This book hit me like a stack of bricks. "Dreamland" tells the story of the rise of OxyContin and the Xalisco heroin operation that have destroyed so many lives in heartland America. Although packed with hard facts, Quionones also follows individual actors in this narco-drama to humanize the supply, demand, and regulatory sides of this horrific market. What emerges is an appalling picture of an opiate epidemic in America - and in my home state of Kentucky in particular - orders of magnitude worse than I had ever imagined.
I did some of my own research to see how the opiate epidemic was playing out in my hometown of Louisville, Kentucky. What I found shocked me. 1 out of every 1,000 people in Jefferson County (my home county) has died of a drug overdose in the last 3 years. That's twice the number of people that died in car accidents in that same time period. The book points out how unusual this is: "Since the rise of the automobile in America, vehicle accidents sat unassailed atop the list of causes of injury death in every state" - other causes weren't even close. Now drug overdoses are double auto accidents. I saw stories like "Overdose deaths in 2015 increased by 17 percent in Kentucky, 31 percent in Louisville" and just months ago "Dozens overdose from mystery heroin mix". And this is from quiet, family-friendly Louisville! This is a crisis on an enormous scale.
Here are some of the biggest "oh wow" moments I had reading this book:
- More Americans die each year of heroin overdoses than car crashes (true since 2008). This is insane.
- Exploding rates of opiate addiction in white America, particularly in the Rust Belt - "virtually all the new addicts were rural and suburban white people"
- Opiate overprescription epidemic (primarily OxyContin) enabled by apparent scientific negligence and corporate marketing pressure
- OxyContin to heroin transition fueled by rapid acquisition of opioid tolerance and cheap, high quality Mexican heroin
- Dominance of decentralized, pizza-delivery-style operations of vertically-integrated, highly entrepreneurial and adaptive cells from Xalisco
- Explicit targeting of middle-class whites by Xalisco cells - "They sell almost exclusively to whites"
- Complete ineffectiveness of "catch-and-deport" policies
- Changing attitudes among Republicans towards addiction policy - primarily driven by increasing prevalence of personal connections to addicts.
I was particularly infuriated by the failure of our regulatory and scientific apparatus. Most egregiously, "FDA examiner Dr. Curtis Wright, supervisor of the agency’s team that examined Purdue’s [OxyContin] application.. later left the FDA to work for Purdue". Conflicted much? And just as bad - the negligence of the scientific establishment in putting so much weight on the "landmark" Porter and Jick study (which turned out to be a paragraph letter to the editor - not even a peer-reviewed study!) is unacceptable - apparently no one could be troubled to go back and actually read this thing that they were all citing. Disgusting. We have to do a better job than this.
Quinones doesn't offer much in the way of hope. He does spend a little time on what I suspect is the underlying cause of the epidemic - cultural bankruptcy. Our cultural reorientation towards hedonism and moral relativism has made our society profoundly vulnerable to this opiate epidemic. As one of his interviewees says, "In a culture that demanded comfort... heroin was the final convenience." This observation hurts - a lot. But it hurts because it's true. We can't use poverty or lack of economic opportunity as an excuse - after all, hardly anybody in Xalisco is doing heroin. When we don't believe in anything, the siren song of empty, addictive pleasure is impossible to resist. The beliefs and institutions that once held white America together are falling apart. If we're going to fix our opiate addiction problem, that's not a bad place to start.
My highlights are included below:
- 1853: The hypodermic syringe is invented. Inventor’s wife is first to die of injected drug overdose.
- 1898: Bayer chemist invents diacetylmorphine, names it heroin.
- 1935: The Narcotic Farm in Lexington, Kentucky, opens as federal prison/drug rehabilitation and research center.
- 1996: Dr. David Procter’s clinic in South Shore, Kentucky, is presumed the nation’s first pill mill.
- 2008: Drug overdoses, mostly from opiates, surpass auto fatalities as leading cause of accidental death in the United States.
- 2013: The College on the Problems of Drug Dependence turns seventy-five without finding the Holy Grail of a nonaddictive painkiller.
Some of these addicts were from rough corners of rural Appalachia. But many more were from the U.S. middle class. They lived in communities where the driveways were clean, the cars were new, and the shopping centers attracted congregations of Starbucks, Home Depot, CVS, and Applebee’s. They were the daughters of preachers, the sons of cops and doctors, the children of contractors and teachers and business owners and bankers. And almost every one was white. Children of the most privileged group in the wealthiest country in the history of the world were getting hooked and dying in almost epidemic numbers from substances meant to, of all things, numb pain. “What pain?” a South Carolina cop asked rhetorically one afternoon as we toured the fine neighborhoods south of Charlotte where he arrested kids for pills and heroin. Crime was at historic lows, drug overdose deaths at record highs. A happy façade covered a disturbing reality.
“I no longer judge drug addicts,” Carol said. “I no longer judge prostitutes.” I left Herb & Thelma’s and drove the streets, stunned that so random an encounter in America’s heartland could yield such personal connections to heroin.
All from the Same Town Huntington, West Virginia
West Virginia was one of the seven states with no known Mexican drug-trafficking presence, according to a U.S. Department of Justice 2009 report I had seen. Police had a simple reason for this: There was no Mexican community in which to hide. Mexican immigrants followed the jobs, functioning as a sort of economic barometer: Mexicans in your community meant your area was growing. Huntington and West Virginia had no jobs, no Mexicans either.
I called the DEA in Columbus and spoke with an especially loquacious agent. “We got dozens of Mexican heroin traffickers. They all drive around selling their dope in small balloons, delivering it to the addicts. They’re like teams, or cells. We arrest the drivers all the time and they send new ones up from Mexico,” he said. “They never go away.”
“They’re in many others. All over the country,” he said. Salt Lake, Charlotte, Las Vegas, Cincinnati, Nashville, Minneapolis, Columbia, Indianapolis, Honolulu. They were working full-time in seventeen states. They’d been in another seven or eight states at one time or another. He went on. The cities he mentioned all had large white middle classes that benefited hugely from the economic booms of the previous dozen years, and now had large Mexican immigrant populations as well. I hardly associated these cities with heroin. Were there heroin markets in these towns? I wondered. Yes, he assured me, they were big and getting bigger. He hadn’t even mentioned America’s traditional heroin capital, I noticed. “No, in New York are gangs, with guns,” he said. “They’re afraid of New York City. They don’t go to New York.”
The Adman New York, New York
Valium was marketed above all to women, pitched as way of bearing the stress of lives as wives and mothers. Before the feminist movement, women were presumed to need that kind of help for the rest of their lives, thus there was no worry then about its addictiveness.
Arthur Sackler never retired. In 1987, at age seventy-three, he had a heart attack and died. He left behind a wife and two ex-wives, a spectacular fortune, and an industry so indebted that it referred to him by his first name. Today, his name is on galleries or wings of the Smithsonian Institution, the Metropolitan Museum of Art in New York City, the Royal Academy in London, as well as at Princeton, Harvard, and Beijing universities. Medical facilities bear his name at Tel Aviv, Tufts, and New York Universities. In 1996, he was one of the five first inductees into the Medical Advertising Hall of Fame. But Arthur Sackler is important to this story because he founded modern pharmaceutical advertising and, in the words of John Kallir, showed the industry “that amazing things can be achieved with direct selling and intensive direct advertising.” Years later, Purdue would put those strategies to use marketing its new opiate painkiller OxyContin.
In heroin addicts, I had seen the debasement that comes from the loss of free will and enslavement to what amounts to an idea: permanent pleasure, numbness, and the avoidance of pain. But man’s decay has always begun as soon as he has it all, and is free of friction, pain, and the deprivation that temper his behavior.
Most drugs are easily reduced to water-soluble glucose in the human body, which then expels them. Alone in nature, the morphine molecule rebelled. It resisted being turned into glucose and it stayed in the body.
Delivered Like Pizza
Cell profits were based on the markup inherent in retail. Their customers were strung-out, desperate junkies who couldn’t afford a half a kilo of heroin. Anyone looking for a large amount of heroin was probably a cop aiming for a case that would land the dealer in prison for years. 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.
Moreover, the Xalisco cells never deal with African Americans. They don’t sell to black people; nor do they buy from blacks, who they fear will rob them. They sell almost exclusively to whites.
By the mid-1990s, Chavez’s informant counted a dozen major metro areas in the western United States where cells from tiny Xalisco, Nayarit, operated. In Denver by then he could count eight or ten cells, each with three or four drivers, working daily.
Most Mexican immigrants spent years in the United States not melting in but imagining instead the day when they would go home for good. This was their American Dream: to return to Mexico better off than they had left it and show everyone back home that that’s how it was. They called home and sent money constantly. They were usually far more involved in, say, the digging of a new well in the rancho than in the workings of the school their children attended in the United States. They returned home for the village’s annual fiesta and spent money they couldn’t afford on barbecues, weddings, and quinceañeras. To that end, as they worked the toughest jobs in America, they assiduously built houses in the rancho back home that stood as monuments to their desire to return for good one day. These houses took a decade to finish. Immigrants added to their houses each time they returned. They invariably extended rebar from the top of the houses’ first floors. Rebar was a promise that as soon as he got the money together, the owner was adding a second story. Rods of rebar, standing at attention, became part of the skyline of literally thousands of Mexican immigrant villages and ranchos.
Those Xalisco traffickers who didn’t end up in prison went back to live in those houses. They put down no roots in this country; they spent as little money in America as they could, in fact. Jamaicans, Russians, Italians, even other Mexican traffickers, all bought property and broadcasted their wealth in the United States. The Xalisco traffickers were the only immigrant narcotics mafia Chavez knew of that aimed to just go home, and with nary a shot fired.
The ancient Egyptians first produced opium as a drug. Thebaine, an opium derivative, is named for Thebes, the Egyptian city that was the first great center of opium-poppy production. Indians also grew the poppy and used opium. So did the Greeks. Homer and Virgil mention opium, and potions derived from it. The expanding Arab empire and later the Venetians, both inveterate traders, helped spread the drug.
War spread the morphine molecule through the nineteenth century. More than 330 wars broke out, forcing countries to learn to produce morphine. The U.S. Civil War prompted the planting of opium poppies in Virginia, Georgia, and South Carolina for the first time, and bequeathed the country thousands of morphine-addicted soldiers.
Patent medicines with morphine and opium, meanwhile, were sold as miracle cures. These elixirs were branded with names evoking quaint home remedies. Opium was the active ingredient in, for example, Mrs. Winslow’s Soothing Syrup, which was used to pacify children. These remedies were marketed aggressively in newspapers and popular media. Patent medicines sales exploded, rising from $3.5 million in 1859 to almost $75 million by the twentieth century.
Heroin was first believed to be nonaddictive. Heroin pills were marketed as a remedy for coughs and respiratory ailments. With tuberculosis a public health threat, this was no small point. As junkies ever since have discovered, heroin is an effective constipator and was thus marketed as an antidiarrheal. Women used it, on doctor’s orders, for menstrual cramps and respiratory problems. Doctors didn’t have much else to prescribe for pain or disease. Thus addiction exploded—to a drug that people believed was safe because doctors said so.
Easier than Sugarcane
Cars and beepers allowed a heroin crew access to a broader client base, and made the Xalisco Boys less obvious to police. In cars, dealers avoided gang taxation and the violence that accompanied the street crack trade.
Most Mexican traffickers naturally followed the immigrants from their home states. This was astute and common sense, for no immigrant group has settled in such numbers in so many parts of America as Mexicans had by the end of the 1990s. Mexican immigrants were in rural areas where local police were often monolingual and understaffed. Those areas had cash-only businesses—Mexican restaurants and money-wiring services—that could be used to launder cash. By the 1990s, small towns and communities in rural Colorado, Georgia, and Arkansas, where Mexicans worked in meat plants, became major hubs for traffickers, places where they divided the dope loads they’d brought in and with which they supplied much larger towns. Mexican traffickers did this by following the immigrants. Thus by the 1990s, for example, it was possible for Sinaloan traffickers to find drug markets in many parts of America using Sinaloan immigrant communities as their point of contact and place to blend in. Michoacan traffickers did the same in the many U.S. regions where Michoacan immigrants became essential parts of the local economy.
Spaniards relied on Indians who hated the Aztecs to guide them across the New World to Tenochtitlán, the capital of the Aztec Empire, now Mexico City. Junkies did the same for the Xalisco Boys. The Xalisco Boys supplied these junkies’ habits in exchange for help in moving into a new area, and in renting apartments, in registering cellular phones, and buying cars.
Most important of all—and crucial to the expansion of the Xalisco Boys — was that junkies could navigate America’s methadone clinics.
The painkiller known as methadone was synthesized by German scientists in the effort to make Nazi Germany medicinally self-reliant as it prepared for war. The Allies took the patent after the war, and Eli Lilly Company introduced the drug in the United States in 1947. U.S. doctors identified it as a potential aide to heroin addicts.
Methadone was a better alternative to weak powder heroin, which was more expensive and available only in dangerous housing projects or skid rows. But maintaining large numbers of people on any kind of opiate, particularly on low doses, made them easy prey for someone with a more efficient and convenient opiate delivery system. For years, though, no one could conceive of such a thing: a system of retailing street heroin that was cheaper than, as safe as, and more convenient than a methadone clinic. But in the mid-1990s, that’s exactly what the Xalisco Boys brought to towns across America. They discovered that methadone clinics were, in effect, game preserves.
Searching for the Holy Grail
In 1928, what would become known as the Committee on Problems of Drug Dependence (CPDD) brought together the country’s best researchers to do just that. John D. Rockefeller Jr. organized it using money his father had set aside. The CPDD promoted cooperation among drug researchers in government, academia, and industry. German science used this kind of collaboration to come up with some of the world’s best drugs. But German drug supplies to America ceased during World War I. After the war, American scientists concluded that the country was vulnerable because U.S. drug research was random and haphazard. The CPDD funded chemists and pharmacologists, academics and industrial scientists, toward the goal of finding a nonaddictive painkiller.
The Farm contained a section known as the Addiction Research Center (ARC). For decades, the ARC tested on inmates every major opiate that Committee-sponsored chemists produced: Dilaudid, Demerol, darvon, codeine, as well as Thorazine and many tranquilizers and sedatives.
The research at Lexington generated hundreds of scholarly articles and amounted to the only serious study of addiction in the world at the time. The World Health Organization relied on it for data. Addiction study emerged there as a scientific field, and ARC staff were the first to conceive of addiction as not a character failing, or a crime, but rather a chronic brain disorder. The ARC was shut down in the 1970s, when the U.S. Senate’s Church Committee, investigating the Central Intelligence Agency, found that the ARC had done experiments with LSD on inmates at the behest of the CIA. With that, an era ended. The Farm was transformed into the prison and hospital that it is today. But for forty years, all the drugs created in the CPDD’s search for the Holy Grail were tested on inmates at the Narcotic Farm in Lexington, Kentucky.
In 1972, a British company called Napp Pharmaceuticals developed a controlled-release formula, known as Continus, that the company first put to use with an asthma medicine. One day Twycross suggested to some Napp reps that their company might use Continus to develop a timed-release morphine pill. Napp eventually did so, and this proved important to this story. It offered doctors a new tool for treating pain in dying patients. Napp, also, is owned by Purdue, the laxative manufacturer that Arthur Sackler and his brothers had purchased in the 1950s.
Meanwhile, a Swedish cancer physician named Jan Stjernsward was put in a position to change pain treatment worldwide. Stjernsward was made chief of the cancer program for the World Health Organization in Geneva in 1980. He’d spent time years before in a Kenyan hospital, where he witnessed acres of cancer patients dying in agony. The third world lacked the resources to treat cancer. With morphine, Stjernsward felt, patients could at least spend their last days pain-free. But doctors refused to use it, fearing addiction.
WHO went further. It claimed freedom from pain as a universal human right. The Ladder was accompanied by a concept relevant to our story that moved public and medical opinion. It was this: If a patient said he was in pain, doctors should believe him and prescribe accordingly.
Worldwide morphine consumption began to climb, rising thirtyfold between 1980 and 2011. But a strange thing happened. Use didn’t rise in the developing world, which might reasonably be viewed as the region in most acute pain. Instead, the wealthiest countries, with 20 percent of the world’s population, came to consume almost all — more than 90 percent — of the world’s morphine.
From all this, the idea took hold that America was undertreating pain. Tens of millions of people, surveys reported, were in pain that wasn’t being treated. Pain’s undertreatment was viewed as an unnecessary epidemic, for medicine now had tools to treat it. A 2001 survey of a thousand people living at home with pain due to a medical condition reported: Half couldn’t remember what it felt like to not be in pain, 40 percent said pain was constant, and 22 percent said they suffered severe pain. Only 13 percent had seen a pain specialist.
Through all this, patients were getting used to demanding drugs for treatment. They did not, however, have to accept the idea that they might, say, eat better and exercise more, and that this might help them lose weight and feel better. Doctors, of course, couldn’t insist. As the defenestration of the physician’s authority and clinical experience was under way, patients didn’t have to take accountability for their own behavior.
And there was another problem. No one had done serious, long-term studies of whether opiates actually were nonaddictive when used by such patients. Years later, in fact, there still is no evidence of how many chronic-pain patients can be successfully treated with opiates without growing dependent, then addicted. Determining who is a good candidate for opiate treatment is a mystery, and particularly difficult when doctors have no pain-management training and only thirteen minutes with each patient.
The Landmark Study
Porter and Jick appeared in that bible of scholarly and journalistic rectitude, the New England Journal of Medicine. Medical professionals assumed everyone else had read it. 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. Instead, primary care docs took the word of pain specialists, who pointed to Porter and Jick as evidence that opiates were far less addictive for chronic-pain patients than previously thought. Not that primary care doctors needed much encouragement. Chronic-pain patients, desperate for relief, could be insistent, rude, and abusive to staff, and took a lot of time to diagnose and treat. Physicians had a mantra: “One chronic-pain patient can ruin your whole day.” Now a solution was at hand. That single paragraph, buried in the back pages of the New England Journal of Medicine, was mentioned, lectured on, and cited until it emerged transformed into, in the words of one textbook, a “landmark report” that “did much to counteract” fears of addiction in pain patients treated with opiates. It did nothing of the kind.
Then, the final anointing: Time magazine in a 2001 story titled “Less Pain, More Gain,” called Porter and Jick a “landmark study” showing that the “exaggerated fear that patients would become addicted” to opiates was “basically unwarranted.”
Patients, too, were hard to motivate when the treatment required behavior changes, such as more exercise. Pills were an easier solution. Multidisciplinary clinics began to fade. Over a thousand such clinics existed nationwide in 1998; only eighty-five were around seven years later.
“No physician would simply go on with the same unsuccessful treatment, but that is what happens with opioids,” said Loeser. “Patients come and say, ‘That’s great, Doc, but I need more.’ The doctor gives them a higher dose. Then, three months later, they say the same thing, and so on. The point is if it were working, you wouldn’t need more.”
We Realized This Is Corporate
This was part of why the Xalisco Boys succeeded. To their customers, many Xalisco Boys were not like typical heroin dealers, who were addicts as well, cold and conniving. Some of the boys became friendly with their addict customers. Even through the language barrier, they were personable, sometimes charming.
Multnomah County had 10 heroin overdose deaths in 1991, about the time the Xalisco Boys arrived, and ended 1999 with 111 — a 1,000 percent increase in eight years. “By the time we discovered it,” Oxman said years later, “it wasn’t a new wave at all.” Unbeknownst to anyone, heroin overdoses had become Multnomah County’s second cause of accidental death among men twenty to fifty-four years old — after car crashes.
On the contrary, once these cops understood the Xalisco Boys’ system and reach, they realized that the small quantities of dope seized were even more ominous than large seizures. It meant that a vast network of traffickers had figured out what defined a successful drug bust for U.S. narcotics agents, their bosses, the media, and the public: large amounts of dope, money, and guns. It meant they had rules and practices in place so they’d never be caught with any of that. And they did this relentlessly, over and over, across the country.
Sources revealed why dealers didn’t step on the heroin. “It’s because they’re salaried,” Stone said. “The runners are up here, nephews of the regional sales manager, and just coming to do a job, paid five hundred dollars a week. They didn’t care what the potency was; they made the salary no matter how much they sold.” Salaried employees were unheard-of in the drug business. “We realized this is corporate,” Stone said. “These are company cars, company apartments, company phones. And it all gets handed to the next guy when they move on.”
Stone did some math. Each tenth of a gram sold for about fifteen dollars. The cells were grossing $150,000 from each kilo. Informants told him that it cost about two thousand dollars to produce a kilo of black tar heroin in Nayarit. In Portland, their overhead was cheap apartments, old cars, gas, food, and five hundred dollars a week for each driver. Profit per kilo, Stone figured, was well over a hundred thousand dollars.
The result was the decadelong rise in overdoses that Gary Oxman had found — a relatively small group of people creating a major drug plague.
By 1999, the Xalisco Boys had been in Portland, Oregon, for almost a decade and brought the price down to where “you could maintain a moderate heroin habit for about the same price as a six-pack of premium beer” per day, Oxman told me years later. “The economy was booming, and there was a huge number of addicts, most of whom were functional. Most of the users went to work high, had a habit [while] working at jobs.”
OxyContin is a simple pill. It contains only one drug: oxycodone, a painkiller that Germans synthesized in 1916 from thebaine, an opium derivative. Molecularly, oxycodone is similar to heroin.
But OxyContin came out in 1996, which was a very different time in American medicine than 1984, when MS Contin appeared, or its story might have been similarly pedestrian. In the 1980s, few people in medicine accepted prescribing a strong opiate for chronic pain. By 1996, however, the opiate revolution wrought by the pain crusaders had been changing minds in American medicine for a decade. More insurance companies were reimbursing for pills, but not for therapy that was not strictly medical. Pain was now considered a vital sign, measured by a subjective scale between 1 and 10, and treated aggressively. Later, Purdue officials would say that what happened with OxyContin surprised them because MS Contin hadn’t been abused. That wasn’t entirely accurate. Detectives in Ohio I spoke to remembered that MS Contin was stolen and abused. Doctors were conned into prescribing it to drug addicts in some cities, but not others — in Cincinnati but not in Columbus, for example. But certainly abuse of MS Contin was sporadic and never hit the levels that its cousin, OxyContin, would attain.
“We went from not having very potent drugs . . . to an oral morphine form and to a pharmaceutical industry that wanted to promote it,” Kathy Foley said in an oral history interview in 1996, the year OxyContin was released. “So we, for the first time, then, had a marketer and a distributor for a drug that we had, and an educator. We knew then that oral morphine was effective. We can get away from these silly elixirs and cocktails into tablets that people take once or twice a day, and we’re into a revolutionary field of pain management . . . It was the drug-delivery device that changed, not the drug, and with that the whole mentality, ‘Well, now that we have this drug, we can treat pain.’ Really extraordinary.”
FDA examiner Dr. Curtis Wright, supervisor of the agency’s team that examined Purdue’s application, thought OxyContin might well possess addictive side effects and thought its only benefit was to reduce the number of pills a patient had to take every day. “Care should be taken to limit competitive promotion,” Wright is quoted as writing in an FDA report by the New York Times’s Barry Meier in his 2003 book on OxyContin, Pain Killer. Wright later left the FDA to work for Purdue.
To get there, Purdue had to answer doctors’ first doubt: Isn’t this stuff addictive? As Arthur Sackler had done with Valium in the 1960s, Purdue set about promoting OxyContin as virtually risk-free and a solution to the problems patients presented doctors with every day. The company urged salespeople, meanwhile, to “attach an emotional aspect to non-cancer pain so physicians treat it more seriously and aggressively.” Many pain patients suffered badly. Purdue urged doctors to believe that Oxy was the drug to “start with and stay with.” The doctors needn’t worry because the oxycodone was released slowly over many hours. Thus, OxyContin did not create the steep highs and lows that created cravings.
Swing with OxyContin
During the 1990s and into the next decade, Arthur Sackler’s vision of pharmaceutical promotion reached its most exquisite expression as drug companies hired ever-larger sales teams. 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. Some Purdue reps — particularly in southern Ohio, eastern Kentucky, and other areas first afflicted with rampant Oxy addiction — were reported to have made as much as a hundred thousand dollars in bonuses in one quarter during these years. Those were unlike any bonuses ever paid in the U.S. pharmaceutical industry.
Purdue also made continuing medical education (CME) an important part of its campaign. By the 1990s, CME had been around for a decade but had grown largely dependent on drug company funding. The companies shelled out hundreds of millions of dollars, usually from their marketing budgets, to fly medical practitioners to resorts. There, the companies plied them with dinners, golf outings, and spa treatments while sending them to seminars on a medical issue, led by specialists that the companies often suggested. Often the conclusion was that a drug the companies made was a solution to a medical problem.
"He was a godsend for Purdue. 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."
Seniors realized they could subsidize their retirement by selling their prescription Oxys to younger folks. Some of the first Oxy dealers, in fact, were seniors who saw the value of the pills in their cabinets. “It’s like hitting the Lotto if your doctor will put you on OxyContin,” Prior said. “People don’t even think twice about selling.”
Smack Clans in the Sanctuary
Chimayo has the highest rate of heroin addiction in America. When people discuss heroin addiction in Chimayo, they tend to talk of it in terms of a culture, something passed down through generations. Entire Chimayo families are addicted, beginning with the grandparents or even great-grandparents.
Liberace Shows the Way
Waves of people sought disability as a way to survive as jobs departed. Legions of doctors arose who were not so well-meaning, or who simply found a livelihood helping people who were looking for a monthly government disability check as a solution to unemployment. By the time the pain revolution changed U.S. medicine, the Ohio River valley had a class of these docs. They were an economic coping strategy for a lot of folks. They charged cash for each visit and were quick with the prescription pad, willing to go along with whatever the patient claimed was pain, wherever the patient claimed he had it. Then along came OxyContin.
About that year, reports from the Kentucky Board of Medical Licensure’s second investigation into David Procter began telling strange tales. He was losing all control, manipulating damaged and addicted women for sex.
The pain clinic became a business model, repeated over and over, and many were legitimate. But the business also attracted doctors who were unethical or compromised from the start. Even doctors whose intentions were honorable occasionally had their scruples worn out and warped by the temptation and constant pressure from pain patients and drug-seeking addicts.
I asked a detective, seasoned by investigations into many of these clinics, to describe the difference between a pill mill and a legitimate pain clinic. Look at the parking lot, he said. If you see lines of people standing around outside, smoking, people getting pizza delivered, fistfights, and traffic jams — if you see people in pajamas who don’t care what they look like in public—that’s a pill mill.
Procter was returned to Kentucky, where he had already testified against Drs. Williams and Santos in court in return for a lighter sentence in his own case. He eventually served eleven years in prison. Santos and Williams also went off to prison, as did Cohn and Snyder and Billiter. With that, the era of the pill mill owned by doctors from out of town drew to a close in Portsmouth, Ohio. David Procter ended up at the federal prison and hospital in Lexington, Kentucky, that once was the Narcotic Farm.
The Man in the Heartland
Central Ohio, in other words, was about to be a great place to be a heroin dealer. His black tar, once it came to an area where OxyContin had already tenderized the terrain, sold not to tapped-out old junkies but to younger kids, many from the suburbs, most of whom had money and all of whom were white. Their transition from Oxy to heroin, he saw, was a natural and easy one. Oxy addicts began by sucking on and dissolving the pills’ timed-release coating. They were left with 40 or 80 mg of pure oxycodone. At first, addicts crushed the pills and snorted the powder. As their tolerance built, they used more. To get a bigger bang from the pill, they liquefied it and injected it. But their tolerance never stopped climbing. OxyContin sold on the street for a dollar a milligram and addicts very quickly were using well over 100 mg a day. As they reached their financial limits, many switched to heroin, since they were already shooting up Oxy and had lost any fear of the needle.
Across the country that day, 182 people were arrested in a dozen cities in Operation Tar Pit. Agents seized relatively small quantities of drugs and cash: sixty pounds of heroin and two hundred thousand dollars. Yet Tar Pit remains the largest case—geographically and in terms of manpower used—the DEA and FBI have ever mounted jointly.
Mexicans were the largest influx of foreign-born labor to the American South since slavery. They were in the biggest cities and were revitalizing parts of heartland America. The only locally owned new businesses in many rural towns were those that Mexicans started, and it was common by 2000 to find Mexican restaurants in Mississippi or an out-of-the-way burg in Tennessee.
“Gram for gram,” a group of specialists wrote in the journal Pain Physician in 2012, “people in the United States consume more narcotic medication than any other nation worldwide.”
Amid all this, opiate abusers began to get younger. In a 2004 survey by the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), 2.4 million people twelve years or older had used a prescription pain reliever nonmedically for the first time within the previous year — more than the estimated numbers using marijuana for the first time. The pain-pill abuser’s average age was twenty-two. Overdose deaths involving opiates rose from ten a day in 1999 to one every half hour by 2012. Abuse of prescription painkillers was behind 488,000 emergency room visits in 2011, almost triple the number of seven years before.
A decade after OxyContin’s release, meanwhile, 6.1 million people had abused it — that is to say, 2.4 percent of all Americans.
Baltimore, with a robust heroin market dating back decades, is considered the country’s heroin capital — with the DEA and the city’s health department estimating that roughly 10 percent of the city’s residents are addicted. The crack epidemic, at its height, involved fewer than half a million users a year nationwide, according to SAMHSA estimates.
Either way, a government survey found that the number of people who reported using heroin in the previous year rose from 373,000 in 2007 to 620,000 in 2011. Eighty percent of them had used a prescription painkiller first.
Collision: Ground Zero
This synergy between pills and heroin happened first in one place. OxyContin’s popularity was spreading west just as the trafficker I call the Man brought Xalisco black tar heroin east. They collided in central and southern Ohio. Roughly drawn, the region with Columbus to the north, and including parts of West Virginia and eastern Kentucky to the south, became the barometer for all that followed elsewhere in the country.
Canaries in Coal Mines
One key to the pill mill explosion was the discovery of locum tenens lists, a clearinghouse for doctors around the country seeking temporary employment. Many of these doctors were desperate. They had license problems, or couldn’t get malpractice insurance, or were alcoholics. These were the docs Procter had hired. Now other clinic owners did the same and quacks flocked to Portsmouth.
Junkie Kingdom in Dreamland
If you could get a prescription from a willing doctor — and Portsmouth had plenty of those — the Medicaid health insurance cards paid for that prescription every month. For a three-dollar Medicaid co-pay, therefore, an addict got pills priced at a thousand dollars, with the difference paid for by U.S. and state taxpayers.
The Oxy black market might never have spread and deepened so quickly had addicts been forced to pay for all those pills with cash at market prices.
"We can talk morality all day long, but if you’re drawing five hundred dollars a month and you have a Medicaid card that allows you to get a monthly supply of pills worth several thousand dollars, you’re going to sell your pills.”
Shoplifters, in fact, were the wandering peddlers in Portsmouth’s junkie kingdom, providing the goods central to daily life in the OxyContin economy and taking only pills in payment. They stole groceries or tampons or detergent or microwaves on order. Shoplifters’ importance to the OxyContin economy grew, in turn, from a new and indispensable rural institution. In Portsmouth, as in much of rural America, most of what there is to buy is sold only at Walmart.
Some large though immeasurable amount of the merchandise supporting addiction, as the opiates settled on heartland America, was mined from the aisles of Walmart, where Main Streets had gone to die.
Took Over the OxyContin Belt”
Yet all these gangs were known for their violence and gunplay. To me, that made them almost passé — like Wild West gunslingers. None of them controlled the drug from its production in Mexico to its sale by the tenth of a gram on streets across the United States. The Xalisco Boys did. They were dope traffickers for a new age when marketing is king and even people are brands.
The Final Convenience
Keep talking, Foushee learned. Like a salesman. If you’re talking you’re still alive. Talk was the undercover cop’s great gift and Foushee came to rely on it in times of stress. The kid wasn’t stupid, Foushee thought later. He was just begging to be persuaded, letting greed control his better judgment. Street dealers made money on each sale and thus wanted to be convinced. Talk long enough, desperately enough, and you could usually get them to sell to you. Talking and convincing people, using his wits, were what selling Bibles trained him to do.
Black tar heroin dominated the caseload. The Xalisco Boys were relentless, and what made them so was that the workers, the drivers, were disposable. The bosses didn’t seem to care how many got arrested. They always sent more.
But by the early 2000s, whenever police corralled a dozen Xalisco heroin dealers, Martin saw no new flood of addicts rushing to his beds. There was no drought. The bust didn’t affect the area’s supply of heroin. “No matter how many million-dollar busts you guys do,” he told the officers, “it doesn’t show up on our radar.”
In a culture that demanded comfort, he thought, heroin was the final convenience.
We Was Carrying the Epidemic”
Some of the most potent early vectors were newly christened junkies from eastern Kentucky, where coal mines were closing and SSI and Medicaid cards sustained life. These addicts, feigning pain and injury, mined local doctors and pharmacists, who quickly got wise. Kentucky, to its credit, was one of the first to put in a system tracking what drugs each patient had been prescribed and by whom. But seven states border Kentucky. Many eastern Kentuckians have relatives who left to find work in other states, and, after decades of out-migration, state lines tend not to matter much to folks from the region. The Kentucky prescription monitoring system, therefore, very quickly had the unintended consequence of pushing the state’s new opiate addicts out across state lines in search of pills, tapping first their networks of friends and relatives.
With the opening of the Florida territory, a new Appalachian migration began, south this time. Campers voyaged weekly down from the Oxy-wracked regions of Ohio, Kentucky, and West Virginia for doctor visits. The OxyContin Express was the name given to flights from Huntington, West Virginia, to Fort Lauderdale.
More Cases Than Car Crashes
That’s when they realized that right then and there drug overdose deaths were about to surpass fatal auto crashes as Ohio’s top cause of injury death. This was a stunning moment in the history of U.S. public health. Since the rise of the automobile in America, vehicle accidents sat unassailed atop the list of causes of injury death in every state, and in the United States as a whole. Now Ed Socie’s numbers showed that would soon no longer be true in Ohio. And by the end of 2007, it wasn’t.
Drug overdoses passed fatal vehicle accidents nationwide for the first time in 2008. But it happened first in Ohio, where two complementary opiate plagues met and gathered strength in the late 1990s: prescription painkillers, especially Purdue’s OxyContin, moving east to west; the Xalisco Boys’ black tar heroin moving west to east.
Dispensed grams of oxycodone — the only drug in OxyContin — rose by almost 1,000 percent in Ohio during those years. They wrote a report revealing once-camouflaged facts:
- The number of Ohioans dead from drug overdoses between 2003 and 2008 was 50 percent higher than the number of U.S. soldiers who died in the entire Iraq War.
- Three times as many people died of prescription pill overdoses between 1999 and 2008 as died in the eight peak years of the crack cocaine epidemic.
- In 2005, Ohio’s overdose deaths exceeded those at the height of the state’s HIV/AIDS epidemic in the mid-1990s.
“That was Joe Gay,” he said, chuckling and shaking his head after he clicked off the phone. “He says he’s found a 0.979 correlation between prescription pain pills dispensed and the number of overdose deaths from opiates.” This was preposterous. Never in thirty years of statistical mechanics had Orman Hall heard of a correlation that close to 1.0, which was almost as if the charts were saying that dispensing prescription painkillers was the same thing as people dying.
Every statistician knows correlation does not mean causation. But to Gay the correlations did mean that Ohio could all but predict one overdose death for roughly every two months’ worth of prescription opiates dispensed.
A Pro Wrestler’s Legacy
Bonica, the anesthesiologist and former pro wrestler, had founded the clinic. He wrote a classic pain-management textbook from what he learned. He retired in 1977 and died in 1994. Later, his disciple, Dr. John Loeser, expanded Bonica’s clinic. Hundreds of clinics followed across the country. But insurance companies gradually stopped paying for the services that made the clinics multidisciplinary. Prescription pills were easier and cheaper, and at least for a while they worked well. In 1998, Loeser resigned as the multidisciplinary clinic was marginalized at the school that had invented the idea.
The school agreed. On April Fools’ Day 2008, Cahana started his new job. He was immediately shocked at the patients in the UW clinic. “These were people on tons of opioids for a long time, completely broken and abused. We’re talking hundreds of milligrams of morphine-equivalent doses. Doses I’d never seen in my life: four hundred, five hundred, six hundred milligrams a day.” What’s more, no one tracked the effects of opiates on a patient’s pain, function, depression, sleep. He called colleagues elsewhere and found this to be true across the United States. “Not one center had measurements-based pain care. This is 2008,” he said. “It would all be subjective: They’re doing fine or not doing fine. There was a pain rating scale: one to ten. It was insane. A multibillion-dollar industry was based on no measurements whatsoever.”
There Alex Cahana ran into the problem John Loeser faced. An insurance company would reimburse thousands of dollars for a procedure. But Cahana couldn’t get them to reimburse seventy-five dollars for a social worker, even if it was likely that some part of a patient’s pain was rooted in unemployment or marital strife. “Nobody thinks those things are of value. Talk therapy is reimbursed at fifteen dollars an hour,” Cahana said. “But for me to stick a needle in you I can get eight hundred to five thousand dollars. The system values things that aren’t only not helpful but sometimes hurtful to patients. Science has shown things to have worked and the insurance companies won’t pay for them.”
Great Time to Be a Heroin Dealer
Soon, suburban kids and students from Indiana University in Bloomington were coming in to buy. Xalisco black tar spread out for a hundred miles around Indianapolis.
In several Xalisco neighborhoods virtually every able-bodied young man had gone north to sell heroin.
The Criminal Case
However, Purdue Pharma pleaded guilty to a felony count of “misbranding” OxyContin. To avoid federal prison sentences for its executives, the company paid a $634.5 million fine, among the largest in the history of the pharmaceutical industry at the time. Three executives — CEO Michael Friedman, General Counsel Howard Udell, and the by-then-departed chief medical officer, Dr. Paul Goldenheim — paid $34.5 million of that. Each pleaded guilty to a single misdemeanor of misbranding the drug. They were also placed on probation for three years and ordered to perform four hundred hours of community service. In July 2007, the Purdue executives appeared in federal court for sentencing. Lee Nuss, the mother of a Florida man who died of an OxyContin overdose, rose to speak. “You are,” she told them, “nothing more than a large corporate drug cartel.”
Phillip Prior was now knee-deep in what was unthinkable a few years before: rural, white heroin junkies. “I’ve yet to find one who didn’t start with OxyContin,” he said. “They wouldn’t be selling this quantity of heroin on the street right now if they hadn’t made these decisions in the boardroom.”
Now It’s Your Neighbor’s Kid”
For the first time since the years after heroin was invented, the root of the scourge was not some street gang or drug mafia but doctors and drug companies.
virtually all the new addicts were rural and suburban white people.
The cost savings weren’t what did the trick, though. Treatment has always been more effective and cheaper than prison for true drug addicts. What’s changed, Norman said, is that no longer are most of the accused African American inner-city crack users and dealers. Most of the new Tennessee junkies come from the white middle and upper-middle classes, and from the state’s white rural heartland — people who vote for, donate to, live near, do business with, or are related to the majority of Tennessee legislators.
“One thing that makes [legislators] more amenable to treatment is that it’s hard to find a family now that hasn’t been hit by addiction."
“You’re seeing this huge groundswell for criminal justice reform really being driven by conservative circles,” said Chris Deutsch, with the National Association of Drug Court Professionals. “Conservative governors are starting to invest in drug courts. In the last five years, we’re really starting to see statewide drug courts in every county.”
Kentucky congressman Hal Rogers, a staunchly conservative Republican, has become a strong proponent for drug courts since his district, which included Floyd County, has been hammered by prescription pill abuse.
Drug enslavement and death, so close at hand, were touching the lives, and softening the hearts, of many Republican lawmakers and constituents. I’ll count this as a national moment of Christian forgiveness. But I also know that it was a forgiveness that many of these lawmakers didn’t warm to when urban crack users were the defendants. Let’s just say that firsthand exposure to opiate addiction can change a person’s mind about a lot of things. Many of their constituents were no longer so enamored with that “tough on crime” talk now that it was their kids who were involved. So a new euphemism emerged — “smart on crime” — to allow these politicians to support the kind of rehabilitation programs that many of them had used to attack others not so long ago.
Meanwhile, buoyed by his new purchase with Tennessee’s political class, Judge Seth Norman had done some thinking. Four or five drug courts like his could be funded with a one-penny tax on every prescription opiate pill sold in Tennessee. After all, some four hundred million of the pills were prescribed annually to a state of six million people.
Like Cigarette Executives
“They are the Philip Morris of heroin,” she told me in her office in downtown Portland one day. “They think like cigarette company executives. The corporate nature of the model—they depend on that cash flow. They’re not going to go away because you incarcerate a few individuals. You have to cut the labor force off at the knees. You have to make the people from Nayarit realize: When you come up here, you may never go back, or it may be fifteen years before you go back.”
“In Portland,” he said, “I’d see [the police] grab people with twenty or thirty balloons and they’d let them go. That’s why people began to come to Portland, because they weren’t afraid. They saw there were no consequences. ‘We get caught with this and they let us go.’”
This reminded me so much of small-town Mexican business culture. I once visited a village in central Mexico—Tzintzuntzan, Michoacán. Tzintzuntzan had at least two-dozen vendors all selling the same kind of pottery on its main street. Once one person did well selling pottery, everyone started doing it. No one thought to vary the offering. The stores stretched for five or six blocks — with each selling identical pots and bowls, eager to undercut the others. Mexican small-business culture, born of crisis and peso devaluations, was risk averse and imitative. That described the Xalisco cells. They came and imitated those who’d come before. In so doing, they dropped prices and raised their potency and the natural result, particularly as OxyContin tenderized the market terrain, was more addiction and overdoses. None of this was on a kingpin’s order. It was something far more powerful than that. It was the free market.
Portland’s catch-and-deport policy was an important reason why.
So for many years, when they were caught they were deported and faced little jail time, and no prison time. As farm boys on the make, they drew a very different message from leniency than what these Portland officials intended. To them, catch and release looked more like an invitation.
No Scarface, No Kingpins
This bust was small-time by traditional narcotics standards. Yet, short of arresting the cell owner down in Mexico, the narcotics team, from Denver’s District 3, was doing what probably harmed the Xalisco heroin business model most: raising its cost of business. The Xalisco system succeeded because it reacted to how American cops traditionally worked drugs. Narcotics teams found barren apartments and peons like Jose Carlos; the money and most of the drugs were back in Mexico. This deflated cops and prosecutors. Thus, more so than any traditional drug network in the country, the Xalisco Boys were forcing law enforcement to rethink old strategies, particularly as the opiate epidemic took hold.
A Parent’s Soul Pain
The signature location of this drug scourge, meanwhile, was not the teeming, public crack houses. It was, instead, kids’ private suburban bedrooms and cars — the products of American prosperity. The bedroom was the addict’s sanctuary, the shrine to the self-involvement dope provokes. It was their own little dreamland, though quite the opposite of Portsmouth’s legendary community pool, where kids grew up in public and under a hundred watchful eyes. Each suburban middle-class kid had a private bedroom and the new addicts retreated to them to dope up and die. “We lived in our bedroom,” said one woman in recovery. “You could have a big, huge house, but you could lock that door, isolated. Everybody I ever got high with, it was always in their bedroom. It was privacy. Don’t come knock on my bedroom door.”
The places where opiate addiction settled hard were often middle- and upper-middle-class. Parents were surgeons and developers and lawyers and provided their kids with everything. Yet sports were as much a narcotic for these communities as they were to any ghetto. Love of learning seemed absent, while their school weight rooms were palatial things, and in many of them pain pills were quietly commonplace. Just as opiates provided doctors with a solution to chronic-pain patients, Vicodin and Percocet provided coaches with the ultimate tool to get kids playing again.
Kids were coming to the center from across Ohio. Many, he said, grew up coddled, bored, and unprepared for life’s hazards and difficulties. They’d grown up amid the consumerist boom that began in the mid-1990s. Parenting was changing then, too, Hughes believed. “Spoiled rich kid” syndrome seeped into America’s middle classes. Parents shielded their kids from complications and hardships, and praised them for minor accomplishments—all as they had less time for their kids. “You only develop self-esteem one way, and that’s through accomplishment,” Hughes said. “You have a lot of kids who have everything and look good, but they don’t have any self-esteem. You see twentysomethings: They have a nice car, money in their pocket, and they got a cell phone . . . a big-screen TV. I ask them, ‘Where the hell did all that stuff come from? You’re a student.’ ‘My mom and dad gave it to me.’ . . . And you put opiate addiction in the middle of that?” He winced. “Then the third leg of the stool is the fifteen-year-old brain.”
Low crime and high fatal overdose rates — this was the new American paradigm. A happy surface over an ominous reality.
By the end of the 2000s, it was already common for people to go from abusing OxyContin to a heroin habit. Purdue Pharma recognized this and in 2010 reformulated OxyContin with an abuse deterrent, making the drug harder to deconstruct and inject. The intent was to make Oxy less abusable. It did. Had the company done this in 1996, our story might have been different. But now there was a swollen population of OxyContin addicts nationwide. Without Oxy, they flocked to heroin in even greater numbers.
Heroin had spread to most corners of the country because the rising sea level of opiates flowed there first. The story resembled the heroin scourge a century before, ushered in on the prescription pads of physicians, the vast majority of whom were sincere in intent. Drug traffickers only arrived later, and took far less profit than did the companies that made the legitimate drugs that started it all.
Pfizer alone paid more than $3 billion in fines and legal penalties to settle lawsuits alleging, among other things, the misbranding and false advertising of several drugs. That included $2.3 billion to settle a criminal suit in 2009 alleging the company illegally marketed its blockbuster painkiller Bextra. The sum was the largest criminal fine of any kind, though it amounted to less than three weeks of the company’s sales, the New York Times observed.
The Treatment Is You
“All of a sudden, we can’t go to college without Adderall; you can’t do athletics without testosterone; you can’t have intimacy without Viagra. We’re all the time focused on the stuff and not on the people. I tell pain patients, ‘Forget all that; the treatment is you. Take charge of your life and be healthy and do what you love and love what you do.’”
The U.S. medical system is good at fighting disease, Cahana believes, and awful at leading people to wellness.
Nobody Can Do It Alone
In 2013, Governor John Kasich, a Republican, went around the Republican-dominated legislature and expanded Medicaid health insurance to every Ohioan, which in turn gave thousands of families a way to pay for long periods of outpatient drug treatment.
In one three-month period, fully 11 percent of all Ohioans were prescribed opiates.
Had these opiates not appeared, I think we’d have seen a similar number of alcoholics, but later in life. My field used to be middle-aged alcoholics. It usually took twenty years of drinking to get people in enough trouble to need treatment. But with the potency of these drugs, the average age has dropped fifteen years and people get into trouble very quickly with oxycodone, hydrocodone, and heroin.”
The figure I kept hearing was one in ten — the number of people who succeeded in each rehab. That was true, Whitney said, only because so few people get the full treatment they need. Too often they go in for three weeks or six weeks. Brain chemistry needs far more time to recover from the blast it takes from opiates. “We have as good or better treatment results as they do for asthma or congestive heart failure—if we have the tools to work with,” he said. “But people do not get enough treatment to get well. It’s as if we said you only get half the chemotherapy you need to treat your cancer. People wouldn’t stand for that. Insurance companies don’t want to [fund] addiction treatment with enough duration and intensity because we as a society do not demand it.”
“Nobody can do it on their own,” he said. “But no drug dealer, nor cartel, can stand against families, schools, churches, and communities united together.”
Up from the Rubble
By the time I visited, Davis said, Sole Choice had three hundred customers—up from twenty-four. Forty people had their jobs back and more were coming on. The company exported shoelaces to thirty countries, including China and Taiwan. “The outsourcing mentality has cost us millions and millions of jobs. We have now done that for thirty-some years and we have literally destroyed our manufacturing base in this country. It’s all been about money, the mighty dollar. The true entrepreneurial spirit of the U.S. has to be about more than that. It has to be about people, relationships, about building communities. Money—that comes. You’ll get that eventually, but happiness comes from these other things.”
Doctors had failed people, he felt. “We visited incredible harm on the people of America as a profession,” he said. “Pharmacists did also. Every single pill that was killing people in my county was legitimately prescribed, legitimately filled, legitimately paid for.”
Johnson took office in 2011. He and fellow representative Dave Burke, a pharmacist, wrote House Bill 93. This was a rare event. Term limits in Ohio mean that legislators come and go and acquire little knowledge of the issues on which they pass laws by the time they’re termed out. Legislation is often written by lobbyists who are the power that accumulates in Columbus as lawmakers rotate through. “Instead, we came out of left field,” Johnson said, “and wrote our own legislation.”
China, having lost two Opium Wars waged on it by the British Empire, cured itself of its opium addiction by relying on former addicts to mentor their dope-sick brothers and sisters. Portsmouth was doing the same.