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Book Review: Dreamland
(Sam Quinones)

“Dreamland” is about opiate addition, and about an America most of us don’t see. Those most affected by the explosion in opiate use chronicled in “Dreamland” are members of the white underclass, a group with no champions and no power, and therefore little focus on its problems. To the extent it affects those not in the white underclass, the addiction is frequently hidden. Either way, we see little of it. Quinones forces this America forward and explains it. And he simultaneously shows how this America is the bastard child of unfettered welfare and private greed, midwifed by the decayed culture of our time.

“Dreamland” is particularly interesting to me because its pivot point is one American town: Portsmouth, Ohio, a picture of which is on the cover. I spent winter and summer vacations for my entire childhood in Portsmouth, where my grandparents lived, and I have very fond memories of the town. I knew it had fallen on economic hard times in past decades, but the extent and impact of opiate addiction on the town startled and saddened me.

The book consists of Quinones weaving together two threads: the explosion of legal prescription opiates in the 1990s, and the near-simultaneous explosion of cheap Mexican heroin. As to legal opiates (Oxycontin, primarily), the 1990s featured a reversal in American medical thinking, from a decades-old overriding fear of addiction to a junk science universal belief that addiction was uncommon and easily managed. This reversal was the result of three things. First, the increased focus on patient autonomy and away from a paternalistic view of medicine. Second, a belief by doctors that more could be done to alleviate pain, particularly of the intractable, terminal sort (quickly degenerating into prescribing opiates for all types of pain). Third, the development and aggressive marketing of opiates, particularly by Purdue Pharma.

This was a new, yet total, scientific consensus. “Everyone knew” that addiction was extremely unlikely from prescription opiates. Anybody who said otherwise was ridiculed and ostracized by the scientific community. It turned out to be total junk science, as so many similar scientific consensuses have, from the joys of radium to the non-microbial causes of stomach ulcers to the evils of eggs and butter. For some reason, though, we are all supposed to believe the scientific consensuses of today without question. To take only the most prominent example, to the extent there really is a scientific consensus regarding anthropogenic global warming, it MUST NOT BE QUESTIONED! SCIENCE IS NEVER WRONG! DENIALIST! A little humility is probably in order.

Anyway, the result of this new scientific belief was a huge increase in prescription of opiates. Given that resulting addiction was, in reality, very common, millions became addicted. (As one addict says, taking opiates made him feel like “King of the World and President of Everything.” Hard to compete with that.) By itself, the increase in addiction would have been a big problem, but limited by the ability of addicts to purchase opiates. This is where prescription fraud exacerbated the problem. “Pill mills” sprung up, which prescribed medically unnecessary opiates to addicts, using Medicaid to pay for nearly all the prescriptions. The opiates were either used to feed the addiction of the recipient, or sold to other addicts.

Even with Medicaid and other welfare programs fueling the demand, prescription opiates could not always be obtained. Fortunately for addicts, though, at roughly the same time, Mexicans from the small region of Xalisco developed a totally new heroin distribution model, featuring near-limitless supplies of cheap, low-grade “black tar” heroin. These dealers sold on a decentralized, pizza delivery model; they deliberately chose small towns and regional cities, rather than big cities with established drug dealers and violence; and they kept their profile low and their customers happy. So many addicts turned from prescription opiates to black tar, further ruining their lives, and frequently dying from overdoses or from health problems caused by impurities in the low-quality heroin.

None of this would have been possible without two things. First, massive government welfare programs, most of them totally lacking oversight, which created the pill mills. Without these programs, opiate prescriptions might have increased due to the reign of junk science, but not to nearly the same degree. Second, the existence of a huge and growing underclass totally dependent on those government programs and totally lacking in any of the characteristics of what was called, in a more sensible time, the “deserving poor.”

One takeaway of this book is the moral vacuum in which today’s white underclass lives. The black underclass gets studied and talked about a lot, with its modern pathologies created by the welfare state (prior to the 1960s, the social structures, employment rates, and so forth of black families typically were BETTER than those of white families). But today’s white underclass is arguably even worse off, both economically and spiritually. It collects a lot of welfare, but gets little public attention, especially from liberals. This is probably because these days alleged white privilege is a capital sin; because the white underclass is not concentrated in highly visible cities; and because its members don’t spend their days gunning each other down in the streets in highly visible ways. Nonetheless, the huge white underclass is a challenge, particularly for conservatives who think that the biggest problem facing America is its small-but-immensely-powerful execrable coast-based ruling class. Renewing America would require both neutering that ruling class and remaking the underclass—both extremely tall orders.

On a similar note of challenge to conservatives, the complex social reality underlying opiate abuse shows the error Mitt Romney made in claiming that 47% of voters will vote Democratic “no matter what,” because they are “dependent upon government.” While it’s true that far too many people are dependent upon government, and many are featured in this book, I suspect that relatively few of them voted for Obama, if they voted at all. One of the paradoxes of modern conservatism is that in many areas of the country, it’s the poor and dependent that are reliable Republican voters. They are many of the people whom Obama contemptuously characterized as “bitter clingers” (“they get bitter, they cling to guns or religion or antipathy toward people who aren’t like them”).

In some ways they simply believe in common sense—they believe America and Americans should come first, not some effete global elite or illegal immigrants; they realize that guns are tools every person needs; and they don’t pretend that Bruce Jenner is now a woman because he changed his name to Caitlyn and pretends to be a woman. But at the same time they are dependent on the government for everything and they are uneducated and simple-thinking. Conservatives want their votes, but they frequently (and always, in the case of “insider” conservatives) have nearly as much contempt for the actual people as Obama. Of course liberal support comes, to an even greater degree, from the lower, dependent classes, combined with a crust of the wealthy and semi-wealthy who do, in fact, largely sponge off the government (that is, off of their fellow citizens). So there is certainly some truth to Romney’s comment, but it’s probably something like 30%, not 47%.

Finally, this book challenges those who want to legalize drugs. Yes, it’s true that most drug legalization focus is on marijuana, not opiates; and yes, it’s true that marijuana is by no means clearly a gateway to other drug use. The usual argument in favor of legalization is that the costs, in the form of crime resulting from black markets, exceed the benefits, especially since supposedly people will use drugs regardless of legal status. By legalizing drugs, we will supposedly reduce crime and experience little additional addiction. “Dreamland” pushes back against both those arguments. Other than the crime of drug dealing, the Xalisco drug distribution model involved essentially zero violence or crime (although certainly other drug dealing involves black-market fueled crime). It is a free market model not dissimilar to what we might see if opiates were generally legalized. And the result was, and is, the destruction of entire towns and regions. Probably, if opiates were generally legalized, violence would go down. But in modern America, where the structures of community have disappeared and every person’s individual choice is exalted, it seems likely that the result would be massive social destruction.

The book is somewhat longer than is strictly necessary, and it hops back and forth in short chapters among a wide range of players. It gets confusing and sometimes feels repetitive. I think Quinones is trying to maintain the reader’s interest with a “journalistic” style of writing; to me it feels somewhat ADD. But in the end, the vivid portrayals and their lessons stick with the reader, and that, I think, is the author’s ultimate goal, at which he succeeds.

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