These days, few can honestly doubt the seriousness of the opiate crisis in the United States of America. It has come to the attention of those at the top rungs of the country’s government, including President Donald Trump – but the problem remains, as threatening as ever.

To call the opiate crisis an epidemic is by no means hyperbole. Indeed, in 2015, the US Drug Enforcement Administration put it in precisely those terms: overdose deaths, especially those from prescription drugs and heroin, had reached epidemic levels.

What is fascinating about this health crisis is that it is a uniquely American one. American attitudes toward health care, addiction, poverty, the media, crime, law enforcement, large corporations and scientific research have all contributed to this nationwide crisis.

Join Sam Quinones as he details how this epidemic came to be, offering fascinating insights into addiction and health, as well as the very functioning of the United States as a whole. Despite the bleak situation, hope is not lost and the crisis is resolvable. The country can get back on its feet.

In this summary of Dreamland by Sam Quinones, you’ll learn

• what brand of opiates parents used to give to their unruly kids;
• how one letter to a newspaper got mistaken for something it wasn’t; and
• how to run a successful drug cartel.

The opiate crisis is being felt all over the United States – but it didn’t come out of nowhere. It’s a been a slow process, the foundations of which were laid back in the early 1980s.

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.

It was highly successful, so much so that the company released a similar drug in 1996. This new drug had oxycodone as its active ingredient, rather than MS Contin’s morphine. Oxycodone is an opium derivative not dissimilar to heroin, and once more Purdue used its time-release coating formula. The name of this pill was OxyContin.

The FDA approved OxyContin in 1995, as they believed Purdue’s big claim about the pill: supposedly, their time-release coating would limit addiction by preventing the sorts of rapid highs and lows usually associated with opiates.

The consequences of this decision were serious: now Purdue could market OxyContin with a unique safety label that stated the drug had less potential for abuse than other painkilling drugs on the market.

It was this claim that became the cornerstone of OxyContin’s marketing. This wonder drug would purportedly be the only painkiller a doctor would ever need to prescribe. It was to be an almost risk-free solution to chronic pain; unlike other opiates doctors had been prescribing for pain, this new drug had been shown to be addictive in less than 1 percent of patients.

But there was a very specific reason these rates of addiction were so low: MS Contin was being used in carefully controlled hospital conditions. Conversely, OxyContin was marketed to doctors outside hospitals. And these doctors were used to dealing with chronic pain in their patients by prescribing opiates.

Now, these old opiates were quite weak, their dosages were small, and they contained agents such as acetaminophen or Tylenol designed to prevent abuse.

Oxycontin was different. It contained large doses of oxycodone and was only deemed safe because of the special time-release coating designed to supply the active ingredient over a long period.

Purdue soon began pushing its new product. Its representatives visited doctors several times a year and took them out to lavish lunches, attempting to drive home the merits of the time-release coating and how it ensured addiction was not an issue.

It didn’t stop there: mountains of OxyContin merchandise and medical seminars at luxurious resorts were quite the norm.

And it was a success: Purdue’s sales tripled. In fact, bonuses for sales rose from $1 million in 1996 to a whopping $40 million in 2001. By 2003, OxyContin was predominantly being prescribed by primary care doctors with very little pain management training. Purdue had successfully transformed the entire industry: prescribing for pain had become the norm, not the exception.

When telling the history of the opiate crisis and OxyContin, it’s easy to forget that we’re not just talking about the last 40 years – humans have loved opiates for thousands of years. The ancient Sumerians called opium the “joy plant,” while it was also used in ancient Egypt and classical Greece as well as in India and the Arab empire.

The active molecule in opium is morphine. It’s present in a number of other plants too, but not nearly in the same potency. Morphine was first successfully isolated in the early 1800s, and its use spread in the nineteenth century thanks to its properties as a painkiller. It was also put to use in many wars.

The inventor of the hypodermic needle, Alexander Wood, believed his nineteenth-century invention would reduce drug abuse, since users would be able to accurately measure their intake, something impossible through oral ingestion. Sadly, the story goes that Wood's wife became the first recorded victim of an intravenous opiate overdose.

At about the same time in the United States, marketing certain kinds of medicine was big business. Typically, they were sold as miracle cures and, more often than not, they contained opiates.

Boisterous children? Be sure to dose them up with Mrs. Winslow’s Soothing Syrup!

By the beginning of the twentieth century, sales of such patent medicines had reached $75 million per year. It was in this climate that Dr. Alder Wright synthesized the opioid heroin in 1874, as part of an effort to find a nonaddictive alternative to morphine.

Heroin – which is actually highly addictive – went on to be prescribed for everything from coughs to menstrual cramps. Consequently, rates of addiction exploded, and it happened because a doctor swore it was safe.

There’s some solid chemistry to explain why morphine is so addictive. The morphine molecule fits perfectly into the “mu-opioid receptors” present in the brains of all mammals. These normally produce pleasure when they receive endorphins produced by the body, but when morphine is present, there’s no need to wait for the endorphins.

When morphine enters the receptors, they are overwhelmed. The result is intense euphoria as well as a numbing of pain and feelings more generally.

However, the counterbalance to the euphoria is the brutal withdrawal symptoms that addicts face. These include insomnia and diarrhea, on top of weeks of intense pain.

In fact, withdrawal can be so overwhelming for some addicts that it pushes them to lie, steal, betray and even to put their bodies at risk just to get their hands on a dose of the molecule.

The chemistry behind such problematic withdrawals is plain enough: while most drugs can be easily broken down into glucose in the body and then expelled, morphine is different. The morphine molecule stays intact and lingers.

It might seem hard to believe, but a single-paragraph letter published in 1980 changed the course of medical history.

A doctor at Boston University’s School of Medicine, Hershel Jick was asked in the early 1960s to put together a database of the records of patients who’d been hospitalized there.

In 1979, Jick became curious about what he could learn from this amassed data. He wanted to find out how many patients treated with narcotics while at the hospital had become addicted. He discovered that of about 12,000 patients, only four became addicted.

Jick wrote a short paragraph together with Jane Porter, a graduate student who’d been assisting him, in which they described their findings. They sent it to the New England Journal of Medicine, where it was published in the letters section under their names.

Elsewhere in the medical profession at about the same time, doctors were becoming increasingly interested in the idea of pain. For years, they had had patients suffering from chronic pain coming to them and begging for help. The implication seemed clear enough: pain was a serious matter and it was being undertreated.

Consequently, in 1996, the American Pain Society went so far as to declare that pain was the “fifth vital sign.”

It was in this context that advocates pushing for more treatment with opiates, such as California’s Board of Pharmacy, started putting out statements that made bold assertions, such as “studies show [opiates have] an extremely low potential for abuse” when correctly used.

Simultaneously, doctors became fearful. They were told that patient rights meant that they would be sued if they didn’t treat patients’ pain – and that meant doling out opiates.

Suddenly, and seemingly out of nowhere, people starting citing “Porter and Jick,” that little paragraph that had been written years earlier about patients in Boston. But it was being cited by people that hadn’t actually read its few lines, and who were treating it as gospel science.

Indeed, the science magazine Scientific American labelled it an “extensive study” in 1990, while a 2001 Time story casually referred to it as a “landmark study.”

Just like that, long-held wisdom about opiates was being thrown out the window. If a patient asked for higher doses of other drugs, it was taken as an indicator that the treatment wasn’t working. And with opiates, that meant that the dosage prescribed was simply too low.

A new term even cropped up: “pseudoaddiction.” It described the appearance of addiction that manifested in some patients. But in reality, all they wanted was a sufficient dose to end the pain. It was determined that these patients ought to have their dosage increased “aggressively.”

Portsmouth, Ohio was once a bustling town, built by and for American industry. But globalization hit it hard. Factories closed and jobs disappeared. By the 1990s, this town, like so many other cities in the American Rust Belt, was a shadow of its former self.

It was in places like Portsmouth that a sinister industry emerged. The jobs were hard to come by, but Medicare cards were much easier to find. This new economy was based on pill mills, clinics where doctors did little else other than write up prescriptions.

The number of applicants for the disability program called Supplemental Security Income nearly doubled between 1998 and 2008 in Scioto County, Ohio, which includes Portsmouth.

Many of these new applicants made regular visits to pill mills where they could stock up on OxyContin and trade these pills on the black market for whatever else they might need.

Some even got entrepreneurial about it and sought out groups of addicts, whom they would drive to the clinic. In exchange for the ride and for paying the clinic fee, the entrepreneur received half of the pills that were prescribed to the addict.

Before too long, an “Oxy” – a common street name for the OxyContin pill – was worth $1 per mg. From just selling pills, it was possible to buy anything from TVs to laundry detergent.

Subeconomies also developed around the illegal market. Since patients sometimes need to pass urine tests to get their prescriptions, clean urine was also worth a pretty penny. Child’s urine went at a particular premium, up to $40 for a bottle.

Many pill mills weren’t actually opened by doctors, so their success depended on the less reputable sort of medical practitioners. This is when so-called “locum tenens” lists were used. These were lists of doctors who were desperate and on the lookout for temporary employment. This was often because of license problems, substance abuse or simply because they were unable to obtain malpractice insurance.

A perfect ecosystem of abuse had been created, and it wasn’t long before established drug dealers got in on the act.

While Oxy use was on the rise in the Rust Belt in the 1980s, migrants from Xalisco, a small Mexican village, started selling black tar heroin in the San Fernando Valley in the early 1980s. They went by the name of the Xalisco Boys, and they quickly met with success.

Their business strategy was different from the other large heroin dealers. Instead of selling their product wholesale, they sold it retail.

Selling wholesale involves cutting the heroin each time it is sold on, thereby reducing its potency. Before the arrival of the Xalisco Boys, the powdered heroin sold on the streets was very weak, often containing as little as 1 percent heroin.

Black tar heroin was different. It began life as poppies growing in the hills near Xalisco. They were harvested by one member of the family, then refined into heroin by another. A third ran the cells that sold the heroin. The result was that the heroin arrived on the street at full potency.

The Xalisco Boys were also innovative in another way: their system operated similarly to franchises. The manufactured heroin was sent north to a wholesaler, who then supplied small, self-organized cells.

Each cell comprised an owner, usually based in Xalisco, as well as a manager, a phone operator and some drivers.

The operator took calls from addicts, and told them where to meet a driver, who they also kept in the loop.

The drivers drove around all day, their mouths stuffed with tiny balloons. Each had a single dose of heroin contained within. When the drivers met an addict, they spat out the necessary number of balloons and were gone in minutes.

And, if stopped by the police, the drivers would simply swallow the balloons.

The clever part was that the drivers were paid a steady salary, independent of the amount of product shifted, so they had no incentive to rip the addicts off or start cutting the heroin.

It was a good business model. A cell that started out earning $5,000 a day could make an incredible $15,000 a day within just one year.

The next part of the story has its roots back in 1947, the year methadone was invented. It was special because, although an opiate, it did not result in addicts constantly having to increase their dosages over time. It was therefore seen as a way that addicts could be treated: they could be supplied with a regular amount of methadone on a periodic basis to stop their addiction becoming worse.

Based on this principle, methadone clinics were founded. They provided an effective way of treating addicts too. However, over time, the idea took hold that methadone should be used to wean addicts off heroin completely. Consequently, for-profit clinics began reducing the amount of methadone they supplied to each addict.

The results were inevitable. Because these clinics weren’t giving their patients enough opiates, populations of addicts began to search en masse for other means by which they could satisfy their addiction.

This is where the Xalisco boys came in. It was thanks to dissatisfied addicts coming out of these methadone clinics that they were able to expand out across the San Fernando Valley in the 1990s.

Drivers showed up at clinics and handed out free samples of heroin to addicts, along with a phone number they could call to get more. The clinics gave the Xalisco boys access to a new market they hadn’t yet tapped.

It was also training for new drivers. They were taught to loiter near clinics looking for addicts. They came in close when they spotted one and asked for directions. At that moment they would spit out a few balloons of heroin and thrust the phone number into the addicts’ hands. Spitball by spitball, this was how the Xalisco boys built up their client base.

By the late 1990s, the Xalisco Boys were the undisputed drug kings in many cities.

Take the effect they had on Central City Concern, a nonprofit organization running detox centers in Portland, Oregon. In the mid-1990s, 5 to 10 percent of the patients on their books were there to detox from opiates.

When the Xalisco boys showed up, everything changed. By 1997, heroin addicts made up 50 percent of the clinics’ patients, and almost all of them had become initially hooked on Xalisco dope.

It took until 1999 for Portland officials to finally notice that they had an epidemic on their hands.

In 1991, heroin overdoses had resulted in ten deaths. By 1999, that number was 111. In just a few years, it had become the second-largest cause of death among men aged 20 to 54.

If you want to run a good business, you’ve got to keep your customers happy and you’ve got to ensure that it’s convenient to buy your product. The Xalisco Boys knew this well, and it was this approach that set them apart from other dealers. It also meant they were adept at marketing their product to an important demographic: middle-class white kids.

The Xalisco Boys didn’t just hang around on street corners waiting for their customers to show up, like other heroin dealers. They frequently approached potential new customers with free samples and price breaks.

The Xalisco Boys even made follow-up calls to good clients: were they satisfied with the service and product they were receiving? The gang also monitored regular customers for signs they might quit, and even went so far as to give going-away presents of free heroin for customers who said they were checking into rehab.

Recently released prisoners were sometimes even given packs of dope when they got out of prison to get them hooked and to come back to the Xalisco Boys for more.

Their customer service was so good that one undercover cop working narcotics in the police department of Charlotte, North Carolina, even thought their service model was probably better than many legitimate retailers.

The Xalisco Boys’ dealers were different in another way, too. Their drivers didn’t carry guns, were almost never violent and didn’t have much heroin on their persons at any one time. Because of this, if they were arrested and convicted, the punishments weren’t very harsh: maybe a bit of jail time or, at worst, deportation. It was a good deal, and it meant that there was always a steady supply of Xalisco youths eager to leave home to earn lots of cash at relatively low risk.

On top of all that, because each cell effectively operated as a separate franchise, competition between cells was how each cell could differentiate itself. For a cell to succeed, their prices and customer service had to be top notch.

Competition also pushed the Xalisco Boys’ cells into more territories. Working in less saturated markets could also drive success.

They even elicited addicts to help them push new business. For bringing in new customers or providing information about new markets, addicts were given product for free.

The Xalisco network had become monstrous: the authorities realized that something had to be done. On June 15, 2000, the FBI and the Drug Enforcement Agency launched Operation Tar Pit. In terms of geographic spread, it was the largest drug investigation in the country’s history: there were busts in 27 cities across 22 states.

But despite the numbers, the operation caused more problems than it solved.

The arrests didn’t get rid of the addicts; consequently, there was still plenty of demand for dealers. In the vacuum left behind by the Xalisco busts, competition between new suppliers lowered prices and actually increased the supply of black tar heroin across the United States.

By the 2000s, the trajectory of the pain revolution was plain for all to see: opiates had emerged as the victors. Now, most of the United States' 100 million chronic pain sufferers were receiving them. The country was consuming 86 percent of the world’s oxycodone, as well as 99 percent of its hydrocodone, another popular opiate.

In fact, hydrocodone has since become the United States’ most prescribed individual drug. There are currently 136 million prescriptions for hydrocodone-related drugs each year, while opiate painkillers are the most prescribed class of drugs.

There were knock-on effects to these prescriptions too. As more opiates were prescribed, more people began to use them recreationally. Between 2002 and 2011, 25 million Americans took prescription pills in a manner for which they weren’t intended.

On top of that, users were getting younger. In 2004, a study conducted by the Substance Abuse and Mental Health Services Administration showed that 2.4 million people 12 or older had tried prescription pills nonmedically for the first time within the previous year. That’s more than the number trying marijuana for the first time, who are on average 22 years old!

At the same time, opiate overdose deaths rose from ten a day in 1999 to 48 in 2012. Additionally, by 2011, prescription painkillers had resulted in a tripling of emergency room visits when compared to seven years earlier.

But the really shocking statistic is this: a decade after the release of OxyContin, 6.1 million people in the United States had abused it – that’s around 2.4 percent of the country’s entire population.

Now, addiction to opiate painkillers isn’t a new thing. Drugs like Lortab and Vicodin had been used by addicts for years, but their dosages were generally weak, and the pills contained substances like acetaminophen which, as mentioned earlier, limited the potential for abuse. Consequently, abusers rarely died from taking these pills.

OxyContin is different. It contains much higher doses and lacks those addiction-suppressing chemicals. And as for that special time-release coating, well, addicts soon found that they could remove it by sucking on the pills. This meant that pure oxycodone could be easily snorted or injected.

Additionally, patients who were requesting higher doses of Lortab or Vicodin were now being prescribed Oxy instead. This meant the potential for abuse was much higher, as Oxy contains much higher doses. In fact, many users went from orally taking prescribed pills to intravenous use as a way to up their highs. And, of course, once users got used to needles, it was all too easy for them to turn to the far cheaper substance of heroin and become serious addicts.

The number of heroin users in the United States rose from 373,000 in 2007 to 620,000 four years later. Of these, 80 percent had begun by using prescription painkillers.

Opiate abuse in the United States was now getting too big to ignore, and there was increasing pushback against unnecessary opiate prescriptions.

The first lawsuit against the producer of OxyContin, Purdue, was filed by a lawyer named Joe Hale. Hale was a public defender who often worked in an area called the Bottoms, a run-down neighborhood in Lucasville, Ohio, near Portsmouth.

In the late 1990s, he realized everyone in town was talking about pills they were calling OCs. And, apparently, many people were injecting them too.

Then, in 1999, Hale received a visit from the “unofficial godfather” of the Bottoms. The godfather’s daughter had recently died of an OxyContin overdose, and he wanted justice.

And so it was that, in 2001, Hale filed the first wrongful death lawsuit with reference to OxyContin.

However, Hale’s quest for justice didn’t last long. After a few court dates in which he found himself facing down eight sharply dressed Purdue attorneys, he saw no alternative but to drop the suit.

Hale wasn’t alone. In 2005, Ed Socie was working in Ohio’s department of health when he noticed deaths from accidental poisonings were on the increase. He had a look at the data and came to the conclusion that almost all these deaths involved opiates.

But Socie had trouble getting his colleagues interested in his findings. However, in 2007, Christy Beeghly took over as his department supervisor – and she did take notice. In fact, she was utterly astonished. They realized at that moment that overdose deaths were about to overtake auto accidents as the number one cause of accidental death in Ohio.

That’s no mean feat. Ever since its invention, the car had been the leading cause of accidental deaths – until 2008, the year accidental overdoses took the crown.

What’s more, the statistics painted a clear picture. The number of painkillers prescribed directly correlated with overdose deaths. Both had risen by over 300 percent between 1999 and 2008. It was hardly tendentious either: the correlation was a staggeringly high 97.9 percent.

It was becoming increasingly clear that the only way to stop the opiate crisis was to get to the source of the matter. There was no point rearranging the deckchairs – something big had to be done.

John Brownlee was among the first to attempt to face down the opiate epidemic. Brownlee had become a US attorney in 2001 at a time when people across Ohio, Kentucky and Virginia were dying of overdoses.

Brownlee began by doing what many other prosecutors were doing. They had been prosecuting the pill mill doctors, and Brownlee at first followed their lead. But when it was clearly going nowhere, Brownlee reassessed the situation and realized there was no way around it: he’d have to set his sights on Purdue. He subpoenaed all records related to the marketing of OxyContin.

The records showed that Purdue had been actively misleading in their marketing. They were claiming that OxyContin was nonaddictive, and they were doing it in all 50 states.

By fall 2006, Brownlee was ready and filed a case accusing Purdue of criminal misbranding.

He was able to show that despite Purdue’s claims in their ads, they had in fact supplied no evidence to the FDA showing that OxyContin was less addictive than other painkillers.

It was also demonstrated that the company had been teaching sales reps to claim OxyContin was harder to abuse than other drugs, even though Purdue’s own research didn’t show that to be true at all.

On top of that, the reps had been told to say that patients who were using up to 60mg of OxyContin had the ability to stop at any point without suffering withdrawal symptoms. In fact, a 2001 company study showed this not to be the case at all.

It was a strong case and Purdue ultimately pled guilty to the charge of criminal misbranding.

Brownlee set October 25 as the deadline for Purdue to accept a plea agreement. Purdue agreed to pay a $634.5 million fine to avoid prison sentences for its executives, three of whom had pled guilty. Each was sentenced to three years of probation and 400 hours of community service.

And for Brownlee, it was just the start, as successful case followed successful case. The jewel in the crown was Pfizer, against whom he managed to levy $3 billion in fines for false advertising relating to several drugs.

One reason that it’s critical to look at the effect opiates have had on the United States is that it took so long for the issue to be acknowledged. It had rumbled on and on, and there were now 16,000 fatal overdoses each year, but only a handful of parents' groups had formed with the mission of raising public awareness of the issue.

Jo Anna Krohn was one such parent. Her son had been high on Oxy and shot himself in the head while messing around with a gun.

It was while she was sitting by her comatose son’s bedside for his last few hours of life that Krohn decided she had to speak out. If she were honest and truthful, and really pushed the issue, then maybe another family wouldn’t have to go through this pain.

Krohn formed SOLACE as a group for parents mourning the loss of their children to opiates. She also started giving talks at schools in which she detailed her son’s death. Soon, SOLACE had chapters in 16 counties.

Krohn’s method isn't the only way to fight the epidemic. Brad Belcher found a particularly creative method. Belcher had been sober for five years and was tired of the fact that everyone was ignoring the heroin problem in his hometown of Marion, Ohio.

So one evening he ordered 800 large signs, and printed on each was “HEROIN IS MARION’S ECONOMY”.

Late one night, Belcher started hanging them up all around Marion, but he was caught by the city authorities when he got downtown. By morning, only eight of the signs remained: the rest had been taken down.

However, a local drug dealer had seen one of the signs, took a photo of it and posted it online. The image went viral, and, consequently, the town realized it had to act.

The death of one celebrity in particular focused the minds of many. On Super Bowl Sunday, 2014, beloved actor Philip Seymour Hoffman died unexpectedly with a syringe in his arm.

In the days of grief that followed, media outlets around the country seemed to all, suddenly and simultaneously, grasp that the country had an opiate epidemic, some 15 years after it first began.

Two decades after the start of the pain revolution, the tide finally began to turn, and a new consensus has formed as a result. Opiates should no longer be seen as necessary in combating pain. In fact, they can be considered risky at best: up to 24 percent of patients were reporting “aberrant” usage according to one 2007 study.

Purdue eventually acted too, but it was too little too late. In 2010, the company added a new ingredient to OxyContin: an abuse deterrent that made it harder to inject and abuse. If they had done this in 1996, then this story might have been very different indeed.

The FDA began requiring drug companies to educate doctors and patients about the risks of addiction for time-release painkillers. But, once again, this action was taken far later than it should have been.

All the while, OxyContin sales continued to rise. Purdue was netting an incredible $3 billion from sales of the drug each year.

But while they benefited, others suffered. According to the Center for Disease Control, fatal heroin overdoses tripled between 2010 and 2013.

Meanwhile, back in Scioto County, in the last year of their operation before they were officially banned in Ohio, pill mills there legally prescribed 9.7 million pills. The county only has 80,000 people in it.

Unfortunately, even after the pill mills had been closed for two years, doctors were still prescribing 7 million pills in the county each year.

But it’s not all bad news. As the pain revolution is coming to its close, there are signs that from the wreckage of addiction, recovery is possible.

Portsmouth is one town that’s showing the way. As former addicts ditched their drugs, they went on the lookout for a better quality of life. Gyms began to open up there, and former addicts even started setting up counselling centers to help others escape the grip of opiate addiction. People started to see former addicts in a new light: they faced fewer prejudices than before and found it easier to find work.

Now, people from all over the Rust Belt travel to Portsmouth to break their addiction cycles and get clean. In a complete turnaround, a real sense of community is growing in what was once a forgotten town. This part of the American Rust Belt is quietly rejuvenating itself.

The key message in this book summary:

The opiate crisis currently plaguing the United States has its beginnings in the 1980s, when OxyContin, a new opiate-based drug used to treat pain, was introduced. It was designated as safe and treated as such, but addiction to this new drug was soon on the rise. At the same time, increasing amounts of heroin were entering the country through sophisticated drug networks. The failure of regulatory bodies and law enforcement to address the worsening situation has contributed to making drug overdose the number one cause of accidental deaths in the United States.