Dreamland (37 page)

It was as if these guys from Xalisco had done market research to discover new heroin markets. This thought also occurred to a Charlotte undercover police officer who went by the name of Jaime. He had been working narcotics at the Charlotte Police Department since 2007—black tar heroin mostly, buying from Xalisco dealers hundreds of times.

Jaime believed that the Xalisco Boys looked for towns where kids had cell phones, money, and cars and where a lot of people were addicted to prescription painkillers. At first, he saw they were almost sadistic the way they talked down to desperate junkies, leaving them waiting, and insulting them when they finally showed up. But in 2009 that changed. After Jaime bought from them, crew bosses called to ask: Was the service good? Was the runner rude? Once, a crew boss called to apologize for a late driver. He had a lot of customers, he said. And he was going to get on his people to be more prompt.

After another buy, Jaime’s phone rang.

“We’ve heard from others that that batch wasn’t as good,” the guy said in halting English. “What did you think? If it was bad, I want to tell the guys we got it from that we don’t want that stuff anymore.”

Jaime had no choice but to go along.

“Yeah, man, it was crap. Really bad.”

“We’ll make it up to you.”

At the next buy his dealer gave him an extra balloon, and apologies.

Jaime attributed the new attitude to competition among the Xalisco crews in Charlotte. Other higher-ups in Xalisco, he figured, were imposing the quality control of a Fortune 500 company. Their service was better, he noted, than many legitimate retailers.

Meanwhile, though supplies of heroin were unrelenting and addicts were everywhere, Jaime saw no outrage in Charlotte. He spoke to the parents of one junkie after another. As soon as he said the word “heroin,” their minds crashed to a halt. They couldn’t conceive of their children on heroin. For every symptom, the parents had an answer. Did they see burned aluminum foil around the house? We thought he was burning incense. Was he slurring his speech? He was getting over the flu. Were his grades falling? He was going through a phase.

Jaime spoke to the city’s Drug Free Coalition, which was focused on alcohol and marijuana.

“No,” he told them. “Heroin is the real problem.”

He and Gatehouse spoke to a group of headmasters from Charlotte’s best private schools, hoping it would ignite a local crusade. It didn’t.

Despite spreading addiction, no parent in Charlotte, of the dozens he spoke to, came forward to warn school groups, churches, the media. Heroin touched the families of doctors, ministers, bank executives, and lawyers, but they retreated from it, crushed by grief and the drug’s stigma. How a son died with a spike in his arm was not what you talked about at the country club. A half-dozen reporters asked Jaime for contacts with parents who had lost children. He would plead with the parents to come forward and tell their stories to help keep the next kid from dying. None did.

A conspiracy of silence enveloped Charlotte. Heroin seeped through the city and suburbs in South Carolina with only a few cops, prosecutors, and public health officials battling it.

Jaime, meanwhile, grew philosophical. Opium was a trade good that coursed through civilizations, from Alexander the Great to the Chinese to the Turks and Afghans, snaking out to the Golden Triangle of Burma and Laos. It had been a medicine for three millennia as it changed shape into morphine, welcomed by soldiers, then further morphed into heroin, which street dealers promoted and spread to urban denizens.

Now, in gleaming twenty-first-century Charlotte, the clients were no longer America’s outcasts. It wasn’t Puerto Ricans in a rainy back alley in Spanish Harlem, or an East L.A. gang member, or some jazz acolyte of Charlie Parker. Many of the users now were the beneficiaries of the wealthiest country the world had known. They were white kids who lived on winding streets, with garages filled with Jet Skis and shiny SUVs, bedrooms with every digital gadget.

Jaime figured that among the Xalisco Boys’ greatest innovations was figuring out that a mother lode of heroin demand was now waiting to be mined in these neighborhoods if they’d only offer convenience. The Happy Meal of dope, he called it. Marketed like fast food—to young people.

“‘We want what we want when we want it and thus we are entitled to get it,’” he said. “This drug is following the same marketing [strategy] of every other product out there. ‘I’ll give you good heroin at a great price. You don’t have to go to the bad neighborhoods. I’ll deliver it for you.’”

In a culture that demanded comfort, he thought, heroin was the final convenience.

A Tidal Wave Forming

Olympia, Washington

Jennifer Sabel felt like she was sinking.

The epidemiologist for the state of Washington stood before a roomful of fourteen prominent doctors at Seattle’s Warwick Hotel one cold night in December 2005. Jaymie Mai and Gary Franklin from the state’s Labor and Industries had visited her a year before asking if the opiate overdose deaths among disabled workers were also happening in the state’s general population.

Sabel and her team pulled together all the death certificates and coroner’s reports of people who’d died from opiates. It was a complicated task, identifying potential deaths for each year, then requesting the paperwork on each from coroners around the state. Now she was presenting her findings to a collection of some of Washington’s top pain specialists. She kept her eyes on the slides as she spoke.

“We’ve had dramatic increases in the numbers of opioid-overdose deaths,” she said, speaking to the screen.

Twenty-four in 1995. Her pointer followed the graph as it shot up. “In 2004, we found three hundred eighty-six people died of opioid overdoses statewide,” she said. A sixteenfold increase.

She went on, detailing some of the cases from each year. Finally, Sabel turned to face her audience. The room was silent. This couldn’t be true, said one doctor, finally. There must have been some coding error, another said. Death certificates are notoriously unreliable, said a third. Others spoke skeptically of Sabel’s data. The message was clear: Several doctors in the room did not believe her.

Sabel grew queasy, trying to defend the data but aware that she was new to the issue.

“What am I doing here?” she thought. “How did I get into this?”

Gary Franklin jumped in to help.

“This is similar to what we found at L and I and I think there’s really something here,” he told the specialists.

Sabel sat in silence.

“This group of physicians,” she said when we met in 2013. “They’ve been convinced by the drug companies that it’s okay to prescribe these medications for people with chronic pain because here’s the studies that show very few of them will become addicted. They don’t want to hear that the people they’re prescribing these drugs to might die. They’re physicians and they’re trying to help people.”

Sitting near Sabel that night, Jaymie Mai also couldn’t believe what the doctors were saying. Four years had passed since Mai first saw those death reports of workers overdosing on the opiate painkillers they were taking for lower back pain and carpal tunnel syndrome. Worker overdose deaths from opiates climbed each year. Mai’s backyard rose garden grew ornate as amid expanding death cases she tended it relentlessly to relieve the stress.

Sabel’s statewide figures showed a tidal wave forming out in the distance. Overdose deaths, Mai knew, now far outstripped those during the crack rage in the late 1980s and even those when heroin was last popular: the mid-1970s. Overdose deaths advanced in lockstep with the amount of opiates prescribed statewide. These were not pills stolen in pharmacy holdups. The size of the problem could only come from overprescribing.

Mai said, “We couldn’t believe the volume, the number of cases. You’re looking at the whole state and potentially the whole nation. That [idea] took us a couple days to wrap our arms around. This is a huge problem and it’s just going to increase every year unless we do something about it.”

L&I came up with a guideline for general practitioners when prescribing these drugs. It went like this: If doctors had patients taking more than 120 mg a day with no reduction in pain, then they should stop and get a pain specialist’s opinion before prescribing higher doses.

It was simple and reasonable enough, particularly in light of the new overdose deaths among workers. But it was contrary to an idea central to the pain revolution: that there was no limit on how much opiate painkiller a patient might be prescribed. The guideline Mai and Franklin were proposing would make Washington the first in the country to even suggest some control on how many narcotic pills doctors were prescribing. They could almost hear the criticism if they did this on their own: Government is going overboard, meddling in medicine, taking away rights. So they brought together the state’s top pain specialists that night at the Warwick Hotel.

“We asked them,” Sabel said. “This is your specialty. At what dose do you say, ‘I need to step back and reevaluate this patient because this may not be working?’”

As rough as the Warwick Hotel meeting was for Jennifer Sabel, the pain specialists came around. In later meetings, they themselves suggested that L&I put out guidelines for prescribers suggesting limits, and that not every increase in pain should be met with higher doses of narcotics.

Yet before those guidelines could be issued, Franklin got a letter from two Purdue Pharma executives. They objected to the idea of a ceiling on opiate doses.

“Limiting the access to opioids for people in chronic pain is not the answer,” wrote Lally Samuel and Dr. J. David Haddox in the 2007 letter. Haddox is the coauthor of the concept of pseudoaddiction and was now working for the drug manufacturer. One three-year study of 219 patients with arthritis and lower back pain performed by Russell Portenoy and seven other researchers at Beth Israel, they wrote, found patients taking 293 mg of OxyContin a day without a problem.

They were concerned, Samuel and Haddox wrote, that patients needing more opiates “may be undertreated while they are waiting for consultations with pain specialists, as required by the guideline.”

Not long after that, a Spokane doctor named Merle Janes sued L&I. Dr. Janes was assisted by five law firms, four of which were from outside Washington State. The guideline, they alleged in a court brief, was an example of “an extreme anti-opioid discriminatory animus or zealotry known as Opiophobia that informs, permeates, and perniciously corrupts the development and management of public health policy” in Washington.

So L&I’s prescribing guidelines hung in limbo for two years. Twenty-five workers, each of whom had gone to a workers’ comp doc with an injury, died of opiate overdoses in 2008; in 2009, thirty-two more died.

Nevertheless, the state of Washington, L&I, and that Warwick Hotel meeting, however, began a rethinking of the widespread use of prescription painkillers—the first reappraisal since the pain revolution had become conventional wisdom. It was rooted in Mai’s investigation into those first worker overdose-death reports in 2001. The paper she wrote with Franklin, and Jennifer Sabel’s investigation into overdose deaths for the state, in turn, alerted the Centers for Disease Control in Atlanta. Its epidemiologists began examining the death rates from opiate ODs nationwide. Epidemiologists would follow suit in the state of Ohio, where a few years earlier black tar heroin had collided with aggressive pain pill prescribing, and where the first pill mill emerged.

In May 2011, meanwhile, a judge threw out Dr. Janes’s lawsuit. The next year, Washington issued the guidelines on prescribing that Franklin and Mai had come up with—the first state to suggest doctors temper their opiate prescribing. Washington legislators also repealed the intractable pain regulations allowing for unlimited dosing of opiates.

I called Dr. Janes later to ask about his lawsuit and how he could afford the help of so many law firms. A secretary took my message and said they were getting out of prescribing opiates for pain due to “problems that the state was causing for doctors.” Dr. Janes didn’t return my call.

Pentecostal Piety, Fierce Scratches

Portland, Oregon

In 1906, a delirious Christian revival roared out of Los Angeles.

It was an African American movement, but soon was integrated. It took the name of the street where the home church resided. The Azusa Street Revival marked the first explosion of the Pentecostal faith. With it came fervent praying, speaking in tongues, and the belief in a personal rebirth in the Lord. The revival spread east across America to the Midwest and South. Within a decade, the movement arrived in New York City. Among those who embraced it there were numerous Russian immigrant workers.

They returned to Russia to preach their new gospel as communist revolutionaries were toppling the czarist government. These Pentecostal pioneers converted thousands in Russia, the Ukraine, and Belarus. The new Soviet state sent many to gulags. Other believers soldiered on. They held all-day Sunday services in houses where they spoke in tongues, preached baptism by hardship, and became clannish in self-defense. The women wore head scarves. Dancing, jewelry, and makeup were prohibited. They were pacifists and foreswore guns and television. They married young and had lots of children. Higher education was blocked to them, so they became welders and truck drivers.