I was in a darkened room listening to two presenters with their different vantage points on opiates in the workplace, and during the talk, they mentioned the book Dreamland: The True Tale of America’s Opiate Epidemic. I disagreed with what seemed to be the presenters’ fundamental premise that drugs are evil, and are to blame for the problems we face as a society, but that made me more interested in reading the book they seemed to be drawing from. Perhaps, in my desire to understand addiction, I had somehow ended up on a side street rather than a main thoroughfare of perspectives on addiction.

As I began to read, I realized that, much like my perspective in my review of The Fearless Organization, there’s a component of the problem related to the coverage in the book – but that there are many factors that have received insufficient coverage. In the case of Dreamland, it’s not just about the morphine molecule but also about people.

Oxycontin

The poppy plant, and the opiates it produces, have been with us since the start of civilization between the Tigress and Euphrates rivers. Morphine may have only been first distilled in 1804, but its history travels back much further than that. However, as recently as 1999, pain management became important to medicine through the work of the American Pain Society. Press Ganey surveys became powerful forces in medicine to assess patients’ satisfaction with their doctors. The lower the pain, the better the scores. Even today, patients are asked whether they feel as if their pain is well-managed.

Though the American Pain Society promoted pain to be the fifth vital sign, it is different than the other four, which can be measured by calibrated instruments. Pain is whatever the patient says it is – and that opens the door for problems.

About the same time, in 1996, in the search for the perfect, non-addicting version of the morphine molecule, Purdue Pharmaceuticals took oxycodone, a synthetic opioid, and packaged it in a time-release pill called OxyContin. The aggressive marketing of OxyContin along with other factors led to a massive increase in the use of opiates – in the form of OxyContin – to treat pain.

Pharmacological Theory of Addiction

At that time, it was believed that high and low feelings created addiction. It was further believed that OxyContin solved this problem by continuous dosing, and therefore it was non-addictive. However, the story has its problems. The first is what was purported as strong evidence that people who were prescribed opiates didn’t get addicted – as was previously believed. The “strong evidence” was a single paragraph written as an editorial about the results of the progression of abuse in inpatient settings – not the outpatient prescriptions OxyContin was being suggested for. The editorial was written based on a database query of those inpatients who developed addiction which as a result of controlled settings was relatively few. In short, OxyContin was sold as non-addictive. An army of drug representatives sold it to doctors this way, who, in turn, prescribed it for patients.

There was another problem, too. OxyContin contains a high dose of oxycodone. It was the time release formula that made this make sense. If you don’t crush the tablet, all is fine. However, like a child who is told not to do something, the cat slipped out of the bag. If you crush the tablets – which you learned not to do by a warning label – you can remove the time-delay of release, resulting in a dose of oxycodone all at once and creating a euphoria.

The understanding of morphine and related opioids is that they overwhelm a receptor in our brains – the mu receptor. In doing so, they are far more powerful than any high that people can get naturally. It’s also understood that, after the influence of opioids, these receptors take some time to recover. In effect, the belief is that no one stands a chance against a morphine-based drug.

Retraining the Brain

Support for the idea that opioids can reprogram a brain comes from Toxoplasma gondii. It’s a parasite that infects cats. It’s excreted in their feces and ingested by rats. T. gondii, Dreamland reports, “reprograms the infected rat to love cat urine, which, to healthy rats, is a predator warning.” There’s a problem with this. When I went to investigate this fascinating idea, it seemed more far-fetched than reality. When humans are infected with T. gondii, they are higher in extraversion and lower in conscientiousness (fear). This is the kind of behavior you might define in rats as loving cat urine: less fear and greater extraversion.

While it’s possible that opioids literally reprogram the addict’s brain (or even the first-time user), it seems like this is more like propaganda than reality. (See Chasing the Scream for more on how drug addiction has been propagandized.) It’s certainly possible that opioids change biases in the brain, and acclimatization happens, meaning higher amounts of natural endorphins are required to activate the same response as was previously possible. But, again, this is a far cry from reprogramming.

The secondary support for the reprogramming idea comes from the fact that addicts will do things that are harmful to them. The problem is that they’re only harmful in the long term. Humans use stress to get a performance boost and pay the long-term consequences. (See Why Zebras Don’t Get Ulcers.) It’s true that our ability to defer gratification and do long-term planning is a large part of our success. But it’s a far cry to say that anyone who eats an extra cookie at the picnic is an addict. (See The Marshmallow Test for more about the positive impacts of delayed gratification.)

Addictive Tendencies

If you rule out that drugs are inherently evil and can reprogram the brain, you’re left with the reality that people are getting addicted, and they’re getting addicted at a very high rate. There’s something going on. It seems to be that “something” is susceptibility to being addicted. Some would argue that we can be genetically predisposed to being addicted. The answer might be a bit more complicated than that.

The Globalization of Addiction shares Bruce Alexander and his colleagues’ work, including a very interesting experiment called “rat park.” The research indicated that rats will continue to drink morphine-laced water until they kill themselves, but Alexander and his colleagues found that’s only true when the rats are bored. If you give the rats a social interaction and playthings, they much prefer that to overusing morphine. In short, when you deprive rats of the kinds of stimulation and community they need, they turn to drugs.

If our addictive tendencies are anything like rats’ tendencies, it’s because of things that are missing in our lives. We see this trend happening today. Robert Putnam has written about how our communities and connections are unraveling in both Bowling Alone and Our Kids. (Each book approaches the problem from a different lens.) Sherry Turkle in Alone Together writes about how technology has changed the way we interact, making us simultaneously more connected and disconnected. In short, the breakdown in our communities is leading to more capacity for addiction.

Interestingly, it may be one of the reasons why successful programs involve communities, such as Delancey Street (see Change or Die and Change Anything for two places where this program is cited) and twelve-step programs (see Why and How 12-Step Groups Work). Even the growth of gangs seems deterred by improving communities, as they tend to be another way people escape their existence. (See Trust: Human Nature and the Reconstitution of Social Order for more.)

Drug Community

Communities may be a way of staying out of drugs – but once you’re in a community that centers around drugs, it becomes harder to get out. When all your friends are users or dealers, they’ll inevitably pull you back in. (There’s a story related in 12 Rules for Life about Satan touring Hell and showing off the cauldrons – including the one with no need for protection, as anytime a Russian starts to get out, the others pull them back in.) So, while community is necessary to avoid addiction, it can, at times, create a safe haven for drug addiction.

That’s what happened when OxyContin gained acceptance in the medical community and at large. It’s not that abuse didn’t happen before – it did. What changed was the constraints that limited addiction were removed, and, as a result, addiction soared. What started with honest primary care physicians prescribing a little more than they should because they’re weren’t well-trained in pain management degenerated in to pill mills.

Pill Mills

If you want to tell the difference between a regular doctor’s office and a pill mill, all you have to do is look at the parking lot. Dreamland recounts, “If you see lines of people standing around outside, smoking, people getting pizza delivered, fistfights, and traffic jams – if you see people in pajamas who don’t care what they look like in public – that’s a pill mill.” What’s a pill mill? It’s a cash-only business, where “patients” pay a fee to get a prescription for narcotics. The visits are notoriously short, and the doctors don’t suggest alternative treatments or understanding pain better. It’s a “just take this and it will get better” approach with no thought given to the root cause or how to stop the pain. All that’s hoped for is temporary relief.

These pill mills spawned their own systems. People would get put on disability not for the somewhat trivial monthly amount but because it also gave them Medicaid. And Medicaid would pay the sometimes $1,200 fee for their drugs. The street value of the drugs was often even higher than this. The result is a system where those with a little money would pay for the exam fee at a pill mill and split the pills they got after filling the prescription. The elderly would sell some of their drugs to make a little bit of money. It seemed like anyone addicted to pills would need to support their habit by selling some of them.

Another solution was to steal. Walmart grew in rural America and brought economies of scale and globalization. In turn, it shut down local retailers, who couldn’t compete. In many Walmart stores across rural America, theft is just a part of business. The Walmart greeters aren’t really there to greet people as much as they are there to deter theft. However, addicts weren’t deterred and instead found ways to work around the system.

Dial for Drugs

The socioeconomic system was primed. Many people were hooked on pills they couldn’t afford. They needed a cheaper solution, and it came in the form of a phone number. Mexicans from Xalisco began taking calls and delivering drugs to addicts. Farmers and their children barely subsisted on sugar cane they could grow. However, poppies and the black tar heroin harvested from it was very lucrative in the United States. They created a system of drivers, and selling small amounts made heroin more accessible and cheaper than it had ever been. Some reports are that a one-gram hit of heroin cost roughly the same as a pack of cigarettes.

The Xalisco boys would come into town through an addict who got them connected to the community – usually in exchange for supplying their addiction. They’d find methadone clinics – which were sometimes described as game preserves for addicts. Handing out a phone number and some free samples, they’d quickly develop a clientele. That would be the start of a new drug cell.

Police Presence

The system worked well. Drivers never had much heroin on them and what they did have were in balloons in their mouths. If they were about to be arrested, they’d swallow what they had. Even when that didn’t work, they never had enough to be perceived as a threat, so they either got small sentences or were simply deported. The drivers were mostly illegal immigrants, all from the area of Xalisco.

The Xalisco boys made a point of blending in. Simple cars and apartments were traded in frequently. Just enough for them to run their system. Even after the largest scale drug enforcement action ever executed, there was only a one-day blip in the supply of drugs to most cities. The structure was an organization of individual small business owners, each trying to bring heroin to a place that wanted it.

The Cost

The cost wasn’t measured in dollars. It was measured in lives. It’s tragic. Drug overdoses in some communities outpaced deaths due to automobile accidents. It killed indiscriminately. It was no longer limited to skid-row junkies that no one knew or cared about. It happened to children. It happened to businessmen, politicians, policemen, and the wealthy. Still, it was quiet for a long time. The shame and stigma wouldn’t let go. Slowly, the story changed. Slowly, people began to recognize the truth that had been forgotten and ignored – that treatment is more cost-effective than incarceration. Medical professionals started treating the addicted not as pariahs but instead as people who needed help.

People still die every day of drug addiction. They die directly through overdose and indirectly through the complications of drug use. We haven’t – and cannot – stop it, no more than we can stop the legions of drug dealers from trying to make a profit. However, the tide is slowly changing. We’re recognizing that we need to support and help rather than condemn and confine.

The Road Back

The road back from the path that liberalized the prescription of painkillers and the systems of drug dealers that our police were ill-equipped to fight is long. Those who succumb to addiction are prisoners who need to be set free. They need to understand that their lives can be filled with positive things. They need to understand that they can accomplish something – and that something can lead them to their own Dreamland.

Footnote

There’s so much more to Dreamland that I didn’t share. My point wasn’t to convey the entire length and breadth of the book. Instead, in this review, my hope was to share the core of the very real problem that gripped, then strangled, much of America. My hope has been and always is that anyone struggling with addiction can escape their prison and find their own personal Dreamland.