The U.S. opioid epidemic left roughly 30,000 people dead in 2014 -- with overdose deaths outnumbering fatalities from car accidents in 16 states.
In his book, "Dreamland: The True Tale of America's Opiate Epidemic," , a former reporter for the Los Angeles Times, traces the history of this epidemic, and the forces that fueled the crisis to grow, unnoticed and unabated for years.
The story begins in the "ranchos" of one small Mexican community, continues at paid speaker training seminars in Boca Raton, Fla., and slowly unravels in places like Portsmouth, Ohio; Huntington, W.Va.; and Denver.
Quinones met with addicts and others who've witnessed the crisis up close. He spoke with scientists, physicians, marketing representatives, and former drug dealers. He spoke with ľֱ (MPT) about his quest to answer the question -- how did this epidemic happen? This interview has been edited for length and clarity.
MPT: What surprised you the most when you spoke with healthcare professionals about the opioid epidemic?
Quinones: I guess how many of them actually bought the idea that you could prescribe [opioids] without any consequences. That was weird...but when you have forces of economics and law and culture and peer pressure all in play, things like this can happen.
In the book, you describe a pivotal 1980 letter to the editor of the, in which the writers stated, "Although there were 11,882 patients who received at least one narcotic preparation, there were only four cases of reasonably well documented addiction in patients who had a history of addiction... We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction." What role did this letter play in how physicians justified the use of opioids to treat pain?
Quinones: The problem was that headline 'Addiction rare in patients treated with narcotics.' People [read that and] said 'Oh, addictions rare when treated with narcotics, Oh great.' The letter was completely misinterpreted. It was written based on data from the 1960s and 70s. Those were years when you didn't get opiates unless doctors were hovering over you.
The [letter authors] didn't go back and say 'Under what circumstances were those 11,000 people given opiates?' Were they ever given [opioids] to take home with them? Hell, no. Never! It was a hospital setting. What the letter said was that, in a hospital setting when [opioid use is] very judiciously overseen, and [no medications are] sent home with people...sure, there's nothing wrong with that letter.
But at the time, there was this revolutionary, almost religious fervor, to treat pain -- the fifth vital sign -- [and] that message was lost. Porter and Jick's 101-word letter becomes characterized as a 'landmark study' that changes what we know about addiction and opiate pain killers.
How could that have happened?
Quinones: My impression is it kind of turned into a cross between telephone and the [story] the Emperor Has No Clothes. What [the letter] says is exaggerated or misconstrued or misinterpreted, at the same time people are citing it, saying, 'Well, if you don't know what Porter and Jick said, you must not be with it.'
No one goes back and looks in the dusty files of archives of NEJM at the local university where they practice [The letter wasn't available in the journal's online archives until 2010]. Because they didn't have the time, and I think largely because people wanted it to be true.
What about the environment physicians were working in as the opioid epidemic began to grow?
Quinones: Being a doctor in certain areas is a withering, wearying job, because you are constantly confronted with people whose health is part of a much larger issue -- lack of work , maybe a culture of poverty, poor diet, there's a long list of things. People tend to look at these doctors like keys to life strategies; a linchpin to a survival strategy: 'Get me workers comp.' How do I get [supplemental security income]?' The only way you can get that is with a doctor.
You tell the story of "pill mill " doctor ; how did he become the "villain" in this story?
Quinones: If you read the 1988 investigation of Procter by the Kentucky State Board of Medical Licensure, he was seen to be a doctor who was looking for other options for his patients, getting second opinions, that kind of thing. Fast forward 10 years, and I mean it's another guy. He's a devil. He's extorting sex from addicted women. It seems to me he went through a period of gradual corruption until he was at the point where he was like 'I just want to get laid every time a woman's in here. I don't care if her toddler son's in the room.'
Then he begins to hire doctors to run the clinics for him, many of them locum tenens, some of them addicts themselves. They all begin to go out and start their own clinics. So Procter is know as the godfather of the pill mill because others learned it from him.
The book also covers how the healthcare system inadvertently incentivized opioid pill-pushing, because physicians were being pressured to see more patients and spend less time with each one.
Quinones: These pills were billed as a boon to doctors -- a tool that all of a sudden [solved] all your problem with chronic pain. It actually ended up being a huge curse for doctors. It made them lazy sometimes. It made them corrupt. And all of a sudden [physicians] were violating laws that maybe you didn't think you were violating. And it made the patients more insistent than ever.
You got to the point where you almost had to be an over-prescriber or a non-prescriber. It was very hard to walk that middle line, and I feel for doctors who've tried it.
Big Pharma takes some blame for its questionable marketing and the surge in opioid prescriptions. Do you see parallels between pharma's tactics, and those of the who brought heroin to the U.S.?
Quinones: They both were about solving an essential problem for their customers. For pharma, that meant doctors. Doctors were asking 'What are we going to do with all of these pain patients taking up all our time?' OxyContin. One in the morning. One at night. You don't feel that pain anymore. It was promoted as 'the one to start with and to stay with.'
The Xalisco Boys were providing a solution to the addict, whose biggest problem was 'Where do I find my dope every day?' They made it convenient. They branded it in these little balloons with a tenth of a gram dose of heroin. Just like you know what's in every can of Coke you buy, same with them.
These [Xalisco Boys] were always giving it away free. You get out of jail, they give you free dope. You like it, you give a call back. These were not drug traffickers who were interested in shooting it out. They were using branding, marketing and customer service. That's pretty much exactly what pharma did. Knowing, I suppose, that what they were saying about that drug was not true: it was not virtually non-addictive.
Some media reports have suggested that as physicians have become more strict with their opioid prescriptions, more addicts have turned to heroin. Is that what you found in your reporting?
Quinones: People were transitioning from pills to heroin long before they began began shutting down the supplies. It's a natural progression. The [prescription] pills are really expensive on the street and, at a certain point, don't give you the boost that heroin would give you. So people would switch to heroin. The first guys that I encountered had done it in 1998 and 1999.
What responsibility do healthcare providers have for the opioid crisis, and how can they help to resolve it?
Quinones: I feel for doctors. They were in a very difficult place. If they didn't give people these pills, then people might be in horrible pain, and if they did, they might risk addiction.
Doctors who may not have believed this all along now have more freedom to come out and say so. Pain specialists who thought that maybe that they were doing the right thing 15 years ago are behaving like scientists and saying 'Evidence shows that it's not such a good thing, so I 'm cutting back.'
A doctor from Ohio told me, 'I used to do this [prescribe opioids readily] and now I don't even believe that opiates have a role in chronic pain treatment.' I'm not sure that's true either. I just know that doctors now are feeling more free to reassess how they've practiced pain management for the last 20 years. And that's probably a good thing.