The Connection Between Prescription Painkillers and America's Heroin Problem

The story of pain pill and heroin abuse and addiction in the United States is often so surreal one might think parts were ripped from a serialized cable drama: from polite, nonviolent drug dealers who prize customer service above all else, to a one-paragraph letter to the editor of a science journal taken out of context and used to support the erroneous hypothesis that drugs used to treat pain could not be addictive, to a small American town in which pain pills function as the de facto currency. 

This is the story journalist Sam Quinones tells in “Dreamland: The True Tale of America’s Opiate Epidemic.” Quinones spent years researching and writing about the abuse of prescription opiates, especially Purdue Pharmaceutical’s painkiller OxyContin, released in 1996, and the market of addicts that the abuse of prescription painkillers created.

“Sales of oxycodone—the drug in OxyContin, but also sold in smaller-dose generic pills—rose almost ninefold between 1999 and 2010,” Quinones writes in “Dreamland.” Many Americans became addicted to this drug or other prescription painkillers; others recognized the business opportunity and began selling painkillers on the black market. According to Quinones, in 1999, opiate overdoses contributed to ten deaths per day—by 2012, opiate overdoses contributed to one death every half hour.

Prescription opiates are just part of the story. Quinones also tells the story of another addictive drug: heroin.

The Xalisco Boys, a network of relatives and acquaintances from the town of Xalisco in the small Mexican state of Nayarit, began selling black tar heroin in rural America in the early 1990s, and quickly learned to exploit the market created by rampant over-prescription of painkillers. The infiltration of black tar heroin into America's heartland contributed to a dramatic increase in heroin usage: from 2007 to 2012, reported heroin usage rose from 373,000 people to 620,000. According to Quinones, 80 percent of these heroin users had first used a prescription painkiller. 

ATTN: spoke with Sam Quinones about the fraught history of prescription painkiller abuse and heroin addiction in the United States. This interview has been edited for clarity and length. 

Can you describe how the dramatic spike in pill and heroin abusers, who were often young and white, changed American attitudes towards incarcerating drug addicts? 

A lot of people, particularly in areas that have been historically tough on crime, are [living in] the areas where people are getting addicted. And these addicts are kids, or young adults, sometimes mid-level adults, that a lot of people know, and in large part it’s a sensitization. 

Before, a lot of legislators didn’t know any addicts. Now they do. Now they go to church with their parents, or their son played on the same football team with the kid who just died…There’s a proximity of addiction to people who never saw it before and therefore could comfortably have attitudes of "lock ‘em up and throw away the key." Now those attitudes are being revised because all around them people are becoming addicted. This is changing a lot of minds. 

It also just so happens that this is happening to lots and lots of white kids, so white legislators, white business owners, white constituents are seeing the effects of addiction. But also really important in all this is that they are seeing the effects of prison. A felony record is almost harder to shake than an addiction. Forget about a future. You can barely rent a house when you have a felony record in some areas, and finding a job, any kind of job, is very difficult with a felony record, and so a lot of people are saying, "Why don’t we have more options?"

We don’t have more options because twenty five years ago or more, during the crack years, legislators decided to lock [drug users] up and throw away the key, and not provide many options at all. So we’re living with the legacy of all that -- of the previous drug scourges -- and the reaction to them. People are readjusting now that someone close to them is addicted or dying, and families that they know to be good, decent families are suffering through this. 

You mentioned in your recent "New York Times" piece that the legalization of heroin doesn’t necessarily make sense because of the methadone clinics that already exist. Can you speak to that? 

The idea would be, well, we’ve got all these heroin addicts out there, so what we should do is to allow them to simply exist with their addiction without resorting to crime, without resorting to buying it on the street and not knowing what they’ve got. Needles are a big health problem. All of this is presumably related to the fact that heroin is illegal. But all of those problems have been ameliorated with methadone. You don’t have crime associated really with methadone. Methadone has no needles. It’s liquid. You go once a day. Methadone is also far more calming of a drug. 

Heroin spikes and crashes like crack. It’s up and down all day long. Heroin is such a great underworld business because you are always buying it, every day you’ve got to buy it four or five times a day…You’re constantly consumed with finding it, and taking it, and finding it again and taking it. I think as a legal opiate, [methadone] is in some ways a better solution.

The problem is, of course, all of these drugs are disastrous, Methadone too. If you’re in that, you are tethered to it. It’s a horribly addictive thing. But I would simply say, in response to people who might say what we need to do is legalize heroin…we already have a legalized opiate. It’s called methadone. 

You outline a variety of reasons for the abuse of prescription pills including OxyContin in “Dreamland,” from widely circulated pseudoscience, to aggressive marketing on the part of Purdue Pharmaceutical, to time-strapped doctors whose hands were often tied by the mandates passed down to them by hospitals, insurance companies, even their own patients. How would you characterize the motives of doctors who over-prescribed opiates? 

A lot of them were very sincere in believing that this was really a good idea, and that’s the problem. The nuance here is that there are some bogeymen, but they’re not the main problem. The main problem is widespread acceptance of the idea that this was the [only] way to treat pain. 

That’s why we have this rising sea level all across the country of pills. A few nasty, unscrupulous docs would not have created that. It’s impossible for them to have done that. It had to have been a widespread societal acceptance of this idea. And the problem was not so much that these pills aren’t really good for some kinds of pain, they are, particularly when very judiciously prescribed and controlled, but also widespread prescribing seemed to suck all of the oxygen out of the room, in a sense. 

There was no room for any other approach. Insurance companies stopped funding other approaches. There are a lot of ways you can attempt to control pain, this was only one of them, but it was so dominant that no other approach was really tried. If another approach was tried, it was de-funded eventually or not reimbursed. 

The last section of “Dreamland” seems to me to be describing a winding down, or at least society waking up to, the prescription opiate and heroin epidemics, yet your recent article in the Times mentions that fatal heroin overdoses have almost tripled in the past three years. Are the Xalisco Boys still operating in the same capacity today? 

I focused on the Xalisco Boys because they were the first ones to understand, in a systematic way, the pill market as a precursor to the heroin market, and go to areas where pills were creating a lot of addicts, and sell heroin there. Xalisco Boys are not the only ones selling heroin anymore. The word is out in the underworld. On top of that, most addicts are also dealers. It’s pretty easy to understand that, because most addicts can’t hold another job. I studied the Xalisco Boys because I thought they were a fascinating example of a new kind of trafficking, without violence—it’s about marketing, not gunplay. 

It’s been a long time now. People act as if this is somehow this new thing these last couple of years. This problem has been developing since the mid-90s, but we just haven’t really had to pay attention to it until recently. Now that there are lots of people dying of heroin, I have no doubt that that’s going to continue. Heroin overdoes deaths are now the leading cause of accidental death in Ohio. It used to be traffic accidents, then it was pill deaths, and now it’s heroin. I’ve talked to people there and they say it’s most likely going to happen for another couple of years. That does not all have to do with the Xalisco Boys. That has to do with a massive expansion of everybody getting into the market now. 

The town of Portsmouth [Ohio], though, has been in this longer than anybody. They were our canary. If we’d watched what happened in Portsmouth, and really paid attention, and really ratcheted back [on over-prescribing painkillers], we’d have had a running start on this problem years ago. But we ignored it. Portsmouth was one of the towns to lead us into this whole thing, and it also seems to me to be leading us out of it, in really important ways.  

What would you say to teens or young adults tempted to try pills like OxyContin without a prescription?

There is absolutely no way to use these drugs recreationally. Not that you will be addicted immediately, but very quickly. There’s no playing around with these drugs. It is a scary thought to think that someone would say, “It’s prescribed by doctors, and it’s got the pharmaceutical marking on it, it must be fine.” That ought to be clear to everybody now. It is not fine. The morphine molecule, which is in heroin and is in these pills as well, can be a slave master, because it will take you and mangle your life. 

For many years, heroin has been the ultimate outsider’s drug. The interesting thing that dawned on me when I was doing this story was that heroin is really the most conformist, middle-brow drug that we have, because it’s about one thing, and one thing only: the most conformist part of America, business. Heroin should have been forgotten. It has no real good medical use that other pills and drugs can’t fill. The reason it wasn’t forgotten is that it was perfect for drug traffickers. You could make it in a very condensed way, you could dilute it then and expand your profit, and it’s a drug that requires [addicts] to take it four or five times a day, so you have a constant client. 

Heroin is not about some sort of romantic idea of being outside society. Heroin is completely within the mainstream of our country. It's about business, 100 percent. 

How does our society avoid falling into another trap of pseudoscience and overly aggressive pharmaceutical marketing? 

All addiction is very self-centered, but these opiate drugs are the worst in that regard. They create people that have no relationship to anything else. The morphine molecule is a very jealous mistress. Everything else that you enjoyed doing at one point, you stop doing. It’s all about satisfying your need, and it is an intensely individualizing drug. 

It seems to me that the way to combat that is through community. The areas that were first lambasted by this problem were areas that had had their community destroyed—Rust Belt, Appalachian areas—and it spread into areas where people had lots more money, but they didn’t seem to have more community. They didn’t seem to be out on the streets and enjoying each other’s company, and there weren’t common places to meet and to hang out. 

In Portsmouth, that’s what’s happening. Portsmouth has done a number of things to help forge again the bonds of community that once were enormously strong, that once were forged in Dreamland [a community pool in Portsmouth which gave this book its name] and were then torn and shredded. Now they’ve got a better municipal government. That’s really important because municipal government provides a lot of solutions through which community becomes achievable. This is a town that’s taking accountability for itself and not letting other people say, “This is what you are, this is what you will be.” That’s what happens to addicts—dope determines everything about them. Portsmouth is like a recovering junkie in that way, saying “I’m no longer going to let somebody determine my future for me.” 

Here we’ve got a community that’s building itself up again into something like what it was. I don’t want to over-romanticize it either; it’s got a long way to go. It’s been beaten for years, for decades it’s been trashed, but it seems to me to be moving in a really positive direction.