Dreamland (18 page)

Ruplinger got permission to run wiretaps on Polla’s phones. The extent of Polla’s business then grew clearer. He had crews in Portland, too, and in Salt Lake City and Honolulu. Salt Lake did more business than Boise. Ruplinger heard Polla complain that he left Denver because it got so he couldn’t make any money there with crews from his hometown competing for the same addicts. New cells took his clients and to win them back he had to lower his prices.

Ruplinger marveled at how massive and connected the Xalisco network was. Polla’s heroin store practiced just-in-time supply, with women as mules every couple weeks bringing up a pound of heroin at a time. Keen to keep competitors at bay, Polla insisted that his drivers provide excellent customer service. Once when a driver reported a customer complaint of a bad batch of dope, Polla promised to make it right; the driver delivered better-quality stuff to the client the next day. When Ruplinger heard that, he felt he was watching the expansion of some new scary thing, as if he were all alone in a lab where a virus had escaped its test tube.

One day, Ruplinger heard one of the drivers tell Polla that he was afraid of delivering to the nearby town of Caldwell because the gangs there scared him. Polla told him he’d handle it. The conversation stayed with Ruplinger, who had worked in Southern California and knew that the gangs in tiny Caldwell were but faint echoes of gangs elsewhere. What kind of drug crew was this that was scared of the wannabe gangs of Caldwell, Idaho?

Every narcotics agent in the 1990s had the Bloods and Crips crack warfare as a precedent, and the Colombian cocaine cowboys in Miami before that. The Nayarits weren’t that way. With faith in their addictive product, they didn’t need to shoot it out for 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.

In two years, from 1995 to 1997, Boise’s minor market had a half-dozen crews selling heroin like pizza. But that wasn’t all. From the wiretaps, Ruplinger heard Polla call Phoenix, Ontario, El Monte, Salt Lake, Portland, Billings, Las Vegas, Honolulu. If Boise had a half dozen, how many crews must Denver have? What about Portland? Las Vegas? The heroin cells were like ants in a garden: You didn’t see them unless you got close enough and knew what to look for. Then, even when you stamped them out, more came to take their place.

It was 1997. Well before most other cops in the country, Ed Ruplinger was figuring out how to see the ants.

The Landmark Study

By the 1990s, it would have alarmed Dr. Hershel Jick, out in Boston, to know that his letter to the editor of the
New England Journal of Medicine
, which he had long forgotten, had become a foundation for a revolution in U.S. medical practice. This was wildly beyond anything Herschel Jick intended when he penned it.

But that’s what happened. The revolution extended to hospitals, medical clinics, and family practices across the country.

It’s unclear who retrieved the Porter and Jick letter from obscurity. But it appears to have been cited first as a footnote in Kathy Foley and Russell Portenoy’s 1986 paper in
Pain
. In time, the paragraph became known simply as Porter and Jick. That shorthand, in turn, lent prestige to the tiny thing and the claim attributed to it: that less than 1 percent of patients treated with narcotics developed addictions to them.

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. It was a bizarre misinterpretation, for Jick’s letter really supported a contrary claim: that when used in hospitals for acute pain, and then when mightily controlled, opiates rarely produce addiction. Nevertheless, its message was transformed into that broad headline: “Addiction Rare in Patients Treated with Narcotics.”

Others began citing its purported claim. Marsha Stanton remembers citing Porter and Jick frequently in educational seminars that she gave through the 1990s to doctors and nurses on pain treatment: “Everybody heard it everywhere. It was Porter and Jick. We all used it. We all thought it was gospel.”

A lot went into making it so. 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.

In a 1989 monograph for the National Institutes of Health, physicians from Harvard and Johns Hopkins urged readers to “consider the work” of Porter and Jick, which showed “clearly” that fear of addiction in those with no past drug abuse didn’t justify avoiding opiates, since the “study” showed that addiction among patients “given these drugs in a hospital setting was extremely low.” One researcher, writing in 1990 in
Scientific American
, called Porter and Jick “an extensive study.” A paper for the Institute for Clinical Systems Improvement called Porter and Jick “a landmark report.”

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.”

For years in medical schools, Marsha Stanton recalled, “I clearly remember instructors saying, ‘Don’t overdose, don’t overdose, don’t overdose. Don’t make these patients addicted.’ But now here’s this statistic: Look, oh, it’s in print. It’s gospel. I used [Porter and Jick] in lectures all the time. Everybody did. It didn’t matter whether you were a physician, a pharmacist, or a nurse; you used it. No one disputed it. Should we have? Of course we should have.”

Everyone knew of opiates’ painkilling benefits. But how
addictive
were they? That was the question. Most doctors figured history and experience showed that the answer was: very. Porter and Jick, as it was cited, suggested otherwise. So did Dr. Portenoy: Depending on the patient, he believed, these drugs might be used to great advantage.

Portenoy was a pain-management pioneer. In addition to his Beth Israel appointment, he was an editor in chief at the
Journal of Pain and Symptom Management
, an editor at
Pain
, and on the editorial board of other medical journals. He would write numerous books, textbooks that students used in medical school. He was quoted often in newspapers. Above all, Portenoy took his message on the road to the kinds of association conferences where new ideas in medicine are proposed: the International Association for the Study of Pain, the American Pain Society, the American Academy of Pain Medicine.

All of this helped create, by the mid-1990s, a new conventional wisdom that science had advanced and now knew that opiates wouldn’t addict a pain patient. Addicts and pain patients were two different things. “With addicts, their quality of life goes down as they use drugs,” one leading pain doctor, Scott Fishman, told
New York
magazine in 2000. “With pain patients, it improves. They’re entirely different phenomena.”

This spelled bad times for the more complicated multidisciplinary approach to pain. Why, after all, was all that effort necessary if pain patients could be given pills with little risk of addiction? 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.

Out in Seattle, Dr. John Loeser and his staff soldiered on at the University of Washington’s Center for Pain Relief, expanding on the ideas of John Bonica. But as insurance companies stopped paying for pain services, the university’s medical center eliminated them. In 1998, Loeser resigned in disgust. The university eventually moved the historic clinic to a basement. There it remained, a game preserve of sorts for a few multidisciplinary holdouts who kept their heads down. A plastic surgery unit moved into the space the pain clinic once occupied.

Use of opiates, meanwhile, changed medical thinking. Usually, a patient demanding ever-higher doses of a drug would be proof that the drug wasn’t working. But in opiate pain treatment, it was taken as proof that the doctor hadn’t yet prescribed enough. Indeed, some doctors came to believe that a pain patient demanding higher doses was likely to be exhibiting signs of “pseudoaddiction,” looking for a dose large enough to kill the pain—the cure for which was more opiates.

Two doctors writing in 1989 in the journal
Pain
coined the term to describe the case of a seventeen-year-old suffering from leukemia, pneumonia, and chest pain and asking for opiate painkillers, which physicians had misdiagnosed as addiction. One of the authors, J. David Haddox, later went to work at Purdue Pharma as vice president for health policy. The other, David Weissman, later described what doctors ought to do in cases of pseudoaddiction. Build trust and “aggressively” increase the dose of opiates until pain was relieved, Weissman wrote.

For all I know, pseudoaddiction may well be a real syndrome. But its importance to this story lies in that it helped nourish a growing body of thought that there was conceivably no limit to the amount of opiates a patient might need. Doctors might prescribe hundreds of milligrams a day. Certainly according to the widely accepted misinterpretation of Porter and Jick at least, there was minimal risk.

“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.”

Nevertheless, a movement was born, radiating out from a simple one-paragraph statement in 1980. Other documents were used as well. Portenoy and Foley’s own 1986 paper about thirty-eight patients—citing Porter and Jick—was among them. So, too, was a 1982 survey of supervisors at ninety-three burn units that found no patients growing addicted to opiate painkillers, and a 1977 study of drug dependency in patients with chronic headaches. But it appears that none was cited, nor misinterpreted, as often as Porter and Jick.

Dr. Hershel Jick, meanwhile, kept plumbing his ever-expanding patient databases. They could be, he believed, a source of clinically based information about drugs and their effects, something mankind had never possessed. He produced papers on a wide variety of topics: whether oral polio vaccines caused a collapsing of the bowels in children; whether certain oral contraceptives caused blood clots in women; and on the origin of a mumps epidemic in England.

All the while, his 1980 letter was sparking a movement.

“It’s an amazing thing,” he said, many years later. “That particular letter, for me, is very near the bottom of a long list of studies that I’ve done. It’s useful as it stands because there’s nothing else like it on hospitalized patients. But if you read it carefully, it does
not
speak to the level of addiction in outpatients who take these drugs for chronic pain.”

Enrique Redeemed

Xalisco, Nayarit

One day in the fall of 1993, a tall, slender, light-skinned man in new cowboy boots and a cowboy hat low over his eyes boarded a bus in Nogales, Sonora, and headed south to his home in Nayarit.

Enrique wore a new pair of dark-blue Levi’s 501s. His hat cost five hundred dollars, his boots a thousand dollars—at a western wear shop in Phoenix, Arizona. He had another fifteen thousand dollars in cash in his right pants pocket. His bus wound out of Nogales and down Mexico’s Highway 15 that runs parallel to the Pacific coast. He sat wary of his surroundings, even when the driver put on a movie starring the comedian Cantinflas. He didn’t watch it. He kept a hand on his right pants pocket and didn’t dare sleep.