Dreamland

How did the drive to relieve pain turn into a nationwide crisis? In Dreamland, journalist Sam Quinones argues that the American opioid epidemic was not born overnight—it emerged from the intersection of medical compassion, aggressive marketing, and entrepreneurial drug trafficking. Quinones reveals how a quest to eradicate pain created a marketplace for addiction, linking doctors, corporations, and small-town dealers into a complex web that transformed U.S. communities.

The story begins with the biochemistry of morphine—a molecule so adept at stimulating opioid receptors that it overrides human restraint. Its power to soothe and enslave makes dependence not an exception but a biochemical certainty. Morphine derivatives such as oxycodone and heroin act as both medicine and trap, promising freedom from pain even as they build tolerance and withdrawal. Understanding this molecule’s mechanics is crucial to grasping why repeated exposure inevitably produces compulsive demand.

The Medical Turn Toward Pain

By the 1980s, a reform movement known as the Pain Revolution encouraged doctors to treat pain as a humanitarian priority. Inspired by the hospice work of Cicely Saunders and WHO’s pain ladder, physicians were urged to trust patients’ pain reports and prescribe opioids compassionately. But this ethos spread beyond terminal illness. In 1980, a brief letter in the New England Journal of Medicine by Dr. Hershel Jick claimed addiction was rare among hospitalized patients. Misread by thousands, it became the cornerstone of a belief that narcotics were safe for long-term outpatient use.

When specialists like Russell Portenoy repeated that message, they helped build a professional consensus that opened the door for mass prescribing. This shift matched perfectly with institutional incentives—the Joint Commission making pain the ‘fifth vital sign,’ patient satisfaction surveys punishing cautious physicians, and pharmaceutical companies sponsoring pain-education seminars.

Enter Purdue and OxyContin

In 1996, Purdue Pharma seized the moment with OxyContin, a high-dose, timed-release form of oxycodone marketed as safer and less addictive due to its gradual absorption. Reps told doctors that fewer peaks meant less euphoria and lower abuse potential, citing selectively interpreted data. The company deployed lavish campaigns: seminars, giveaways, coupons, and personal visits. For busy physicians, the pill seemed an innovation and a moral answer to under-treated pain. Within a few years, prescriptions exploded, especially in regions already struggling economically.

Addicts quickly discovered that crushing the pill released the entire dose. Whole networks emerged to divert prescriptions—seniors selling surplus pills, clinic operators taking cash for scripts, and patients traveling hundreds of miles to ‘pill mills.’ Quinones’s portrait of Portsmouth, Ohio, reveals how legal pain clinics morphed into the epicenter of illicit opiate commerce, fueling a new rural economy of addiction.

The Mexican Connection

Meanwhile, thousands of miles south in Nayarit, Mexico, enterprising families perfected the Xalisco delivery model—a decentralized, corporate-like system for selling black tar heroin door-to-door. Young men worked as drivers, carrying small balloons of tar stored in their mouths, while phone dispatchers coordinated deliveries. Each cell operated as a small franchise with its own manager, avoiding guns and violence to stay invisible. Police happened upon drivers with minuscule quantities, mistaking them for local dealers, never realizing they were part of an interstate retail chain. This model spread through Boise, Denver, and Portland—cities far from traditional heroin hubs—precisely where new pill addiction created fresh markets.

The pills made the customers; the Xalisco Boys supplied them when prescriptions ran out. Cheap, reliable heroin became the bridge from clinic dependency to street addiction. Quinones tracks this transition through parents like Paul and Ellen Schoonover, whose son Matt died after evolving from prescribed OxyContin to black tar heroin—a pattern repeated thousands of times.

From Epidemic to Response

As the death toll rose, two systems—law enforcement and public health—struggled to respond. Federal operations such as Tar Pit and Black Gold Rush exposed the reach of Xalisco networks but couldn’t eradicate them, while epidemiologists like Jaymie Mai and Ed Socie used data to reveal the correlation between prescriptions and overdose deaths. Their findings inspired guideline reforms and clinic regulations, forcing medicine to confront its role in the crisis. Communities followed: grassroots groups like SOLACE and Tyler’s Light turned grief into activism, drug courts embraced treatment, and towns sought to rebuild around recovery and economic renewal.

When you finish Quinones’s account, you realize the opioid epidemic is not one story but an ecosystem—connecting molecules, marketing, medicine, and migration. It’s about how compassion without evidence, commerce without ethics, and enforcement without understanding combined to create an addiction economy. The recovery that follows must be equally integrated: science, medicine, community, and moral accountability working together to rewrite the story that pain relief once promised.

Quinones begins his investigation with the molecule itself. Morphine binds perfectly to the brain’s mu-opioid receptors—sites evolved to process endorphins that reward survival and affection. When morphine or its derivatives attach, they hijack that system, flooding it with unnatural pleasure and erasing the brain’s internal limit. What follows is not mere habit but chemical learning: each dose teaches the body to expect relief and punishes its absence.

Black Tar: The Rural Innovation

In Nayarit’s highlands, small producers cook poppy sap into black tar heroin—a sticky, impure variant that’s easy to smuggle and potent enough for small doses. Because it clogs needles and veins, users often switch to muscle injection or smoking, spreading infections but ensuring repeat use. Each balloon contains days of escape, and because heroin metabolizes swiftly and withdrawal strikes hard, demand becomes self-sustaining. For traffickers, this chemistry guarantees steady income: the molecule builds loyalty stronger than any contract.

Biochemical Demand and Moral Blindness

Addiction here is not moral failure but physiology meeting opportunity. Once tolerance sets in, users must consume constantly to function. Ranchero families in Xalisco understood this dynamic intuitively: their product was not about one-time highs, but dependable daily consumption—an exact parallel to legitimate businesses selling recurrent-use goods.

(In effect, chemistry dictates economics. Quinones shows that the morphine molecule’s stubborn binding and slow metabolism make withdrawal unbearable, explaining why customers return, how doctors misjudge dependence, and why synthetic opioids later worsen the same pattern.) When you grasp this molecule’s grip, you understand the rest of the book: it is biology manipulating supply and demand at the most intimate level.

To understand the medical side of the story, you trace how the effort to ease suffering evolved into permissive prescribing. In the 1980s, pain researchers argued that opiates could help chronic patients safely if ‘properly managed.’ Drs. Russell Portenoy and Kathleen Foley, working at Sloan Kettering, used small observational studies to question old prohibitions. Their work, combined with Hershel Jick’s misinterpreted 1980 letter, seemed to prove addiction was rare. Within a decade, this claim reshaped medical ethics itself.

Institutional Pressures and Industry Influence

Hospitals and regulators elevated pain to the status of a measurable vital sign. The Veterans Health Administration and JCAHO implemented protocols that required evaluation and treatment of pain, while patient satisfaction metrics penalized doctors who hesitated to prescribe. Pharmaceutical companies sponsored continuing-education courses, flooding practitioners with the ‘Addiction is rare’ mantra. Most physicians—especially general practitioners lacking pain-specialty training—followed what seemed scientific consensus rather than marketing script.

Consequences of Compassion Without Caution

The result was an era defined by abundance: widespread oxycodone, hydrocodone, and methadone prescriptions. For genuine pain sufferers, it meant relief; for many others, exposure to a molecule too powerful for chronic use. Quinones emphasizes that these medical changes created the demand that traffickers would later meet. OxyContin’s launch wasn’t a disruption from outside—it was an amplification of beliefs built inside modern medicine.

(Note: Quinones’s analysis parallels historian Keith Wailoo’s research on pain politics, showing how cultural compassion can eclipse scientific rigor.) By the time overdoses appeared in public records, the epidemic was already embedded in America’s clinical routine.

Purdue Pharma operationalized the pain revolution’s promise. With Arthur Sackler’s marketing innovations as blueprint, the company launched OxyContin as a miracle drug in 1996. Sales reps, armed with glossy charts and emotional appeals, reassured doctors that its timed-release protected against addiction. The FDA label permitted those inferences, giving Purdue legitimacy and reach.

Building National Demand

Purdue’s strategy combined repetition with relationship. Reps visited prescribers weekly, hosted conferences, and funded continuing education. They distributed logoed merchandise and free starter coupons. Doctors, influenced by the phrase ‘less than 1 percent addiction risk,’ began prescribing OxyContin broadly—for back pain, arthritis, even dental recovery. Within a few years, small towns in Appalachia and the Midwest became saturated with pills.

The Street Conversion

On the street, addicts learned to crush or dissolve the pills, releasing their full power. The warning on packaging inadvertently detailed how to abuse the drug. Single pills worth $1 apiece at pharmacies sold for $40 or more illicitly. Cash-only clinics—like Dr. David Procter's in Portsmouth—became assembly lines for addiction. Pharmacies filled prescriptions hourly; Medicaid cards and disability checks financed transactions; and shoplifting rings traded stolen goods for pills. Quinones calls this the ‘Oxy economy,’ where a legitimate substance became currency in declining towns.

The result was economic and social collapse: families bankrupted, crime rising, clinics multiplying. When users could no longer afford pills, many turned to heroin sold by the Xalisco crews, whose product cost a fraction of Oxy but delivered the same relief. Purdue’s eventual 2007 criminal plea exposed deceptive marketing but came long after entire regions had succumbed. Quinones makes clear that the company’s success didn’t just sell a drug—it built the conditions for heroin to thrive.

While America turned pain into profit, a modest town in Mexico turned heroin into business. The Xalisco Boys perfected a low-profile, customer-service model of drug delivery that mirrored corporate franchises more than criminal gangs. Each cell operated independently but followed shared principles: reliability, low violence, and professional management. The result was a national distribution system for black tar heroin.

Structure and Operation

A typical cell included an owner in Nayarit, a U.S.-based manager, a phone operator, and salaried drivers. Customers called, orders were logged, and drivers delivered balloons—tiny capsules of heroin carried in their mouths for safety. Arrests were minor; deportations merely recycled the workforce. The system maintained discretion by banning guns and violence, rotating drivers, and housing them together. Branding mattered: consistent quality, prompt service, and credit for regulars.

Resilience and Spread

Because each cell was small and autonomous, law enforcement couldn’t decapitate the network. When one crew fell, another filled the gap. Operations like Tar Pit in 2000 exposed hundreds of participants but netted only modest quantities. Still, the arrests revealed reach—Boise, Denver, Salt Lake City, Nashville. These weren’t traditional heroin markets; they were pill-soaked towns with new addicts seeking cheaper alternatives.

Like chains following consumer geography, the Xalisco Boys read market signals: where OxyContin made users desperate and heroin unfamiliar, they delivered affordability and convenience. Their method was elegant in design and brutal in consequence. Quinones’s insight—‘It was like McDonald’s; same product, same service everywhere’—refers not just to efficiency but to how modern drug trafficking adopted corporate logic: standardized processes, decentralized management, and customer loyalty.

One of Quinones’s most sobering findings is how the pill epidemic seeded the heroin wave. Prescription exposure primed brains for opioid dependence; when supply tightened or cost increased, heroin filled the gap. Clinical data confirmed the crossover: nearly 80 percent of new heroin users had started with painkillers first. This migration reshaped addiction geography—moving it from big cities to suburbs and rural America.

Economic and Social Mechanics

In places like southern Ohio, pills circulated as local currency. Medicaid cards functioned as funding mechanisms, and welfare-driven clinic visits became substitutes for jobs. When pills dried up—due to reformulated OxyContin or DEA raids—heroin offered continuity at low price. The Xalisco Boys recognized opportunity in these small-city economies: polite service, consistent strength, no guns, and delivery within minutes. They replicated the retail logic of modern convenience stores.

Human Consequences

The Schoonover family’s tragedy illustrates the transition vividly. Matt Schoonover began with prescribed pills after minor injuries, escalated to OxyContin, and when costs soared, turned to heroin—available on Columbus’s streets by phone call. His overdose death mirrors hundreds of similar cases. Families across Appalachia shared this pattern: prescriptions fostering dependence, finances collapsing, heroin finishing the story.

Quinones ties these trajectories to cultural assumptions—that medical authority signals safety and that addiction belongs to the urban poor. When middle-class kids died in suburbs, the illusion shattered, forcing a national reckoning that pain, medicine, and illicit trade had become indistinguishable parts of one economic chain.

Eventually numbers forced recognition. Epidemiologists like Jaymie Mai and Jennifer Sabel in Washington State analyzed death certificates and discovered opioid deaths rising faster than car crashes. Their correlation data proved what anecdote hinted: prescribing rates and fatalities moved together almost perfectly. This evidence spurred the first guidelines to cap dosages and require specialist oversight, repealing permissive laws that had encouraged overprescribing.

Policy Shifts and Local Legislation

Ohio followed with reform: House Bill 93 mandated clinic licensing, prohibited dispensing of narcotics from physician offices, and barred felons from owning clinics. These pragmatic laws arose not from theory but community data—county coroners and affected families demanding action. Public health reclaimed narrative control from pharmaceutical marketing.

Grassroots Recovery

Quinones closes with people rebuilding from loss. Jo Anna Krohn’s SOLACE and Wayne Campbell’s Tyler’s Light transformed grief into advocacy. Judge Seth Norman’s drug court blended punishment with long-term treatment, while towns like Marion pioneered Vivitrol programs and community employment initiatives. Survivors and parents used storytelling to fight stigma, turning despair into civic mobilization.

In the final message, Quinones asserts that recovery is collective. Arrests and guidelines stop symptoms but not causes. Only integrated responses—treatment, public education, job renewal, and compassion—can undo the chain connecting morphine chemistry, corporate greed, and social neglect. In the same way a molecule linked receptors across brains, rebuilding must link hearts across communities.