Tuesday, Nov. 7, 2017
The United States is wrestling with an opioid epidemic that leaves more than 90 people dead each day from prescription painkiller, fentanyl and heroin overdoses. In the view of Sam Quinones, author of “Dreamland: The True Tale of America’s Opiate Epidemic,” the antidote to the crisis is not naloxone, the medication used to treat opioid overdoses. The antidote is community.
“Why … do we wonder that heroin is everywhere? Our very search for painlessness led us to it,” Quinones said Monday at Virginia Commonwealth University. “Isolation is heroin’s natural habitat. Heroin is the perfect symptom of how isolated we have become as Americans, and how much we have killed off or ignored what would bring us together.
Isolation is heroin’s natural habitat.
“You want to keep kids off heroin, make sure people in your neighborhood do things outside in public together,” he said. “Make your kids ride bikes outside, let them skin their knees. There’s nothing wrong with it. We got away from that. We got away from what is great and best about our country. We rid ourselves of things so essential that they have literally no price, and we have been invaded by cheap junk.”
“Dreamland” was the 2017-18 selection of VCU’s Common Book Program, which each year picks a book that explores societal issues without easy answers, encouraging students to move beyond singular solutions to complex problems. The program distributes books to all incoming first-year students, who take part in book discussion groups and engage with it in focused inquiry classes, the small, seminar-style classes that are part of the core curriculum at VCU. The Common Book Program serves as an introduction to VCU’s academic and intellectual culture.
“Before ‘Dreamland’ was selected as the 2017 common book, some faculty and staff worried that the topic was too intense and difficult for incoming students,” said Shelli Fowler, Ph.D., interim dean of University College and director of the Common Book Program. “But with opioids now the leading cause of death in the U.S. for people under 50 and with nearly 64,000 Americans fatally overdosing from opioid addiction in 2016 – an increase of 22 percent from the previous year – it was clear that avoiding the issue was not the answer.
“Not surprisingly, instead of wanting coddling and protection, our VCU students have wrapped their hearts and minds around this issue,” Fowler said. “In fact, they very often broadened our conversations with the personal stories they shared and the questions they asked.”
Quinones delivered his lecture at the W.E. Singleton Center before a crowd of 500 students, faculty, staff and community members. It capped a semester’s worth of events exploring the themes of “Dreamland,” including a speaker series on addiction and recovery, a discussion group with VCU Police academy cadets, a screening of the documentary “Oxyana,” and a community summit titled “Revive RVA: Regional Solutions to the Opioid Crisis.”
Quinones’ visit to VCU on Monday included discussions with common book student ambassadors and focused inquiry faculty, as well as a dialogue with Rams in Recovery at VCU’s Wellness Resource Center.
Today, Quinones is visiting with journalism students in the Richard T. Robertson School of Media and Culture in the College of Humanities and Sciences and focused inquiry students, and he will also meet with participants of the Recovering from Everyday Addictive Lifestyle program at the Richmond City Justice Center.
Origins of an epidemic
In his talk, Quinones outlined the history of the opioid crisis, starting with a movement by young pain management specialists who argued that the medical establishment needed to do a far better job of treating pain and that opioid painkillers were virtually nonaddictive when used to treat pain.
“Science knew nothing of the kind. There was no proof that these pills when used to treat pain would be virtually nonaddictive,” he said. “They made this argument – one guy in particular has acknowledged that ‘We made that argument because we wanted to change people’s minds. We wanted doctors, particularly old doctors, to get behind the idea that they could prescribe these pills far more liberally.’”
Member of the medical establishment eventually agreed that the U.S. was dealing with an epidemic of pain and that they weren’t doing enough about it, Quinones said.
“They began to make the argument that pain should now be considered the fifth vital sign,” Quinones said. “A vital sign is something you cannot live without. You cannot live without a pulse. A pulse is vital sign. Pain, you can live with. We all do. But nevertheless, they focused on this as a way of getting doctors to break down their fear of using opiate painkillers on pain patients.”
Meanwhile, a patients’ rights movement was emerging, suggesting that doctors must listen to patients more, and that pain is what the patient says it is, where the patient says it is, and when the patient says, Quinones said.
“So the doctor really has no control. The patient’s going to tell you, doctor, what the problem is and tell you essentially how to fix it and that you must fix it,” he said. “There were doctor evaluations that grew up in this time. Patients evaluating doctors. The questions were real blunt: Did the doctor help you treat your pain well? If you said no, the doctor could lose revenue, could lose hospital privileges. And, in time, this became a way of extorting pills out of doc. You don’t give me the pills that I want, I’m going to give you a bad evaluation.”
In 1996, he said, the “world changed” when Purdue Pharma released OxyContin. The painkiller was promoted to older doctors as a way to get them past their fear of prescribing opioids for pain management. Essentially, he said, OxyContin was being promoted like an over-the-counter medication.
“In time, what happened was, the marketing worked,” Quinones said. “Doctors began to buy the idea that we were a country in pain, that they were the ones who were required to fix it, and coast-to-coast doctors were either pushed, pressured – maybe reluctantly, maybe very eagerly – through the ‘90s, there was a revolution among doctors in prescribing these pills. It just took off. An enormous new supply was unleashed on the country.”
Quinones’ book describes the experiences of the town of Portsmouth, Ohio, which was once home to a massive swimming pool called “Dreamland” that was a vital center of the community. As the opioid crisis began to take root, economic opportunity declined, the first pill mills began to open and the pool was demolished and turned into a strip mall.
“One doctor invents this idea that you can just sell prescriptions for pain pills,” Quinones said. “It doesn't matter. No diagnosis. No inspection of whether a person really is in pain or not. You can just sell them for cash. Soon his waiting room was packed. People were there in their pajamas. People from other counties, other states. So many pills in time, other people began to open their own pill mills. In time, the only locally owned businesses that were opening in Portsmouth, Ohio were pill mills.”
“By the time the mid-2000s rolls around,” he said, “a dozen of these pill mills were operating in Portsmouth, Ohio, prescribing something on the order of 9 million pills to a town of 20,000 people.”
With OxyContin, people with addiction found themselves needing greater doses. The costs mounted.
“It took your addiction up to 150, 200, 300 milligrams per day and then you had to switch to the street because normally the doctor would be cutting you off, and by that point you were paying a dollar a milligram, so you were paying $150, $200, $300 a day. That’s not sustainable. They began looking around for something that was just as potent and much, much cheaper,” he said. “All of a sudden, cheap Mexican heroin fit that bill perfectly.”
Huntington, West Virginia was the first place where people were switching from pills to heroin and dying in large numbers, Quinones said. Now that trend has spread across the country, starting in Appalachia but soon invading even wealthy localities such as Charlotte, Salt Lake City and the Indianapolis suburbs.
“We would not have a heroin problem in America today without OxyContin. Period,” he said. “We would not have the kind of heroin problem that we have today, as fatal as it is, without cheap Mexican heroin being the alternative.”
The opioid epidemic started with pain pills, marking the first example in modern America in which a drug crisis was not brought about by drug mafias, he said.
“It started because millions of well-meaning doctors believed something that wasn’t always true in their attempt to help assuage this pain that we apparently could not live with,” he said.
What is behind the pain?
In documenting the rise of opioid addiction, Quinones found himself facing a question at the heart of the epidemic: What pain were we trying to treat?
“I think it had something to do with the fact that we have spent the last 35 years in this country destroying community,” Quinones said.
“We mock and claw at the earnings of government that provide the public assets and infrastructure that we take for granted and provide community life possible,” he said. “And meanwhile we exalt the private sector. We admire wealthy businesspeople regardless of how they made their money or whether they do anything of value for our community, while we ridicule and criticize government as incompetent, inefficient, wasteful.”
Moreover, he said, Americans seemed to want to embrace easy answers to all of their problems.
“We believe old rules don’t apply to us because we’re Americans,” he said. “These were years back when we believed it was normal for several baseball players every year to hit more than 60 home runs. It happened twice in the entire history of the sport. We believed too that you could package enormous numbers of badly, badly performing home loans ... and all of the sudden that’s a magnificent place to park your money. And we believed that massive prescribing of opiate painkillers from coast to coast, to all manner of people for all manner of conditions, would not result in widespread drug addiction.”
Americans came to see themselves as entitled to a life without pain, and not just physical pain, he said. They wanted solutions to avoid emotional and psychological pain, as well.
“We wound up dangerously separate, dangerously isolated from each other – whether in poverty or in affluence,” he said. “We wound up, in other words, just like Portsmouth after Dreamland closed. Kids no longer play in the street. Parks are unused. Dreamland lies underneath a strip mall.”
Heroin, he said, is what happens when you demolish Dreamland.
And yet, he said, there is hope on the horizon. The opioid crisis is bringing communities together and may lead to positive changes in society.
“Across the country, what I’ve noticed is that heroin, it turns out, is fearsome enough, scary enough, to begin to bring us together,” he said. “[I’ve seen] counties where they’re forming task forces, beginning to work together in ways they never have before.
“I believe, in fact, that it may be one of the most important forces for change in America, for it pushes us to recognize our own isolation from each other as Americans.”
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