Every medical library should have a table of recommended books. After a day of study, I often linger by the one at my school, wishing that I had more time for a good read. I recently picked up a recommendation and didn’t let go. The author’s name was familiar and the praise for the book was compelling, but most of all it was the subtitle that drew me in: The True Tale of America’s Opiate Epidemic.
Dreamland, by Sam Quinones, offered to bolster our relatively scant classroom focus on pain management and opioid addiction. The teaching of these topics has been described as “limited, variable, and often fragmentary” across U.S. medical schools. Nevertheless, the topic of opioid addiction has come up repeatedly in the past year. The first baby I helped deliver during my OB/GYN rotation was born opioid-dependent and immediately taken into Department of Children & Families (DCF) custody. I’ve seen what a vicious withdrawal looks like during Inpatient Medicine, and I’ve observed buprenorphine treatment encounters in Vermont’s Hub & Spoke program. As students, we’re entering practice just as this epidemic is surging into the public sphere. Yet many of us have little understanding of its beginnings and how our profession has been implicated. In the telling of this history, Quinones weaves together one of the most cautionary tales for the practice of medicine in recent history.
In raw language that draws from the heroin economy, pill mills, drug diversion and family tragedy, Quinones channels the anger and despair that has brewed across the country for decades. The book pulls together two nationwide stories that collide in the small city of Portsmouth, Ohio. Framed by the downward economic trajectory of rust-belt America, Quinones tracks the influx of heroin harvested from a small region in Mexico and the simultaneous rise of prescription opioids. As innovative dealers worked eastward to find new markets for uncut heroin in the early 1990s, opioid prescribing for chronic pain was garnering influence in medical conferences, pharmaceutical companies and doctor’s offices.
Through numerous interviews, Quinones details the revolutionary origins of pain management, a discipline that arose to rectify medicine’s previously callous approach to patient suffering. In 1960, the country’s first chronic pain clinic opened at the University of Washington and focused on multidisciplinary approaches that addressed many aspects of a patient’s life. In the 1980s, the World Health Organization developed guidelines for treating intractable cancer pain. However, this humane trend took an ill-fated turn when opioids gained momentum as a stand-alone treatment for chronic pain, notably with Purdue’s introduction of OxyContin in 1996. With the support of influential physicians, Purdue capitalized on the legitimate ‘pain revolution,’ as the movement was called, and aggressively marketed OxyContin as a minimally addictive drug. Quinones reports:
Purdue had its salespeople dig in on doctors who its data showed were already heavy opiate prescribers. To expand the numbers of prescribers, sales reps also visited nurses, pharmacists, hospices, hospitals, and nursing homes. The physician call list used by Purdue sales reps began at thirty-three thousand, then rose to more than seventy thousand doctors nationwide. Purdue’s sales force tripled to more than a thousand as OxyContin gained momentum (p. 133).
As opioid prescribing soared, overdose deaths followed. In 2007, Purdue paid $634.5 million in federal fines for misrepresenting OxyContin’s potential for misuse and addiction, one of the largest penalties levied on a drug company at the time. Since then, prescription opioid overdose death rates continue to rise, and heroin overdose death rates have climbed 4-fold since 2010 as the drug has become an easier and cheaper alternative.
How did physicians, the vast majority of whom were trying to do the right thing for their patients, become accessories to this scourge? Herein lies one of the most cautionary lessons of Dreamland for me: the impact of misrepresented scientific evidence. The widespread acceptance of opioids as a minimally addictive treatment for chronic pain was based on a handful of small studies. These publications carried outsized influence as the pain revolution became married to the fortunes of the prescription opioid industry. One notable example was a 1980 letter-to-the-editor in The New England Journal of Medicine entitled “Addiction Rare in Patients Treated With Narcotics.” In an unforgettable chapter, Quinones documents how the one-paragraph letter’s reputation grew into a “landmark study” showing that “less than 1 percent” of patients treated with narcotics become addicted (p. 107). In a time before a PubMed search could quickly verify the contents of a reference list, this meager letter was cited over and over in conferences and seminars nationwide. Along with other overstated studies, it contributed to a groundswell of liberalized opioid prescribing and the once widely-held tenet that pain protects against addiction, a theory that I’ve still heard referenced despite up-to-date evidence to the contrary.
The momentum of this multi-decade ‘pain revolution’ in medicine has since been redirected toward mitigating its unanticipated impact while still providing important care for patients with chronic pain. And yet, upon graduation, we’ll encounter the continuing epidemic head-on. If we’re to have a clear understanding of what our patients face, it is incumbent upon us to reckon with our profession’s role in this history and to heed its lessons. To this end, Dreamland provides an indispensable perspective.