODing or becoming addicted, but it has the side effect of making the general public and thus the political class more compassionate and less punitive in their response to addiction and drug use in general.

In a way it’s as if the nexus of pharmaceutical companies and pain management specialists has partially destigmatized opioids. This relaxing of stigmatization has its roots in a revolution in palliative care, as doctors began to understand that pain itself should be treated as much as its underlying causes. Since opioids are still the most efficacious medicines we have for treating many kinds of pain, this has led to increased access and use, at least in the United States. Increased use has led to increased addiction. And increased addiction is finally beginning to have an effect on the insane puritanism and punishment-oriented ethos that underlie much of the War on Drugs. Still, with the sheer number of overdose deaths and families destroyed, it is a high price to pay for modest judicial reform.