Dreamland: The True Tale of America’s Opiate Epidemic

“Later, I met other parents whose children were still alive, but who had shape-shifted into lying, thieving slaves to an unseen molecule. These parents feared each night the call that their child was dead in a McDonald’s bathroom. They went broke paying for rehab, and collect calls from jail. They moved to where no one knew their shame. They prayed that the child they’d known would reemerge. Some considered suicide. They were shell-shocked and unprepared for the sudden nightmare opiate abuse had wreaked and how deeply it mangled their lives.” 

Quinones lays out a key element in the book: the way the opiate epidemic affected mostly white families, often from privileged economic circumstances, in the wealthiest country in the world. Their incomprehension, captured in this quote, also hints at the insidious nature of the opiate epidemic, in that it started with substances marketed as innocuous both on an individual and on a societal level. Quinones also highlights an important element of the book—that despite claims that prescription opiates were nonaddictive, they were in fact composed of a morphine-like molecule, similar to opiates that had been acknowledged for millennia as uniquely euphoric and therefore uniquely capable of enslaving its users.

“Rancheros had little access to education. They learned a trade from relatives—farming or ranching, mostly. But I also knew villages where all the men were itinerant construction workers. Families from one village in the state of Zacatecas I knew started tortilla shops all over Mexico; in another, men hired out as cops around the state. I wrote about Tocumbo, Michoacan, where everyone learned to make popsicles, and run popsicle shops, known as Paleterias La Michoacana, that spread across Mexico, transforming the town and the lives of these rancheros. I had also been to Tenancingo, Tlaxcala, where the young men were all pimps, exporting country girls to Mexico City and to Queens, New York, and building garish mansions back home.” 

In Part 1 Quinones describes his fascination with rancheros as wild, lawless places that entrepreneurial families had fled to, to make a living for themselves. The contrast in this quote shows how other moral considerations fell by the wayside in pursuit of this independent living, with selling popsicles and human trafficking operating on the same plane, so long as they provided independence and a decent living. In setting up this contrast, Quinones is foreshadowing a theme he will develop throughout the book: that despite conservative attitudes in Xalisco that looked down on heroin trafficking, it came to be accepted the more it generated jobs and wealth for the community. This also points to another theme: that in creating a standardized product, allowing competition, and avoiding violence, the sale of black tar heroin was a business like any other.

“Yet if Terramycin was an unmitigated benefit to humankind, Valium was less so; or rather, any benefits were offset by significant risks. There was a little of nineteenth-century patent medicine in Valium’s DNA. It didn’t treat any root cause of stress. Instead, it treated vague symptoms and thus allowed doctors to avoid the complicated work of understanding the causes of that stress. Like patent medicines, Valium was a name-brand drug, promoted together with the idea that a pill could solve any ailment. Four decades later, and well after Arthur Sackler was gone, his company, Purdue, would produce and promote through his ad firm, William Douglas McAdams, a painkiller with similar characteristics.” 

The role of marketing and salesmanship in creating the opiate epidemic is an important theme in Dreamland, and with this quote Quinones points to the root of this approach, which began with physician-turned-advertising executive Arthur Sackler, who encouraged his salesmen to sell drugs directly doctors—first an antibiotic called Terramycin and then Valium, an ancestor of OxyContin. In pioneering this approach Sackler became a giant in pharmaceutical advertising, creating approaches that would be used to sell OxyContin. In mentioning 19th-century patent medicine, Quinones also alludes to the long history of opiate misuse, when opium was mixed into products marketed as innocuous home remedies—despite the fact that the risks of opium, even then, were already clear.

“Cell profits were based on the markup inherent in retail. Their customers were strung-out, desperate junkies who couldn’t afford a half a kilo of heroin. Anyone looking for a large amount of heroin was probably a cop aiming for a case that would land the dealer in prison for years. Ask to buy a large quantity of dope, the informant said, and they’ll shut down their phones. You’ll never hear from them again. That really startled the informant. He knew of no other Mexican trafficking group that preferred to sell tiny quantities.” 

Quinones highlights one of the elements that made the Xalisco Boys unusual relative to other heroin traffickers, which ultimately led to their success: their ability to operate as small, independent cells, selling small amounts of heroin at a time while also generating huge profits. As Quinones explains, this was facilitated by the fact that all black tar heroin trafficking came out of one place—Xalisco—which allowed dealers to procure a potent and standardized supply of the drug and sell it cheaply. This approach, combined with aggressive sales tactics, created a client base so large and consistent that there was no economic need to sell wholesale—instead, profits were made one tiny balloon of heroin at a time.

“But heroin was never about the romantic subversion of societal norms. It was instead about the squarest of American things: business—dull, cold commerce. Heroin lent itself to structured underworld businesses. Addicts had no freewill to choose one day not to buy the product. They were slaves to a take-no-prisoners molecule. Dealers could thus organize heroin distribution almost according to principles taught in business schools, providing they didn’t use the product. And providing they marketed.”

This quote alludes to a theme in the book: that in selling heroin, dealers were not seeking a criminal activity but the possibility of a consistent, scalable business model. This was particularly true with heroin, which has no varietals and therefore can only be marketed based on how pure it is—or how pure salespeople claim it to be. This quote also highlights something that was unusual about the opiate epidemic: The drug that was once favored by artists, jazz musicians, and other members of the counterculture had ensnared football players, cheerleaders, and other members of America’s white middle class, who had started experimenting with opiates in the form of prescription drugs and eventually turned to heroin, desperate for the escape it offered.

“El Gato later gave Levine a Buck knife, perhaps feeling he could use some protection. Levine realized he was worlds away now from how heroin had operated for so long.

‘You didn’t have to leave your house. Dealing with those people was paradise. You could nickel-and-dime them too, when they got here. They were eager for the green money.’

Levine had never known any dealer to give away free dugs to get people hooked, or to keep addicts from getting clean—the kind of mythical pushers the government and the media had invented amid the ‘dope fiend’ scare. Until he met the Xalisco Boys.

‘This marketing technique was about that. They knew what they were doing. They were marketers.’” 

Throughout the book Quinones demonstrates how marketing and salesmanship were key to the Xalisco Boys’ success and the expansion of black tar heroin across the United States. This quote exemplifies how Quinones relays this narrative through the voices and experiences of people caught up in the epidemic—in this case, an addict named Alan Levine who was a heroin addict for many years before encountering the Xalisco Boys, at which point he realized they operated on a different plane than other heroin dealers. Quinones brings the story to life through anecdotes like this, which depict the experiences of drug users, who were among the first to observe the shift.

“So as the movement to destigmatize opiates and use them for chronic pain gained energy, the seeds of discontent were already being sown. These drugs were advertised mostly to primary care physicians, who had little pain-management training and were making their money by churning patients through their offices at a thirteen-minute clip. Not much time for nuance. Not much time for listening, or for open-ended questions that might elicit long and complicated answers. On the contrary, just as Valium helped doctors deal with anxious patients in the 1960s, opiates helped a harried doctor with what was now the largest drain on his time: chronic-pain patients.” 

In pursuing a desire to relieve the suffering of patients in pain, the medical field bypassed more complex solutions and went directly to a technological fix—a drug that promised nonaddictive pain relief. This quote illustrates part of why this approach was so appealing; it offered increasingly time-strapped doctors an easy way to address their patients’ complaints. This quote also connects OxyContin and other opiates to the roots of the modern pharmaceutical industry, when the marketing approach pioneered by Arthur Sackler to sell Valium—by appealing directly to doctors—helped create a blockbuster drug and set the stage for further advertising.

“Thus with an addict’s energy and single-mindedness, she said, the Xalisco Boys sought new markets with higher profit margins, awaiting the chance to go back home, the kings of their dreamland for a week or two. Only the self-centeredness of addiction, she said, explained how farm boys from a traditional and conservative small town could sell a product, anathema to their parents, to sad-eyed, vulnerable junkies and not be tormented.” 

Quinones points to other varieties of isolation and addiction that drove the opiate crisis. For the Xalisco Boys, the addiction was to consumer goods they could never have afforded otherwise, and the status and regard this brought them in Xalisco. But to pursue this objective, they had to ignore the cost their actions had on individuals and communities in the United States, by isolating themselves from them. This quote also alludes to the motif of dreamlands, in this case the dream of young men to broadcast wealth and success in their hometown.

“In a 1989 monograph for the National Institutes of Health, physicians from Harvard and Johns Hopkins urged readers to ‘consider the work’ of Porter and Jick, which showed ‘clearly’ that fear of addiction in those with no past drug abuse didn’t justify avoiding opiates, since the ‘study’ showed that addiction among patients ‘given these drugs in a hospital setting was extremely low.’ One researcher, writing in 1990 in Scientific American, called Porter and Jick ‘an extensive study.’ A paper for the Institute for Clinical Systems Improvement called Porter and Jick ‘a landmark report.’” 

Throughout the book Quinones describes how prescription opiates were pitched to doctors—and patients—under the pretense of being nonaddictive, despite the lack of any evidence to support that claim. This quote illustrates how an important part of that argument was based on a letter to the editor by Dr. Hershel Jick, who, noticing a lack of research on the subject, recorded a low rate of addiction among the patients in his hospital. Though this observation was published as a letter to the editor rather than a peer-reviewed study, it came to form the foundation of the pharmaceutical industry’s claims about opiates and their perception in the wider culture. This underscores just how little research and oversight there was with these drugs.

“At first, Jeremy didn’t use the drugs he sold. But one night at a party, he broke down and snorted an Oxy. That was it. Soon he was selling to support his habit. Then, in Cincinnati one day, he couldn’t find Oxys. A neighbor of his Cincinnati connection could get something else: black tar heroin. Jeremy balked. He wanted no in heroin. But the next day, he couldn’t take the dope sick anymore. The guy phoned a Mexican, who brought over small balloons of black tar heroin. Jeremy never took the pills again.” 

This quote illustrates the transition from prescription opiates to black tar heroin that constituted the opiate crisis. Jeremy Wilder initially obtained pills through a pill mill for the purposes of sale, part of the opiate economy that rose to prominence in parts of Appalachia like Ohio. But as addicts like Jeremy ran out of money for OxyContin, couldn’t find it, or developed a tolerance for it, they switched to cheaper and more potent black tar heroin. This quote also illustrates Quinones’s style of using individual experiences to highlight aspects of the opiate crisis, such as the synergy between prescription opiates and black tar heroin trafficked by the Xalisco Boys.

“Seeing his son with some cocaine one day, his father took Enrique aside. Be careful with that stuff, he said. Don’t use it. He admitted he had been a drunk for too long. It was the first time he had spoken to Enrique as a father should to his son.

‘That’s all fine,’ Enrique said. ‘But why didn’t you speak to me like this before?’

His father said nothing.

‘You have to change,’ he upbraided his father. ‘No more yelling.’” 

The scale and scope of the opiate crisis brought about cultural changes in the United States and Mexico, even as it was also a product of these changes. Quinones shows how the sale of black tar heroin rewrote cultural norms in Xalisco, where there was a conservative, paternalistic culture. As black tar heroin sales rose, and as Enrique and others expanded their cells across the United States, they returned home with enough money and status to change social codes—as Enrique does here, in criticizing his abusive and domineering father.

“They were a new kind of drug trafficking in America. The Xalisco Boys weren’t the General Motors of drugs. They succeeded because they were the Internet of dope: a network of cells with no one in charge of them all, with drivers rotating in and out, complementing each other as they competed for every junkie’s last twenty bucks, yet doing this without guns, shutting down their phones as fast as a website at any hint of law enforcement’s approach.” 

The relationship between cross-border movement and drug trafficking is an important theme in Dreamland. The drive to pursue economic opportunities in the United States, combined with the desire to improve their circumstances in Xalisco, encouraged many of the Xalisco Boys to work for black tar heroin cells in America or start their own. These motivating forces contributed to the success of this kind of heroin trafficking; as Quinones points out here, it led to a steady supply of labor that could fly under the radar or be replaced quickly after arrests. Additionally, the fact that they all came from the same place—with a highly addictive, standardized product—meant competition was possible and violence unnecessary, unlike what was common between other drug trafficking organizations. This approach made black tar heroin all but impossible to stamp out.

“Up in the United States, the Boys no longer had to rely on the limited universe of older junkies. A younger and much larger population of heroin users was emerging—casualties of the nation’s pain revolution. This synergy between pills and heroin happened first in one place. OxyContin’s popularity was spreading west just as the trafficker I call the Man brought Xalisco black tar heroin east. They collided in central and southern Ohio.” 

Quinones explains the synergy between prescription opiates and heroin: Young opiate addicts, many of whom were prescribed painkillers for legitimate reasons, such as sports injuries, ended up abusing those drugs and eventually turning to heroin. This synergy wrought particular havoc in small-town and rural America, in once-successful communities like those found in Ohio, which had an especially high number of pain clinics, where pills were dispensed per capita. Quinones also highlights the role of early pioneers of black tar heroin, including the Man, in bringing heroin to communities that had never heard of the drug before.

“Much like the Xalisco heroin system, OxyContin didn’t have king-pins. Instead, the market was moved by a bunch of small-time operators relying on newly relaxed attitudes regarding pain pill prescribing, a new pill with a huge whack of dope, and the Medicaid card. Medicaid cards had been around for years. With OxyContin, they became licenses to print money.” 

In Part 2 Quinones describes a number of government systems that exacerbated the opiate epidemic, once prescription opiates became commonplace. One of these was the Medicaid card, which allowed people to fill prescriptions for opiates that would have cost $1,000 for $3—a boon for families who had seen their government benefits reduced in other ways. As this quote highlights, OxyContin played a particularly important role in this, as other forms of opiates were harder to abuse, and fewer people did so; with the rise of OxyContin, prescription pill use and abuse became more prevalent, and the Medicaid card became more valuable.

“So many addicts crowded into cars, driven by dealers like Mary Ann, and set of rummaging through rural towns for hours looking for willing pharmacists. The whole time they talked about dope like gold miners about all they were going to do with their pills this time. This time, they vowed, they weren’t going to use them. Rather, they were going to sell them and accumulate some cash. Then they would be the ones to drive junkies to clinics and pay their visits. Those dreams evaporated on the long ride home as they snorted or injected their pills and were left again with nothing.”

This quote details an aspect of the opiate economy in Portsmouth, wherein addicts traveled between towns looking to procure prescription opiates with the intent to sell. As getting those prescriptions filled grew more difficult, since pharmacists mistrusted many of the clinics, dealers drove addicts to pharmacies around the county. Despite their intent to sell, the addicts never managed to resist taking the drugs. This mirrors the Xalisco Boys, who, rather than using the money they made selling heroin to get themselves out of the business and established in Xalisco, instead remained addicted to a cycle of consumer spending that forced them to continue traveling back to the United States.

“But by and large, it was the dealers who fueled the shoplifting trade and prodded the boosters to new ingenuity. As dealers prepared their kids to return to school in August, shoplifters fanned out armed with long order lists of clothes with kids’ sizes in shoes, shirts and pants, and school supplies. One kid I talked to wheeled flat-screen TVs through a Walmart tire shop, which rarely had much supervision, and had a door with no alarm. Line a purse with aluminum foil and the sensors of any merchandise you put in it wouldn’t activate the alarms as you exited Walmart.” 

Quinones describes the important role Walmart played in the opiate economy of Portsmouth and other Appalachian communities. As these communities declined, Walmart was often the only store left; this fueled the opiate crisis, as addicts stole from Walmart to procure OxyContin. This speaks to the degree in which people were divested from their community; this kind of shoplifting would have been more difficult if it took place at stores owned by community members, where owners and staff had more of a stake in what happened to the business. This, in turn, alludes to a theme of the book: the role community collapse and revival play in creating and addressing the opiate crisis.

“Every one of them went with the dream of earning enough to start a car shop, or open a tortilla stand, or buy a taxi. Not one ever did. True, they built houses and bought clothes for their families, those Levi’s 501s especially. But they spent the rest on beer, strip clubs, and cocaine, and walked the streets of Xalisco for a week or two the object of other men’s envy. When their money dried up, jonesing for that quick cash, they went north as heroin peons again and again.” 

After Operation Tar Pit resulted in the arrest of many of the Xalisco Boys, there was more incentive for new people to move into the business; the removal of individuals from the families who had dominated the trafficking cells meant dealers recruited workers they were not related to. Meanwhile, more young men were lured into the business by the wealth displayed by heroin traffickers; this was appealing enough to overcome negative attitudes many people had toward heroin. As this quote notes, many saw this as a temporary arrangement. They always intended to return to Mexico permanently, but the development of a lifestyle that needed quick cash made that impossible.

“Treatment has always been more effective and cheaper than prison for true drug addicts. What’s changed, Norman said, is that no longer are most of the accused African American inner-city crack users and dealers. Most of the new Tennessee junkies come from the white middle and upper-middle classes, and from the state’s white rural heartland—people who vote for, donate to, live near, do business with, or are related to the majority of Tennessee legislators.” 

Because the opiate crisis affected so many people, it forced a change in attitudes about drug addiction. In places like Portsmouth this meant recognizing that addiction was a disease rather than a weakness or moral failing, and seeing the value in providing addicts in recovery with a second chance. But this also had a lot to do with who was affected by the crisis—young white people. This quote also alludes to the fact that a tragic element of the opiate crisis—that it ensnared a whole new generation of young people who were not previously vulnerable to drugs—helped provide some of the momentum to address it, as people with decision-making power were affected and demanded action.

“As opiates quietly killed unprecedented numbers of kids, it was as if the morphine molecule narcotized public ire as well. That it began in voiceless parts of the country—in Appalachia and rural America—helped keep it quiet at first. To even see the plague required examining confusing and incomplete data. A generation of coroners had grown up unused to reporting on drug overdoses. The nuances of whether someone died from opiates, and if so, whether that was oxycodone, hydrocodone, methadone, or heroin were sometimes lost.”

Quinones references the culture of silence that existed around opiate addiction for many years, fueling the opiate crisis. This applies to the families affected, who didn’t want to speak out for fear of judgment, but it also reflects that the crisis began in economically marginalized communities, where few thought it worthy of attention. As Quinones notes elsewhere in the book, it took a high-profile death—that of actor Philip Seymour Hoffman, from a heroin overdose—to bring the opiate crisis into the national consciousness. This quote also highlights another narrative device in the book, the comparison of the opiate crisis to opiates themselves: private, selfish drugs that send their users into a fantasy.

“Many athlete-addicts were not from poor towns where sports might be a ticket out for a lucky few. The places where opiate addiction settled hard were often middle- and upper-middle-class. Parents were surgeons and developers and lawyers and provided their kids with everything. Yet sports were as much a narcotic for these communities as they were to any ghetto. Love of learning seemed absent, while their school weight rooms were palatial things, and in many of them pain pills were quietly commonplace.” 

In the final sections of the book, Quinones describes how privilege seemingly undermined the resilience of middle- and upper-middle-class kids, leaving them vulnerable to opiate abuse. But another element of this equation was the importance placed on sports in communities where opiate abuse later became endemic; as Quinones notes, football players and other athletes were given opiates by their trainers and coaches to keep them playing; when they started selling these drugs, their high status as athletes shielded them from any real consequences. And their parents, reluctant to speak about what was happening, kept quiet even as they sent their kids to rehab. As a result, many former athletes used, and overdosed, in secret.

“The Xalisco Boys’ drivers worked hard to look small-time. In reality, they were the only visible stands of large webs that sold hundreds of kilos of black tar a year across America, by the tenth of a gram. So for many years, when they were caught they were deported and faced little jail time, and no prison time. As farm boys on the make, they drew a very different message from leniency than what these Portland officials intended. To them, catch and release looked more like an invitation.”

This quote captures an important element of the cross-border migration that made black tar heroin possible: the fact that the Xalisco Boys never intended to stay in the United States and only wanted to sell enough heroin to return home relatively wealthy. Thus, getting caught and deported helped them fulfill their original objective. More cells, aware of the minimal consequences of getting caught, were drawn to places like Portland, imitating exactly what the cells before them had done and fanning the flames of the opiate crisis. The use of the Len Bias strategy in drug prosecutions, which carried the possibility of 20-year prison sentences, was a powerful tool in disrupting this chain.

“After more than a decade in which chronic pain was treated with highly addictive medicine, there was still no attempt to bring the stories of pain and addiction together. Specialists in pain and in addiction operated in different worlds. They appeared not to know each other socially. They saw the same patients; a pain patient now might soon be an addict, after all. But there were no conferences where they shared ideas. No journal combined both specialties. Nor could I find any study that attempted to measure this crucial question: How many people grew addicted to pills they were prescribed?” 

Quinones describes how, even as more people became aware of the addictive potential of opiates, few understood how to identify which patients were at risk of addiction. This left doctors in a difficult position; they didn’t want to prescribe opiates for fear of addiction, yet the pain patients were experiencing was also ruining their lives. This ignorance hearkens back to the lack of research conducted in the early days of prescription opiates and highlights how initial research into addiction was taken out of context and mischaracterized to sell drugs. Finally, this culture of ignorance reflects other knowledge gaps that Quinones references throughout the book, including the fact that opiate overdose deaths were recorded in different language, meaning few realized how many people were dying from overdoses.

“These measures recognized a recurring theme: the most selfish drug fed on atomized communities. Isolation was now as endemic to wealthy suburbs as to the Rust Belt, and had been building for years. It was true about much of a country where the streets were barren on summer evenings and kids no longer played Kick the Can as parents watched from porches. That dreamland had been lost and replaced, all too often, finally, by empty streets of bigger, nicer houses hiding addiction that each family kept secret.” 

The role of community in building resilience to the opiate crisis is an important theme in Dreamland. Here Quinones emphasizes how the decline of community, whether through postindustrial collapse and the hollowing out of former industrial areas or the acquisition of material wealth, left a generation isolated and vulnerable to drugs, even as that isolation made it harder to address the problem. This quote also references a lost dreamland, in this case the dreamland of a less individualistic and economically unequal society. Finally, this quote references a truth that Quinones discovered in reporting on the opiate crisis: Money doesn’t buy happiness.