Dreamland: The True Tale of America’s Opiate Epidemic

Nonfiction | Book | Adult | Published in 2015

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Chapter Summaries & Analyses

Preface-Part 1

Part 2

Parts 3-5

Key Figures

Themes

Symbols & Motifs

Important Quotes

Essay Topics

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Discussion Questions

Parts 3-5Chapter Summaries & Analyses

Part 3 Summary

Part 3 highlights one of the responses to drug use and addiction: the drug courts created to divert addicts away from jail and prison and into treatment facilities. Though these courts predate the opiate epidemic, they became a more viable alternative to incarceration after prescription opioids created a generation of White, relatively well-off addicts who were closely connected to those in power in places like Tennessee. Quinones writes, “let’s just say that firsthand exposure to opiate addiction can change a person’s mind about a lot of things” (276). This shift also reflected the fact that the opiate epidemic had increased prison populations to an unmanageable level in places like Ohio.

Changes to the criminal justice system were happening in other parts of the United States too. Portland police officers and prosecutors were refining the use of a Len Bias case—where someone who supplies drugs that cause a fatal overdose can be charged with offences that yield a 20-year prison sentence—to work up from low-level dealers to those higher-up in drug organizations, as low-level dealers flip to avoid a long sentence. This was significant because it meant men coming from Xalisco would face long sentences; the previous policy had been to simply deport dealers, leaving other cells to take their place, which favored a business model that was naturally “risk averse and imitative” (281). The use of Len Bias meant deportation was no longer the default—and that there was a stronger deterrent to black tar heroin trafficking.

Meanwhile, another important shift was happening in the opiate crisis: the decision of the parents of those who’d died to speak out about their losses. Many parents found it hard to break away from a culture of silence because these parents were successful professionals in wealthy communities; often, their children were athletes who were prescribed opiates to keep them playing sports like football. Consequently, Quinones comes “to see football players as symbols of this American epidemic” (292). Admitting that their privileged children had become addicted to pills, and eventually to heroin, was inconceivable to most of these parents. Instead, the task fell to activists like Portsmouth mother Jo Anna Krohn, whose son shot himself while high, or Wayne Campbell, whose football player son became addicted while on the high school team and died of a heroin overdose after coming home from rehab. For many parents who spoke out, this was a way of finding meaning amid the grief of losing their children.

Part 4 Summary

Part 4 depicts the opiate crisis in transition. With famous figures like actor Philip Seymour Hoffman dying of heroin overdoses, media outlets across the country started reporting on the surging rates of heroin abuse in many states. Health care providers became aware that opiates were ineffective and dangerous when used to treat chronic pain, and Purdue Pharma reformulated OxyContin to make it harder to abuse. Quinones notes that had this happened earlier, it may have helped, but with many people already addicted to a drug that no longer served their addiction as well, “they flocked to heroin in even greater numbers” (304).

Even though some drug companies were facing criminal cases and lawsuits for misbranding, which included billions of dollars in fines and settlements, this did little to alter the creation of new drugs containing opiates, and sales of OxyContin continued to rise. However, a shift was happening among doctors who had become leery of prescribing any opiate painkillers—and many avoided going into primary care, where they would interact with chronic pain patients, at all. Yet those who continued to work on pain recognized a need to move toward a tailored approach to dealing with each kind of pain rather than chasing a miracle drug that would tackle all of them.

Changes were also happening in the trafficking of black tar heroin. By 2014, the Xalisco Boys were facing competition from new dealers, some of whom were addicts, as well as from heroin coming in from other sources. In Xalisco more men were turning to avocado farming, to avoid long prison sentences if caught returning to the United States.

Part 4 closes by describing the push in the 2010s to develop better services to help opiate addicts, including changes in the viability of alternatives to prison and the need for more comprehensive rehabilitation options, as well as campaigns to bring the opiate crisis into the public consciousness. Ultimately, the solution for the opiate crisis would be found in rebuilding communities.

Part 5 Summary

Quinones opens Part 5 by spotlighting a former addict, Jeremy Wilder, who returned to Portsmouth in search of an escape from his old life. The choice was an ironic one, given Portsmouth’s long decline—including, in the 2000s, the near closure of the last survivor from the town’s zenith, a shoelace company that many people had given up for dead. But as Quinones notes, “any addict knows that rock bottom is where recovery begins” (336). A group of local businesspeople banded together to buy the company, guided not just by profit but also by a sense of the community’s importance.

The town also managed to eradicate the negative presence of pill mills. A former coroner named Terry Johnson was elected to the Ohio House of Representatives and managed to pass a bill that regulated pain clinics. Among other things, the legislation made it illegal for convicted felons to run these clinics or for doctors to give out medication at the clinics. A half-dozen pain clinics closed in the town as a result, and they did not reopen. This didn’t end the opiate crisis in town; many addicts switched to heroin instead, and millions of opiates were still prescribed in the county. But importantly, the fact that the clinics had closed “was an action townspeople took to determine their own future, instead of letting it happen to them” (339).

Other measures also helped the town recover, including a project by a group of sociology students to make small changes, like installing a floodlight in a downtown park, hiring code inspectors for rental properties, and organizing litter cleanups to improve the town’s appearance. Soon, new businesses began opening in Portsmouth, including gyms and cafes. Many of those who were caught up in the opiate crisis as addicts sought treatment and returned to the workforce, and the concentration of former addicts turned Portsmouth into a litmus test for the rest of the country, as it sought a way out of the crisis.

In Portsmouth this meant 12-step meetings in locations across town, university programs where recovering addicts trained to become social workers and drug counselors, and community spaces where people in recovery could socialize in a drug-free environment, orchestrated by an organization that employed hundreds of people, many of whom were in recovery. Though the town’s recovery was not complete—much of the available work was still minimum wage, and hundreds of addicts still lived in the town—it had started on the path. This was proof to the addicts who had arrived from all over Ohio in search of a new life that “though they were adrift, they, too, could begin to find their way back” (345).

Parts 3-5 Analysis

In the final parts of Dreamland, Quinones examines an evolving opiate crisis, as law enforcement adopted a different approach, the Xalisco Boys’ strategy evolved, and parents and addicts pushed back against the culture of silence that had allowed the opiate crisis to metastasize, unaddressed, for so long. Ultimately, he concludes that the solution to the opiate crisis lies not in any one strategy but in the complicated work of rebuilding community—a conclusion that stands in contrast to the search for an opiate painkiller that would be a panacea for all kinds of suffering.

Quinones explores how much silence, passivity, and a desire for pleasure without pain fueled the opiate crisis. This applies both to the everyday pain of trying to survive in the world and the physical pain that comes from injury and illness. In the case of the former, Quinones notes how kids who grew up “coddled, bored, and unprepared for life’s hazards and difficulties” were vulnerable to opiates, as they lacked the self-esteem and self-control needed to resist drugs (292). Drug use in adolescence then impaired the development of mature decision-making faculties, perpetuating the problem. At the same time, families seeking to avoid the pain of seeing their children suffer further, or of having their children’s addiction problems exposed, continued to rescue them, further impeding recovery.

Meanwhile, a generation of doctors came to regard pain as the fifth vital sign, prompting their patients to demand pharmaceutical relief from their pain. But just as some parents came to recognize that giving young people everything they wanted would not make them happy and resilient, more doctors started to acknowledge that treating pain meant looking holistically at the root causes—including sleep, diet, and work—rather than defaulting to a technological solution in the form of pill consumption.

Quinones also explains how addiction to consumption and status—in both the United States and Mexico—fueled the opiate crisis. In peddling black tar heroin, the Xalisco Boys were driven by a dream “to return home, a king, to pay the banda, to dance with the girls, to see other men’s envy and to feel the embrace of their families as they opened boxes containing precious Levi’s 501s and designer jeans” (317-18). Yet this display of wealth was ultimately hollow, as the lavish spending in Xalisco soon forced many men back north to sell more heroin; meanwhile, the fortunes of the community as a whole were little changed. Once in the United States, Xalisco Boys remained isolated in their apartments, rarely interacting with the communities that were being dismantled by the black tar heroin they sold. Similarly, elsewhere in the United States, rising prosperity led not to more prosperous communities but to individuals with bigger houses and garages filled with expensive cars, which provided their children the private bedrooms and cars needed to abuse opiates undetected. In this way, the individualistic drive for material goods and status fueled the opiate crisis on both sides of the equation.

Ultimately, the holistic pain strategies that Quinones describes here mirror the difficult work of rebuilding community. These non-opiate strategies are slower, more difficult to justify to insurers, and require more work on the part of the patient, but if regarded seriously, they hold promise for sustainable pain management. In a similar way, the recovery of communities like Portsmouth is also multifaceted. Through its multipronged approach—resisting the forces of economic decline, pushing back against the pill mills that had ravaged the town, and changing negative attitudes toward addiction so people in recovery could find jobs and support within the community—Portsmouth’s narrative became a story of resilience, of a town that “refused to stay down” (287).