ALiEM Bookclub: Dreamland Review

They started at once, and went about among the Lotus-eaters, who did them no hurt, but gave them to eat of the lotus, which was so delicious that those who ate of it left off caring about home, and did not even want to go back and say what had happened to them, but were for staying and munching lotus with the Lotus-eaters without thinking further of their return.

— Odyssey IX, translated by Samuel Butler

Synopsis of Dreamland: The True Tale of America’s Opiate Epidemic

It most likely happened in a nondescript bedroom tucked away among the leafy parks and manicured cul-de-sacs of a nameless Midwestern suburb. It passed, unburnished by the colorful ribbons and bracelets that adorned the social-awareness movements of the day. There would be no Presidential call-to-action. No After School Special to mark the event with melodramatic flare. It would be a milestone not scarred by gratuitous violence nor graced with spectacular headlines. Nonetheless, recorded somewhere within old hospital records and coroner’s reports from a decade past, among the days where 2008 blurred into 2009 was the moment that drug overdoses, namely from prescription opioids, surpassed motor vehicle collisions as the leading cause of accidental death in the United States.

Tonight, into Emergency Departments across this country an unrelenting stream of heroin overdoses will flow. Violaceus pockmarked arms betraying the nature of cerulean lips. The fortunate, naloxone Lazaruses, will likely elope before their names are ever known; nightly resurrections reduced to minor miracles lost amongst the clatter.

How did we arrive at this place? What sleight of hand turned medications into poisons and patients into addicts? How did these molecules, so parasitic in faculty, slip into our blood and savage our our bodies long before arriving in our collective conscious?

Sam Quinones’ Dreamland: The True Tale of America’s Opiate Epidemic [Amazon link], is a masterpiece of investigative journalism that is essential reading for any healthcare provider whose practice has been affected by opioid abuse. In ways that echo the strongest points of “And The Band Played On“, Randy Shilts’ 1985 account of the AIDS epidemic, Dreamland serves as a journalistic center of gravity around which the complexities of this current epidemic orbit. Quinones’ ability to seamlessly weave in and out of parallel story lines is essential for an undertaking which ultimately refines the amalgamation of what we now call the opioid epidemic into several distinct narratives. Quinones describes how this exploding public health disaster was brewed from a schizophrenic blend of misplaced medicinal altruism, corporate greed and a new brand of narco-globalism. When glanced in passing the intermingling of these realms would seem absurd, improbable at best, however as Quinones exposes their communal hyphae the machinations of an epidemic are inescapable.

Google Hangout with the Author

Edited podcast version of above Google Hangout discussion

Discussion Panel with Sam Quinones:

Dr. Steve Aks (@ERTox)
Medical Toxicologist, EM Physician
Cook County Health and Hospital System
Dr. Alex Harding
Chief Resident
Hackensack University Medical Center
Dr. Nikita Joshi (moderator) (@njoshi8)
Associate Editor of ALiEM
Stanford University Medical Center
Dr. Dennis Mann
Medical Toxicologist, EM Physician
Wright State University
Dr. Reuben Strayer (@emupdates)
EM Physician
Mt. Sinai and New York University
Dr. Rory Stuart (organizer)
Chief Resident
Wright State University

Pain is the fifth vital sign

The exponential rise of opioid abuse was paradoxically fueled by the duality of human nature; on one side the virtuous desire to relieve pain and suffering on the other the trappings of greed and vice. Pain is the fifth vital sign. This mantra, initially introduced into the VA system 1999, was intended to ensure that complaints of pain were treated with the same urgency as abnormalities of heart rate and blood pressure. Offered as a logical extension of the primary Hippocratic ideal of first do no harm, “first treat pain” became a paramount concern for a whole generation of physicians. Soon after pain metrics became embedded into the medical records pain scales, scoring tools and awareness posters became ubiquitous fixtures in hospital corridors. This concerted focus placed enormous pressure on physicians to push the relief of pain into the forefront of medical treatment. The problem with treating pain as if it were a critical vital sign was the implication that it was something amenable to immediate rectification. For many years pain management was a nuanced combination of therapies, equal parts physical and cognitive. The application of pain regulating medications, was but one facet of a larger treatment plan that while not instantly gratifying was ultimately effective. To both patients and physicians alike this long-term approach to pain seemed to offer little immediate solace, so with largely the best intentions in mind many searched for something more…

Born of the pharmacy not the street

The opioids’ affinity for the Mu pain receptors has been long recognized, however for many years concerns of addiction and fears of overdose confined their use to the treatment of cancer related pain. Then in the mid 1990s came the introduction of long acting opioid formulations. The pharmaceutical companies producing these medications claimed that the extended release mechanisms would temper their euphoric effects and make them less susceptible for abuse. Emboldened by a perception that those experiencing true pain would somehow be immune to the addictive nature of the opioids, pharmaceutical sales representatives aggressively sought out new indications for their use. When traced back through the daisy chain of medical references, the science behind these claims was shockingly scant. It would seem that an entire modern movement of pain management was built not upon a wealth of robust clinical trials but rather several misinterpreted historic footnotes mixed in with a heavy dose of industry sponsored studies.

In 2007 the egregiousness of these claims, in concert with questionable marketing tactics resulted in several criminal convictions and a $634 million dollar federal fine against Purdue Pharma, the makers of OxyContin. Despite continued legal action as well as further scrutiny of the underlying literature, nothing seemed to slow the flow of opioids from the oncology wards into the outpatient primary care clinics. From 1993 to 2013 the amount of opioids prescribed in the United States more than quadrupled. In 2012 alone there were over 259 million prescriptions written for opioids. Legions were exposed to the addictive potential of opioids, falsely reassured by prescriptions in hand, blissfully naive of the addiction they were cultivating. By the time the medical community began to realize the magnitude of opioid overuse it was already too late, Pandora’s box had been opened, and no one was prepared for the chaos that would soon follow.

Death rides a pale horse

If the meteoric rise in prescription opioid use could be viewed as the Great Flood then heroin would surely be the Plague of Locusts that followed. As the tide of opioid prescribing patterns reversed millions of, now addicted, patients had to find a fix beyond the safe confines of neighborhood pharmacies. In order to stave off withdrawal, for many, heroin would become the solution.

In one of the most fascinating aspects of this book, Quinones describes how a group of former sugarcane farmers from an isolated area in rural Mexico, used the momentum of the American opioid boom to establish a network of heroin distribution that would stretch from the southwestern borders into the heartland of the midwest. Unlike the cocaine cartels of Miami Vice fame this would be a no-violence, low-profile, user-friendly kind of cartel. The cells, while in competition, would often share product and turf; the family and social connections binding them to small home villages served to discourage the use of violence. Without colorful cartel kingpins or mounting body counts flashing on the evening news local police paid little attention to these, seemingly, small time pushers. Multiple heroin distributors would sprout up in new cities across the country, however the war for customers would not be fought with violence but better service. Discounts, two-for-ones, and refer a friend deals would replace bullets in this new era of narcotic trafficking. And the best part of it all… they came to you. In this internet, on-demand, pizza delivery society it was perfect. Pick up a phone, call a number, and 20 minutes later someone would be there with your heroin. Areas of the country that had been ravaged by prescription opioid abuse were low-hanging fruit for savvy heroin dealers who capitalized on the preexisting addiction.

The exportation of franchised heroin distribution, from rural Mexico, into suburban America is one of many juxtapositions present in an epidemic rife with contrasts. Quinones describes how the loss of manufacturing jobs and the emergence of the modern big-box stores devastated locally owned small businesses throughout the United States. With the disappearance of local business came the loss of community investment leading to the slow erosion of once vital downtowns and public services. These communities in decline proved fertile grounds for opioid and heroin abuse. While small town America drifted further into decay small Mexican villages, once home to rampant poverty, were thriving largely due to money from heroin revenue. The circular irony of it all is inescapable; using national supply chains and predatory pricing corporate franchised mega-stores undermined the entrepreneurial spirit of American small business owners. This often occurred in the same communities left abandoned by the overseas exodus of American manufacturing. Opioid addiction sprouted up among the ruins of broken American dreams. Mexican heroin cells possessed by their own entrepreneurial zeal seized the opportunities created by this addiction to realize their own parallel version of the American dream. Through decentralized supply chains, franchising and aggressive marketing, tactics eerily reminiscent of those used by corporate America, a distribution network was created that relentlessly pumped heroin from now thriving Mexican villages back into ,now poverty ridden, small towns across this country.

Dreamland offers an amazing insight into the origins of an epidemic that has smoldered unseen by many in this country for years. A critical mass has been reached where this festering wound can no longer be ignored. We, in Emergency Medicine, are afforded a unique position along the front lines of this epidemic. As more primary care providers become hesitant to prescribe opioids, the ED has swelled with those seeking relief from both untreated pain and opioid withdrawal. As more patients turn to the respite of heroin we will continue to see the suffering and death that inevitably follow. Our patient interactions, limited to a precious few moments, can so easily be corrupted with self righteous prejudice. However, we as a collective community of medical providers, cannot feign ignorance at the role we’ve played in this catastrophe. Too often the term “drug seeker” is code for “ignore & discharge from the ED ASAP”.

While it’s true that these patients can be extremely difficult to deal with, we have to remember that they are coming into our departments with a disease that can be recognized and if given the right opportunities treated. We need to reach out to local addiction specialists and outpatient treatment centers to try and establish reliable footpaths between the acute care of the department and the long term addiction care these people need. In a budget-tight, time-is-money world I know some of these things are just not available but that doesn’t mean they couldn’t be created. We need to use our clout as a professional community to enlist the help local and federal resources to build better community networks and accessible emergency addiction referral options. We’re supposed to be the safety net that catches those who fall through the cracks of this broken healthcare system. We always do more with less in order to do right by our patients in the ED. I think if we applied this same ingenuity to the issues of opioid and heroin abuse the rest of the hospital would follow suit. I don’t know about you but every time I close another opioid-dependent patient encounter with the lines “sorry buddy but I can’t refill your pain meds, treat your withdrawal, or reliably refer you to counseling- but thanks for stopping by” a part of me dies. I didn’t go into Emergency Medicine to turn my back and walk out on an entire patient population in desperate need.

Discussion Questions

What role do we as Emergency Physicians play in the responsible stewardship of opioid medications?
Portions of the medical community were implicit in the initial propagation of prescription opioid use. What actions can we now, as an entire community, do to help combat this epidemic?
How can acute care providers, like Emergency Physicians, fit into a comprehensive multi-disciplinary long-term approach to addiction treatment?
How do we combat prejudice, both internal and external, when dealing with a population of patients that rarely engenders sympathy?