So I finally read the book Dreamland: The True Tale of America’s Opiate Epidemic and just as everyone had said: it’s very, very good. The book tells two stories in parallel: the first is the tale of the development and marketing of Oxycontin by the now-disgraced pharmaceutical giant Purdue and the second is the story of how a relatively unsophisticated (or at least loosely-organized) group of Mexicans from the small state of Nayarit brought black-tar heroin to the United States and spread it through small predominantly white towns across the entire country.
One good way to measure how much I like a non-fiction book is by the number of highlights I record — in Dreamland I recorded a very substantial 72 highlights which is on the high-end even for me. The book does hit at the sweet-spot of some of my interests — the decline of white middle America, the malfeasance of pharmaceutical executives, and the linking of Mexican and American economies, cultures, and futures via the drug trade.
I take particular interest in the malfeasance of pharmaceutical company executives as a result of having seen it up-close. At the beginning of my career, I was a consultant econometrician and I worked primarily doing paid-research at the behest of pharmaceutical giants. In fact, the last client I worked for (with causality!) was Purdue pharmaceuticals and I left that business just absolutely disgusted with how pharmaceuticals pay for the research that they want and then use that research to convince doctors to prescribe their products. This book actually did a really good job of laying out how dubious “published research” can be used to convince an entire country’s doctors to throw out what they had learned in medical school and begin prescribing highly-addictive narcotics to legions of patients.
As I did in my summary of Evicted, below I’ll include some of the most poignant excerpts from the book and some of the key takeaways that I had.
On the scale of the success of Purdue Pharmaceutical selling legal narcotics
The scale of the success of Arthur Sackler’s Purdue Pharmaceuticals is really mindblowing. The world has really never seen a business that made so much pure profit. They did this by selling addictive narcotics, which they marketed heavily — both to consumers and to doctors.
Valium became the pharmaceutical industry’s first hundred-million-dollar drug, and then its first billion-dollar drug. By the midseventies Valium was found indeed to be addictive and a street trade grew up around it. Hoffman-La Roche was accused of not warning of the drug’s addictive potential.
In 1995, 35,000 Americans were pharmaceutical sales reps. Ten years later, a record 110,000 people—Sackler’s progeny all—were traveling the country selling legal drugs in America.
In 1996, Purdue paid one million dollars in bonuses tied to Oxy sales, and forty million dollars in bonuses five years later.
On how the Xalisco Boys brought a new model of drug-dealing to the US
Last year I read this really thought-provoking history of Domino’s Pizza that laid out how Dominos’ developed a product that came to completely dominate the market for pizza in the united states over the course of a few decades. That product is not pizza: that product is hot food delivered as conveniently as possible. The pizza didn’t even have to be very good, and for years it really wasn’t! Dominos wasn’t selling pizza, it was selling convenience.
The black-tar heroin sellers from Nayarit brought the same innovation to heroin sales in the United States. They brought a safe, simple, and convenient delivery model to addicts in the united states
The Xalisco traffickers’ innovation was literally a delivery mechanism as well. Guys from Xalisco had figured out that what white people—especially middle-class white kids—want most is service, convenience. They didn’t want to go to skid row or some seedy dope house to buy their drugs. Now they didn’t need to. The guys from Xalisco would deliver it to them.
In addition to the innovations around convenience, the black-tar traffickers avoided many of the problems that plagued other heroin operations at the time — large, violent organizations that operate out of a central location both called attention to themselves and were easy to break up and take down via standard police investigations. By using large mobile fleets of dealers never holding more than a few grams worth of heroin at a time, the black-tar dealers were able to deal under-the-rader and avoid long jail sentences.
Ask to buy a large quantity of dope, the informant said, and they’ll shut down their phones. You’ll never hear from them again. That really startled the informant. He knew of no other Mexican trafficking group that preferred to sell tiny quantities.
He nixed Philadelphia, too. It had a huge heroin market, but it was run by the Mafia and street gangs. He didn’t even consider New York or Baltimore. It was crazy to think that a bunch of Mexican farm boys could break in there. Why would they want to? The country was full of towns like Columbus—wealthy places with growing numbers of addicts and no competition. So the contours of the Xalisco heroin nation took shape, based largely on the territory the Man carved out by avoiding the biggest cities where heroin markets were already controlled, and by following the OxyContin.
As camouflage, these Mexican heroin guys used just-in-time supplying, like any global corporation, to ensure they had only tiny quantities in their cars or apartments. This, too, was sophistication Baldessare didn’t see in the heroin underworld.
Finally, because many of these dealers both knew each other from back home in Mexico and planned on permanently returning there after earning enough money (i.e., they never planned to set up a permanent operation in the United States) the drug dealing model was copied and spread across the US by enterprising black-tar entrepreneurs. Because of their aversion to violence, the proliferation of independent heroin shops drove the price of black-tar down and encouraged the dealers to fan out across the country in order to set up their own shops in virgin territory.
These drivers knew each other, and would stop to chat or meet for lunch. Even as they competed and drove down each other’s prices, they did so in peace. They went out of their way to avoid attention. It helped that the drivers had no investment in how much they sold, and that they didn’t use. There was no incentive for them to cut their dope. They didn’t make any more money if they cut it than if they sold it as it came. They were employees, guys on a salary, with their costs covered and a stipend of several hundred dollars a week. The last thing they wanted was violence.
On using “published research” as pharmaceutical advertising
Purdue Pharmaceuticals marketed Oxycontin in a way never before seen (and hopefully in a way we’ll never see again). One of their strategies for marketing Oxycontin was by flying primary-care physicians out to “conferences” (which also met the requirements for ongoing professional training) at nice-weather resorts where pain experts reviewed the latest research on Narcotics. Of course, those pain experts were doctors paid by Purdue.
They cited research that was either out of date, poorly performed, or just completely misinterpreted in order to make their case that opioids like Oxycontin were non-addictive and safe to prescribe.
It’s important to note how devious this can be — most general practice doctors have neither the time nor the inclination to spend their precious free time reading tedious journal articles. If articles did come out saying that narcotics like Oxycontin were addictive, they didn’t get the same kind of publication and advertising muscle that any research (often funded by Purdue!) would get. Even if 10 times as many articles are published show that opioids are addictive if the articles that show the opposite get 100 times the exposure via marketing and conference discussions, which ones do you think will reach more doctors?
That “less than 1 percent” statistic stuck. But a crucial point was lost: Jick’s database consisted of hospitalized patients from years when opiates were strictly controlled in hospitals and given in tiny doses to those suffering the most acute pain, all overseen by doctors. These were not chronic-pain patients going home with bottles of pain pills.
But only in 2010 did the NEJM put all its archives online; before that, the archives only went back to 1993. To actually look up Porter and Jick, to discover that it was a one-paragraph letter to the editor, and not a scientific study, required going to a medical school library and digging up the actual issue, which took time most doctors didn’t have.
All you need is one guy to say what he was saying. The others guys who are sounding a warning about these drugs don’t get funded. They get a journal article, not a megaphone.”
It’s important to remember that this doesn’t just happen with opioids — this is an old trick in the pharmaceutical marketing handbook. Pharmaceutical companies will sponsor enough research to flood the world with journal articles supporting their point of view, and then those articles will get cited by other articles (which might not note the conflict of interest) — through sheer volume of research, the pharmaceutical companies can obtain a large share-of-voice in the market even with less-compelling evidence.
One last fun tidbit
In 1853, meanwhile, an Edinburgh doctor named Alexander Wood invented the hypodermic needle, a delivery system superior to both eating the pills and the then-popular anal suppositories. Needles allowed more accurate dosing. Wood and other doctors also believed needles would literally remove the patient’s appetite for the drug, which no longer had to be eaten. This proved incorrect. Wood’s wife became the first recorded overdose death from an injected opiate.