If you happened to live near a certain clinic in Portsmouth, Ohio, in the early 2000s, you might find yourself regularly answering your doorbell to people asking to buy your urine. The town, once awarded All-American City status by the National Civic League, stands across the Ohio River from the site of America’s first “pill mill” — a medical office, usually posing as a “pain clinic,” where people can easily obtain prescriptions for pain-killers — opened in 1979.
By the dawn of the 21st century, Portsmouth was lousy with pill mills, and Oxycontin tablets served as the area’s informal currency. You could buy refrigerators with pills, pay your dentist with them, or hire an off-duty cable guy to hook you up for a tablet or two. Obtaining the clean urine needed to pass the clinics’ desultory random drug tests, however, clearly required more resourceful tactics.
In time, Portsmouth would join the epicenter of a stealthy, ongoing boom in heroin addiction. The number of people who used heroin in the past year doubled between 2005 and 2012, and the number of deaths from heroin overdose have quintupled in the past decade. The vast majority of these new junkies are white and live in rural areas and small towns and cities in the Midwest and New England. Many are poor, but their ranks are swelling with young people from affluent suburban families, particularly jocks and the kids who hang out with them.
How did this happen and how did it go unnoticed for so long? The story, as related in Sam Quinones’s fascinating new book, “Dreamland: The True Tale of America’s New Opiate Epidemic,” is a tale of convergence. One thread is the decay of cities like Portsmouth, who lost their 20th-century industrial base: jobs in manufacturing, mining and other blue collar fields. Another was a misbegotten “revolution” in standard medical practices for treating pain, funded by a pharmaceutical company with a suite of synthetic opiates to peddle. The third and most remarkable element was a new system of illicit drug distribution, designed and entirely operated by the residents of small backwater village in Mexico.
The current upsurge in heroin addiction attracted little attention at first because its roots lie in what Quinones describes as “voiceless parts of the country — in Appalachia and rural America.” In the unconscious moral mythology of America, small town and rural life is associated with hard work, safety and wholesome virtues, while heroin is an affliction of big cities, with their vice, crime and scary dark-skinned residents. To admit that poverty and despair, irrespective of race, fosters heroin abuse is to undermine entrenched, unspoken prejudices that equate this particular addiction with the moral and cultural weakness of “other people.”
Nevertheless, the meth plague, which flourished in many of the same communities, drew plenty of notice. America’s smack crisis snuck up on us by beginning as a legal, and then a quasi-legal phenomenon. What’s most shocking about Quinones’s history of the rise of addictive pain-killers like OxyContin is that the apotheosis of these drugs was based on completely unfounded scientific claims.
In the 1980s, a small contingent of physicians began to argue that doctors were not treating patients’ pain aggressively enough. Physicians were trained to hold back on effective drugs like morphine for fear of causing dependency. Purdue Pharma, which was developing and promoting OxyContin, a timed-release version of oxycodone, embraced this movement. Purdue sponsored conferences at which advocates for a complete overhaul of pain management protocols urged doctors to prescribe pain-killers more readily. It made sure its sales reps reiterated the claim that only 1 percent of patients prescribed opiate pain-killers become addicted to the drug. Addicts, this line of reason held, were people who used opiates recreationally. Some doctors even insisted that pain prevented addiction by keeping patients from feeling the euphoria that causes you to get hooked.
That 1 percent figure, often cited in pharmaceutical literature, textbooks and medical journals, was attributed “Porter and Jick,” described in one such publication as a “landmark report.” As Quinones establishes, there is no such report. “Porter and Jick,” the chapter and verse of free-handed opiate administration, was actually a letter sent to the New England Journal of Medicine by two researchers in 1980. One paragraph in that letter stated that an informal search of the authors’ database of hospitalized patients in acute pain showed that few became addicted to opiates administered in controlled settings by doctors and nurses. Via a flabbergasting game of scientific Telephone, this paragraph, which no one seems to have bothered to look up and verify, was reimagined as a full-fledged study. Authorities cited it repeatedly to encourage an enormous increase in the prescription of opiates, all under the mistaken belief that they were not addictive as long the patient was actually in pain.
This, of course, proved to be utterly untrue. Outpatients were prescribed long courses of opiates for conditions and injuries that never would have merited it before — including high school athletes, who are often urged to play through injuries. Many became addicted and began to seek the drugs from shady or downright illegal sources. Chronically unemployed people on dwindling benefits used prescriptions from pill mills and their Medicare cards to buy discounted pain-killers and resell them at a considerable profit to addicts. But OxyContin and its pharmaceutical brethren remained fairly expensive — $20 to $60 dollars per pill, depending on the dose. And it was at this point, in the late 1990s, that cheap, plentiful supplies of high-quality heroin became easily available in dozens of mid-sized American cities.
The dealers of this dark, sticky black-tar heroin all hailed from a set of clans out of the obscure Mexican state of Nayarit, specifically from the vicinity of a town called Xalisco (not Jalisco, which is another Mexican state). Xalisco is a rancho, an outpost settlement inhabited by rugged frontier types fleeing the “stifling classism” of Mexico’s cities. Quinones, who knows rancho culture well and confesses to a “romantic infatuation” with it, describes these settlements as “lawless, wild places, full of amazing tales.” The ranchos also foster a tenacious entrepreneurial spirit, and rancheros have founded chains of tortilla shops and paleta (popsicle) stands that extend all over Mexico, funneling the money back home to their villages to build impressive mansions they like to lord over their neighbors.
The genius of the Xalisco Boys, as Quinones calls this new group of heroin dealers, was to run their drug business like a popsicle stand franchise. A central manager parceled out single doses of black-tar heroin into small balloons. Drivers, typically young men from the farms around Xalisco and often relatives of the rest of the crew, stuffed their mouths with the balloons and delivered orders to customers at home. All you had to do to get your fix was telephone, and a polite, clean, peaceable Xalisco Boy would shortly appear at your doorstep. They dealt only in small amounts. The Boys never used the product, and no one carried a gun; that would have meant jail instead of deportation if a driver were picked up by the cops. The heroin the Boys sold was exceptionally pure because instead of having passed through (and been stepped on by) a series of middlemen, it was usually made by a relative back home, from poppies harvested in the mountains above Xalisco.
It’s difficult not to admire the Xalisco Boys just a little bit. They embody the sort of independent industrious spirit that we consider quintessentially American. Unlike the big, vicious, borderland Mexican drug cartels, with which they have sometimes been confused, the Boys were nonviolent and low-profile, preferring to target smaller cities without established dealers or prominent gangs. When another clan came to town to open up a rival tiendita, or store, they didn’t fight over territory. This was a business of return customers, not turf. Instead, they competed on service or — having gotten the drug cheaply, direct from the source — on price. To the amazement of every junkie who bought from them and every cop who tried to roll them up, the Xalisco Boy drivers were on salary, and much of their earnings were sent directly back to their families. All they dreamed of was going home to their villages to impress their neighbors with their wealth.
One reason why the current heroin epidemic is so white is that the rancheros apparently were fearful of African-Americans, who they associated with gangs and the sort of extravagant violence destined to attract police attention. Eventually the big-time cartels did move in on the Xalisco Boys’ action a bit, although tienditas still exist in many small American cities. The heroin that helped kill actor Philip Seymour Hoffman in New York City last year, for example, was a brown powder, most likely supplied by a Mexican cartel instead.
Nevertheless, black tar heroin, however unobtrusive and pacifist its distributors may be, still ruins and takes lives. Despite their gumption, the Xalisco Boys spread a scourge. Strikingly, Quinones found that the only watchmen who noticed the mounting toll, who spoke out about it and and fought it, were people working for the government. “We’ve seen the demonization of government and the exultation of the free market in America over the previous thirty years,” he writes. “But here was a story where the battle against the free market’s worst effects was taken on mostly by anonymous public employees.” The flip side to American individualism is a strong sense of communal responsibility, and that, thank god, has not perished with the factories and mills.