From Small-Town Mexico to Big Pharma, a Look at Opiates for Good and Bad

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Sam Quinones

Through most of the twentieth century, doctors treating the terminally ill faced attitudes that seemed medieval when it came to opiates.

—Sam Quinones


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

Author: Sam Quinones

Publisher: Bloomsbury Press

Publication date:  April 21, 2015

Price: $28.00; hardcover, 384 pages

Despite growing awareness within the oncology community and the emergence of the palliative care discipline, undertreatment of cancer pain in the United States remains a problematic issue. Study results have shown that pain in patients with cancer remains persistently undertreated, and the odds of undertreatment may be twice as high for minority patients. Poor communication skills between oncologists and their patients may be at the heart of the issue in assessing and treating cancer pain.

Patient misperceptions about opioids—such as confusing dependence with addiction—contribute to the problem, as does the rise in illicit drug use. For instance, over the past decade, the highly publicized rise in prescription drug overdoses has led the Drug Enforcement Administration to initiate a rescheduling of hydrocodone combination products from schedule III to schedule II; this step dramatically increased the restrictions on doctors’ prescribing and dispensing practices for these necessary pain-relieving products.

In reaction to the recent rescheduling of hydrocodone, many doctors who treat cancer pain have expressed concern that sensational coverage of illicit sales of opioid analgesics will lead to even tighter restrictions on pain medications. Is our fear of illicit painkilling drugs overblown? Not according to award-winning journalist, Sam Quinones, who has just a penned a book called Dreamland: The True Tale of America’s Opiate Epidemic. With a great reporter’s narrative skill and the storytelling ability of a novelist, the author weaves together tales with hard data on pain medications, making it a compelling read for The ASCO Post audience.

A Revelatory Account

Epidemic is a scary word in medicine, signifying an out-of-control spread of disease, and he boldly says that his book is a revelatory account of the corrosive threat facing America. The title of his book, Dreamland, is taken from a public swimming pool in the blue-collar town of Portsmouth, Ohio, a watery oasis in the heartland, one that over time became an idyllic gathering place for people of all stripes and economic backgrounds.

Then, according to Mr. Quinones, the prescription painkillers arrived, and the town declined. He uses one Matt Schoonover, an all-American boy, as the victim in his allegorical warning: Your town is next. “Across America, thousands of people like Matt Schoonover were dying. Drug overdoses were killing more people every year than car accidents…. Now most of the fatal overdoses were from opiates: prescription painkillers or heroin,” writes Mr. Quinones.

However, you can’t build a nearly 400-page book on victimhood stories about good kids going wrong, falling into the trap of easy-to-access drugs, and bad guys peddling them. To that end, Mr. Quinones tries to balance the personal sagas of drug victims with enough history and facts to make his book interesting for readers looking for a deeper understanding of the drugs people use illicitly to get high and the patients with cancer who need drugs to relieve otherwise unendurable pain.

Pioneers in Pain Control

For the readers of The ASCO Post, there are several specific chapters. One, aptly called “The Pain,” gives a pretty good background of the long and difficult history of pain control. He begins, “Through most of the twentieth century, doctors treating the terminally ill faced attitudes that seemed medieval when it came to opiates.”

To drive home this arresting opening, he tends to drift into brief lapses of hyperbole and some very clunky writing. As the author moves downstream in the chapter, the waters even out, as he gives an interesting background about the nascent years of hospice and the early struggles to bring much needed awareness about unnecessary suffering.

Although the chapters devoted to the emergence of pain management should be the most interesting to the readers of The ASCO Post, they also present territory where the author seems unsteady. For instance, he describes how the World Health Organization’s pioneering cancer chief, Jan Stjernswärd, MD, FRCP, changed pain management worldwide, creating the pain management ladder and finally making the declaration that freedom from pain was a universal human right.

He then segues into one of the true heroes of pain management, Kathleen Foley, MD, giving a fairly good account of her role in pain awareness and treatment. He ends his section on Dr. Foley mentioning that she argues that opiate treatment should not be confined to patients with cancer or postsurgical patients but should be for others with equally debilitating chronic pain. He seemed dangerously close to filling in the blanks for Dr. Foley, as if trying to make his point through her measured discussion on pain management.

A Closer Look at Oxycodone

Since much of the brouhaha reported in the lay press about fatal opioid overdoses has centered on oxycodone, Mr. Quinones’ next chapter put Purdue Pharma in his crosshairs. To his credit, he begins by giving a well-balanced discussion of oxycodone’s history and efficacy in pain management. Then he veers into what I would call slipshod nonsense that will drive the pain community mad. First, he never discusses the highly complex mechanisms that drive pain or the different kinds of pain, from somatic to neuropathic, nor does he talk about opioid receptors and the way these drugs actually assuage pain. Given he’s writing predominantly for a lay audience, that shortcoming may be forgiven.

What cannot be forgiven is his apparent ignorance on addiction. In an effort to vilify oxycodone and the people who make and sell the drug, he launches into a half-baked theory about an advertising campaign that shadily promotes oxycodone as the “Holy Grail that had eluded researchers…a new time-release method that would lead to less addiction.” He continued, “OxyContin theoretically parsed out oxycodone in a way that did not cause the intense highs and lows that cause addiction.”

The causes of psychological addiction to drugs are multifocal. Taking an opioid analgesic does not cause addiction or create an addictive personality. In effect, by vilifying an inanimate substance, the author did to oxycodone what Peter Benchley did to the great white shark.

A Good Storyteller

Mr. Quinones is out of his depth when he discusses pain, but he is a very good storyteller who has traveled the country gathering information about the scourge of illicit drug use. However, there is one message that he fails to deliver. Taking drugs for a recreational high comes with risk, sometimes leading to death, but recreational drug users make a choice to take these drugs. People with advanced cancer do not have the same choice; they need drugs to relieve their suffering. And as Russell Portenoy, MD, was quoted, “I believe in drugs. I think pharmaceuticals are a great gift to humankind.” ■