How America got addicted to heroin

More than half a million Americans now use heroin every year. For many of those users, their addictions began with painkillers like OxyContin.

In his new book "Dreamland: The True Tale of America’s New Opiate Epidemic," Sam Quinones tells the story of how the nation's addiction epidemic was nurtured into a crisis by pharmaceutical salespeople and doctors who promoted OxyContin as a risk-free wonder drug and by traffickers from a small village in Mexico, who delivered black tar heroin to desperate pill addicts in cities and suburbs across the U.S.

Compass spoke with Quinones about some of the larger themes of the crisis and what’s next for a country addicted to heroin. Answers have been edited for brevity and clarity.

On the pain revolution

On the 'gateway' from pills to heroin

Contrary to what these doctors believed, these pills were highly addictive. The problem is you didn’t know who would get addicted and who wouldn’t. So hundreds of thousands of people, and now millions of people, grew addicted to these pills.

These pills are a gateway to heroin. They are molecularly very much the same. They have a similar effect in terms of withdrawals when you’re trying to withdraw from them if you are addicted. The difference really is cost.

Pills cost a whole lot more on the streets than heroin. A key thing to all of that is that heroin is no longer made in Asia. The heroin that we use now in the United States is almost all made in this hemisphere. In the 1970s and ‘80s, it was made in Asia and Turkey, and therefore brought thousands of miles to get here. Now, it comes from hundreds of miles away, and therefore is much cheaper when it gets here.

On how heroin is getting here

Larger trafficking organizations out of Mexico have figured out the heroin market in the United States. All of a sudden, in the last half dozen years maybe, gradually the cartels down there have come to understand the enormous market that they now have available to them, largely because of these pills. And they have responded by expanding the production in all manner of areas, particularly in the Pacific Northwest of Mexico.

On the change of who is getting addicted

The people who are getting addicted very often nowadays are not the ones who had the drug problems before. It was inner-city kids, black kids, Appalachian kids in Columbus who had the real serious problem. With pills and heroin, it’s suburban kids, it’s middle-class kids and even upper-middle-class kids – and almost all white. Almost no one who is non-white is addicted in this way. This is true across the country.

This is very, very different. This is really drawing in on a whole new population that may have drunk a lot of alcohol before and smoked some pot, but never really seemed to get much more heavily involved in anything else. And it was definitely not the population that was doing meth and crack in prior years.

On what has changed about America’s drug use in the past 10 years

We went from using very little morphine in the '70s and '80s – and very little oxycodone and very little hydrocodone – to the point that now we use 98 percent of the world's hydrocodone supply and 83 percent of the world's oxycodone supply. That's the revolution I'm referring to. Where you have a complete change of mind of how these drugs are being used and under what circumstances and what explanation should be given when they are prescribed – which are none. This is the change that we have seen. And these drugs are absolutely the gateway to heroin.

That's why we have heroin in Alabama and in Vermont and in Idaho and in various other parts of the country that have never had this drug ever. It was never a problem. It's because the pills went there first.

On the challenge that faces this country

I think the heroin addiction challenge today is enormous, in part, because it’s in communities that have no experience dealing with it and because the numbers are so large now. Remember that heroin and pills – you treat them very [similarly]. Our rehab infrastructure has largely been overwhelmed by the numbers of people already addicted to pills and/or heroin coming into this. So we, as a country, are not used to this in many areas and we don’t have the rehab facilities in many areas to deal with it.

Nor are we mentally prepared or emotionally prepared for what goes into treating a heroin addict. It's a long, rigorous thing that usually involves the whole family. It's a nightmare – most of the families are just put through hell, lose their savings. So all of this is a part of what we'll be facing.

On government accountability

I think the FDA really needs to look at the drugs they are approving. They approved oxytocin and at the time, you could kind of say, “OK, I understand why they might do that.” All doctors were saying these drugs were virtually nonaddictive. We had a pain epidemic and along comes a pill that allows you to treat pain and take two pills a day instead of six or eight or ten. The same cannot be said, however, for other drugs like Zohydro that have been approved more recently that are very similar to OxyContin, with no abuse deterrent. This kind of approval seems crazy to me.

However, it's also important to understand that this entire epidemic has been fought almost entirely by government employees: coroners, public health nurses, DEA agents, FBI, prosecutors, cops of all types, medical examiners. The thin line between us and these drugs is really made up of a hodgepodge of government employees, who across the country, have taken it upon themselves to alert, try to alert, the population and the media to this serious problem that's been going on for about 15 years, at least. And had it not been for them, it would have been in far, worse shape.

On American patient accountability

A big part of this is that we, as American patients of medical services, after a while developed the idea that we had no accountability for our health. That we would go to a doctor and say, “Fix us. Give me a pill that will fix me. And by the way, I'm really not going to help you with this – I want you to just do it. And when you tell me that I just need to lose weight or just walk more, or for me to stop smoking or drink less, or stop hanging out at bars or whatever it is that was probably really helpful to my overall wellness, I'm probably not going to do this. And if you don't fix me, I'm going to give you a bad mark on your patient evaluation survey that are online and very easy to fill out and make you look like a bad doctor.”

We, as Americans, got into this idea that the doctors are there to fix us. And therefore, we got mad when they didn't. We need, I believe, as Americans, as users and patients of medical services, health services, to take far greater accountability for our own wellness. That is, better eating habits, questioning the drugs that are prescribed to you, questioning the amounts of drugs prescribed to you. We don't ask enough questions: “How do I use this? Why are you giving me 60?”

And that's part of what this problem is all about. We have abdicated our own responsibility and accountability, in too many cases, not always, but in too many cases for our own wellness. And lay it all on the doctor.