How do you know if there’s a “pill mill” in your area? Check if the queue outside the pharmacy has people ordering pizza, if there are fights in the parking lot, and folk are wearing their pyjamas in broad daylight because they no longer care how they look in public.
That’s what a cop told author Sam Quinones, who spent half a decade interviewing junkies, doctors, dealers, lawyers and families who had lost their children to overdoses in writing Dreamland: The True Tale of America’s Opiate Epidemic (Bloomsbury Press, 2015). The strength of this book lies in the often agonising tales told by its protagonists, scrupulously collected and exquisitely related by the author.
Pill mills were doctors’ practices, clinics and pharmacies that prescribed or sold painkillers — by the thousands. Pill mill queues are among many utterly bizarre scenes the author paints as the deadly epidemic gripped America.
Others include junkies shoplifting “to order” from Walmart in exchange for a fix, how towns ran on an economy of pills instead of money, how addicts were ferried across state borders for the contents of their prescriptions. Once in the grip of the morphine molecule, folk behave in exceedingly strange ways.
The epidemic began on the back of relaxed legislation towards the end of the last century concerning how easily the public could obtain opiate-containing painkillers. Taking advantage of this, the Sackler brothers, through the company Purdue Pharma, started selling OxyContin, which contains oxycodone, a morphine derivative.
They marketed their product aggressively, to put it mildly, taking doctors and pharmacists on golfing weekends, and they were soon practically handing out incredibly potent, highly addictive painkillers to white, middle-class Americans.
When the law finally caught up with them last year, hundreds of thousands of deaths and ruined families later, the Sacklers paid a $6 billion fine. They made about $35 billion from OxyContin.
OxyContin tablets were expensive, especially if bought on the street, so users often turned to heroin to keep their withdrawal symptoms at bay.
To meet this demand a group of Mexicans whom Quinones calls the “Xalisco boys” started selling cheap, potent “black tar” heroin in massive amounts across the US.
The modus operandi of the Xalisco brothers was simple — drive their Mexican-made product to parking lots to meet junkies, who no longer had to score from seedy downtown dives. Black tar was cheap and high quality, and demand was high — it was a marriage made in hell.
The Mexicans selling the heroin were sugar farmers who were barely making a living back home. Driving a car around with a few balloons of black tar in your mouth was a chance to “make it”, to go back home and show off your new-found riches.
There was an endless supply of poor Mexican farmers, so catching them proved to be a waste of time — after one huge drug bust by the Drug Enforcement Administration, heroin was back on the streets after just one day. I felt sorry for these farmers, because when maximum sentences were imposed as a supposed deterrent, some ended up in US prisons for 20 years.
Quinones named his book Dreamland after a public pool in Portsmouth, New Hampshire, around which the townsfolk gathered in summer. The central message he plugs in his afterword is that community is the most effective means of fighting addiction and that the lack of it was one of the main drivers of the epidemic itself.
A generation of kids grew up shooting up behind their closed bedroom doors, scoring drugs in cars their parents had given them. When they got kicked out of their homes by parents, they lived in their cars.
It took years for parents to speak up and form communities for treatment and to deal with their loss, because it was “shameful” to have your children hooked on heroin.
In the end, even hardened Republicans began to advocate for treatment instead of incarceration because it was no longer just blacks and Hispanics, but their own white kids, getting criminal records.
The other meaning inherent in the title Dreamland is the universal junkie desire to escape pain — the dream of a life lived without pain. Nobody wants pain but it’s an inescapable part of life — in fact, those who cannot feel pain don’t last long.
Paradoxically, the morphine molecule, which has eased the suffering of the sick and dying for thousands of years, brings with it the most excruciating pain if a user forms a dependency — and this happens very fast.
Quinones writes that “it took heroin to change America” but he spoke too soon. The epidemic has become far worse because, shortly after the book’s publication, the use of fentanyl as a street drug became widespread.
Fifty times more potent than heroin, the painkiller and anaesthetic has been in medical use since the 1960s, but in recent years, it has been combined with other drugs by dealers in the US, with lethal consequences.
Since 2018, overdose deaths in America have shot up from a few thousand to nearly 100 000 a year. It has become a national problem. In 2020 the opioid epidemic cost the US $1.5 trillion, or 7% of its GDP, and was responsible for a fifth of its missing workforce, relative to figures prior to the epidemic. Estimates vary, but the number of Americans who have died in the opioid epidemic is somewhere around a million.
The Biden administration has embarked on several strategies to deal with the crisis, including working with the Mexican government, where most fentanyl-laced drugs come from.
Another strategy is the widespread distribution of Narcan, which contains naloxone, an opioid antagonist that quickly restores normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose.
Across the US, there is a swing towards understanding drug use and abuse as a social problem that requires prevention and treatment policies and programmes rather than incarceration.
In South Africa, where opioid use has risen exponentially over the past 20 years due to widespread use of whoonga and nyaope, it is also slowly being acknowledged that people need long-term support to stay off substances.
The way we intervene in curbing addiction is shifting from the medical model to a comprehensive chronic-care model. Instead of punishing addicts, we are recognising the psychological and social dimensions behind their problems.
Dreamland was named as the best book written in 2015 by, among others, Amazon, The Wall Street Journal and The Guardian. In 2019, Dreamland was selected as one of the Best 10 True-Crime Books of all time by Goodreads.com; in 2021, GQ Magazine selected it as one of the 50 Best Books of Literary Journalism of the 21st Century.
Quinones has given hundreds of lectures on the opioid epidemic to universities, narcotics agents and counsellors. His latest book, The Least of Us, (Bloomsburg Press, 2021) is also about drug addiction in the US and how people are attempting to recover community through simple acts that help the vulnerable.