Sam Quinones on Heroin, the Opioid Epidemic, and Dreamland
Jan 23 2017

Dreamland.jpg How did heroin spread beyond big cities in America? What's the connection between heroin and America's opioid problem? Sam Quinones, author of Dreamland, talks with EconTalk host Russ Roberts about the explosion in heroin use and how one small Mexican town changed how heroin was produced and sold in America. That in turn became entangled with the growth in the use of pain-killers as recreational drugs. Drawing on the investigative reporting that culminated in his book, Quinones lays out the recent history and economics of the growth in heroin and pain-killer usage and the lost lives along the way.

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Author and journalist Sam Quinones talks about his book, The Least of Us, with EconTalk host Russ Roberts. Quinones focuses on the devastation caused by methamphetamine and fentanyl, the latest evolution of innovation in the supply of mind-altering drugs in the United...
Explore audio transcript, further reading that will help you delve deeper into this week’s episode, and vigorous conversations in the form of our comments section below.


Jan 23 2017 at 11:24am

The guest is telling the standard “pain medicine caused an epidemic of opioid addiction” narrative. Well, the government actually does a survey every year to figure out how many people are using various drugs, and “pain relievers” is a category. They actually track past month, past year, and lifetime use and also track “substance abuse disorders”, to distinguish casual users from users with a more serious problem. The numbers haven’t really been rising.

Look at page 7 and page 30 of the document in the link, the SAMHSA drug abuse survey. Both trends look pretty flat to me. The expansion of prescription opioids (the sheer tonnage of which did something like a tripling from 2000 to 2014) didn’t unleash an opioid epidemic. You see the same thing in the Monitoring the Future survey (which focuses on high school age children). You can maybe try to explain it away by saying that the new addicts don’t consider it “nonmedical use” if they have some kind of prescription, but it’s pretty extreme to claim that this reporting bias would totally cancel an enormous trend. The 2015 version of this survey, for the first time, asked about both “any use” and “misuse” and got a number for “misuse” similar to previous years.

The rising number of overdose deaths is another story; these come from the CDC’s mortality database. Trends have been changing rapidly, so even a number from 2010 is out of date here. Russ suggests that drug overdose deaths are actually *undercounted*. This was surprising to me. I think that overdose deaths are significantly overcounted (though there are surely mistakes in both directions). Pick up a copy of Pathology of Drug Abuse by Steven Karch. It is replete with warnings about how you can’t assume the cause of death is the drug just because it shows up on the toxicology screening or because drugs or paraphernalia are found near the body. I think a lot of coroners see these things and they think they have a handy answer to why someone died. A lot of pain patients are walking around with levels of opioids in their system that would kill a naïve user; if such a person drops dead of a sudden heart arrhythmia, a coroner might assume it’s a drug overdose when it isn’t. A lot of these overdoses involve sick people and you find numerous illnesses and infirmities on the death certificate (sleep apnea, various heart conditions, obesity, etc. are common), so it’s not always clear what killed them. With those caveats, here’s what I saw in the most recent year’s drug overdose data.

Russ should have Radley Balko or Jacob Sullum or Jeff Miron on the program to give a contrary take on the “opioid epidemic.” It’s come up a few times on the program. Having dug into this story in great detail, I see that it’s really easy to get it wrong. There are some details that need to be handled more carefully than they typically are. I appreciate the guest’s take on the story, I just think that his narrative fails to consider some important facts.

David Zetland
Jan 23 2017 at 4:15pm

I’ve been following the heroin/opium story in the US since writing a paper on the topic in 2003, so I was quite interested in this program.

The parallels between Mexican heroin dealers and American opiate dealers are a good indicator that they are selling the “same” product to the same users.

What I was surprised to (not) hear was any discussion of the parallels with the (mostly poorer) black community that was blown over by crack cocaine. Same elements of S&D, but an entirely different level of government crackdown and hysteria. There are many many black (dealers) in prison for crack, but not so many white (doctors) for opiates. I’d have loved to hear SQ’s thoughts on that topic.

Second, I was really just WAITING for Russ to ask about Trump’s “Mexican drug dealers” as the scourge of the US, as it seems that his voters come from exactly the areas worst hit by opiate/heroin addiction. Is it possible that they were voting against their dealers? Perhaps, but I wonder if Trump will ever call out the American pharma companies and American (white) doctors who are NOT making America great again.

I agree with Russ that “the government” isn’t going to fix this problem (compared to the community), but it’s surely true that government politicians and bureaucrats have been culpable in encouraging this epidemic, unlike in the Drugs Wars, where they merely made it profitable.

Jan 23 2017 at 5:03pm

The microeconomics of drug dealing was fascinating. Notes;

– I believe that I told this story earlier, but after a major surgery I was prescribed Hydrocodone and took it for about three months. The doctor actually wanted me to take it longer so that I could push my physical therapy harder, however, about a week before a major PT evaluation, I decided that I would quit, see how I did in the eval, then start retaking it if there was still a need. I was not naive as to the potential issues with respect to quitting cold turkey, I knew that I should taper, but I figured that this might be my only chance to go through withdrawal and my scientific curiosity got the best of me.

To be clear, there is no way that a few days post surgery would have been enough, I needed it for those months. Also, I never felt addicted or euphoric and took it as prescribed.

That being said, withdrawal was an experience that I will never forget and will never want to go through again. It was three days of sweats, no sleep, tics and being just miserable. But in this n=1 experiment, I have never had any desire to take it again. Unless you are really, really curious, follow the directions to wean yourself.

– I immediately wondered how many of the KY/WV folks would still get BIG from last week’s episode. I doubt that BIG’s economic assumptions and calculations include or can imagine the creativity of the cash based underground economy.

– A while back Russ speculated that taking drugs might be a rational choice for someone with very few options in life. It was a great question that made me think quite a bit. I could never separate the economics from the morality enough to come up with an answer.

– Russ did a great job at the end letting the author get political for a bit but pulling him back.

– I do not doubt the author’s numbers or lack feeling for the addicted. But heroin can’t be that big of a business as the government hasn’t yet (like other past vices turned into legal revenue sources – alcohol, cigarettes, numbers/Lotto, and lately marijuana) taxed it.

Jan 23 2017 at 6:16pm

This explains the disproportionate reaction to Trump’s proposed border wall which will seriously disrupt the drug trade.

Fact is, Mexico has terrible drug-related violence that they need to fix for the sake of its citizens too. That’s not unusual in Latin America, but other countries don’t have that much direct contact with the U.S.

Jan 23 2017 at 8:58pm

Early on Quinones says that he believes it is very hard to quit a drug like heroin and that addicts lose their free will (!). This kind of hyperbolic language, in which the drug is elevated to something metaphysical is to be expected from the head of DEA not a journalist. So when Russ later says the book is not sensationalist. I just don’t buy it.

Compare heroin with cigarettes is quite instructive. Smoking cigarettes for a long time is very likely to kill you. This is not true of heroin, all harms associated with heroin, come not from the substance itself but from criminalization of it. You might ask about overdoses but why would a user that has access to a safe and reliable supply, who takes his/her drug regularly (five times a day sounds a lot like smoking) overdose? And since Russ quotes Wikipedia, the following is from heroin’s page:

Like most opioids, unadulterated heroin does not cause many long-term complications other than dependence and constipation.

Jan 23 2017 at 9:24pm

Just to conclude why I think this interview makes me very suspicious of Quinones’ book is that ultimately the harm heroin causes and to what extent you can be a functional regular user or an occasional user are empirical questions which he has no qualification to address, yet he makes broad claims.

To the extent that we have scientific examination we know that for society as a whole alcohol is more harmful than heroin or crack (work by Prof. Nutt in UK). You might then say that prohibition of alcohol is not feasible what is wrong with preventing harm from heroin?? The problem is among those who successfully end their addiction a fair number do so by substituting it with alcohol which is widely available and far worse in terms of its health outcomes.

Mark Hatzilambrou
Jan 23 2017 at 9:29pm

One thing I found very interesting was the assertion that heroin is extremely additive and nearly impossible to quit. This is in marked contrast to the writings of Theodore Dalrymple, a British doctor treating prisoners and the underclass, whose portrayal of the medical and social aspects of heroin I had recently become aware of:–stop-spending-millions-treating-it.html

Dr. Dalrymple’s direct experience would seem to lend him some credibility. There could not be more of a contrast with Mr. Quinones’s assertion.

Jan 23 2017 at 9:46pm

[Comment removed. Please consult our comment policies and check your email for explanation.–Econlib Ed.]

Ajit Kirpekar
Jan 24 2017 at 2:30am

I wish there was a better explanation for why this is endemic to rust belt regions and white people specifically. Why indeed?

Heroine is presumably addictive no matter who you are and pain medication was prescribed everywhere as he concedes. Why is it that it seems to be a pandemic to those areas in particular and those racial groups?

I have theories but the fact that this is still a mystery is pretty shocking

Ajit Kirpekar
Jan 24 2017 at 2:35am

Another thought occurred to me. Much like how big software firms will acquire successful startups, why wasn’t the black tar heroine trade been gobbled up by the cartels? If it is indeed lucrative, it would seem like the logical next step.

Forgiving my obvious ignorance, I would imagine heroine would seem to be a competitor to cocaine, crack, and meth so at the very least – competition to a monopoly would attract their attention.

Furthermore, much like a big software firm, the cartels have an extensive network, connections, and an army of ruthless murderers to flood the streets with even more heroine than whatever could be produced by several locales in a small state in Mexico. I’d be curious to know the answer to this question as well.

Jan 24 2017 at 5:41am

Thank you very much for a very interesting podcast, Sam Quinones and Russ Roberts.

Things of history I would have liked brought up to nuance the discussion:

– Veterans returning from Vietnam largely got rid of their heroin addiction acquired overseas, once back in the U.S. The environmental contingency of heroin addiction is also replicated in rat experiments.

– Historically China has had a large opoid addiction problem. Thus, not only a white people problem. What’s the social context there?

– It is said that China under Mao defeated heroin, going after the drug lords, while treating addiction as a medical, not criminal problem. Lately the problem has surged again.

(I apologize for not backing up my claims)

Jan 24 2017 at 11:12am

@Mark Hatzilambrou

I agree, and also see psychologist Gene Heyman’s “Addiction: A Disorder of Choice”. I believe Williams S. Burroughs, who was addict almost his entire life, also had similar views. My own thinking on this is that because the heroin today is far more potent than it was in the past, as Quiones notes, it might alter the brain chemistry in such a way that it makes it very difficult for addicts to quit. I would be interested in seeing more research on this topic.

Jan 24 2017 at 11:18am

A very interesting podcast from where I sit near the medical field.

Pain as “the fifth vital sign” is far more entrenched than simply JACHO. The CMS guidelines recommend reporting this vital sign, and what was done, for each clinic visit or you may NOT GET PAID. Additionally, there are quality metrics that impact reimbursement by various percentages tied to how pain is reported and how it was addressed.

The government has come down strong on the need to address pain, while the surgeon general sends warning to doctors that they need to restrict opioid use and many doctors fear prescribing them as the DEA looms over their shoulders tracking every prescription they write. Doctors live in fear that a patient will divert their prescription or get multiple prescriptions they did not know about.

I also found the podcast an interesting argument for why legalizing all drugs is potentially very dangerous and each needs to be evaluated individually. Marijuana – sounds great! Heroin – sounds awful.

Finally, an illustration of how much evil can be done chasing filthy lucre. These people destroyed countless lives to turn a profit. Poverty can be quite motivating, but so can moral systems that treat other humans with enough respect not to want to subject them to the sufferings and potential death of addiction.

Jan 24 2017 at 12:05pm

I am wondering how marijuana, which is considered a more “benign” drug, fits into the addiction/epidemic story of the podcast. I am wondering if the author, Russ, or any commenters here have an opinion about the addictive dangers, if any, of marijuana. Specifically, what would you do if your teenage child was on it? Would you think small amounts, like having a few beers over the weekend, is not much to worry about and can still maintain good study and work habits while taking?


Jan 24 2017 at 12:18pm

First, @38:30 Sam Quinones said, “they developed this kind of new way of trafficking that was based on marketing now. Very heavy on marketing. Almost no violence. No violence at all. ‘Violence, bad; can get us a lot of prison years.’”

This is, honestly, the first positive outcome I have ever heard coming from the war on drugs–that it incentivized non-violent distribution. That’s interesting and encouraging.

Second, the current state of medical understanding of opiate benefit and risk is still deplorable. The expert doctor panels that make up the advisory boards to the different medical professions and the central government who forged legislation enforcing the opinions and guidelines passed by those expert advisory boards built their case on hope, optimism, and, frankly, ignorance. This is just another story of the failure of central planning. Read the conclusions of a few of these abstracts to get a flavor of what we know right now about opiates:

Finally, my housekeeper was evesdropping on this episode of Econtalk while she was working around me. She made me stop it so she could tell me a story. She said that she is friends with a human resources manager at a local Wal-mart who told her,

“You know how everyone is talking about the big problem in this country where low skilled workers can’t find employment? Well, we’re hiring every single day! There’s not a single day of the year we’re not looking for more low skill employees. The problem is the drug tests. The obscene majority of the people who apply can’t pass the drug tests!”

It’s a second hand quote and a single data point, but it’s tantalizing to think the minimum wage may have an underappreciated rival as a barrier of entry for poor people accessing work.

Jan 24 2017 at 12:44pm

@ Alvin

The only marijuana problems I see coming through the ER is from the synthetic stuff. It kills people or makes them act very, very strangely. It is very unsettling, even to hardened ER staff, to witness the strangeness synthetic THC can cause. But I caution, MJ use is generally casual and intermittent right now. If it was legal and used regularly, like cigarettes, you’d probably see the same increase in cancer, lung failure, stroke, and heart attacks that you see with regular cigarette use.

Mike Riddiford
Jan 24 2017 at 3:01pm

Interesting program. As well as the human tragedy that was described, I was particularly interested in the economic aspects of the apparent over-prescription of pain killers e.g. 30 days supply when 3-5 days of pain was expected (see transcript). Questions are:

what incentives did doctors have to do this? e.g. from drug companies, meeting patient expectations etc
were any doctors sanctioned for malpractice over this? (imagine prescribing a month of antibiotics for a 3-5 day illness)
Was over-prescription used as a kind of novel transfer payments system? e.g. I give you lots of this subsidized drug that you can resell for profit illegally. It seems the low cost of the painkillers to both doctor and patient meant there was no price signal to lower consumption

Ajit Kirpekar
Jan 24 2017 at 3:14pm

This episode builds nicely with all the prior episodes that touch on this topic, but notice how the explanation for why this epidemic keeps changing from guest to guest.

Prof Skinner suggested it was a kind of desperation due to joblessness and depression. Angus Deaton seemed to agree.

Arnade suggested it was aimlessness, boredom, anger, and ennui that caused this.

And now Sam Quinones is suggesting its because of heroin innovation and over prescription of pain killers.

Which one is the primary reason because it seems lazy to say all three. Also, we’re not even synced up on just who it is. Are they rich addicts, poor addicts, young, old, unemployed men, low skilled men, women…or is it just anyone who is white and with a pulse?

And why again is it just whites?

Marilyne Tolle
Jan 24 2017 at 5:15pm

This conversation reminded me of the following adage, taken from the very instructive documentary “Prescription Thugs”:

“The pharmaceutical industry is not in the business of healing and curing; it’s in the business of disease management and symptom maintenance.”

Ed Dentzel
Jan 24 2017 at 7:36pm

He had me until the last five minutes. Then he lost his mind. That was a rant that may be unprecedented on this podcast. Russ tried to stop him and the guy was so involved in his words, he didn’t hear Russ. That makes me question the entire thing.

Jan 25 2017 at 12:17pm

Excellent program and I can’t wait to read the book. My neighborhood — upper middle class — has seen a number of kids with heroine addictions. My son has one friend who has died of an OD. This is getting very close to home.

The Original CC
Jan 25 2017 at 2:28pm

I second GregS’s motion to have Radley Balko on the show!

Mark Crankshaw
Jan 25 2017 at 3:19pm

I’m with Ed Dentzel here, Quinones definitely goes off the rails when discussing the ‘Afterwards’ of his book. I almost thought that the podcast had been interrupted by an old Bernie Sanders campaign ad. Well, I must respectfully disagree with Mr. Quinones and his assessment of the past “35 years”.

Do liberals really imagine that everything was a social Garden of Eden pre-Reagan? Or have they forgotten the riots and social melt-down of the 60’s and the malaise and the deep economic turmoil of the 70’s? I wasn’t around in the 60’s, but I remember the 70’s and they were rank.

Perhaps, Mr. Quinones, the government has received such abuse on merit. It has been incompetent, not to mention corrupt, irresponsible, and a highly divisive part of society. Having read Robert Putnam’s Bowling Alone and Charles Murray’s Coming Apart, my prognosis for the revitalizing of “community” within America is grim. We are hurdling at breakneck speed is precisely the opposite direction.

Unlike Mr. Quinones, I do not lay blame on the “free market”, the “private sector”, or even the effects of globalization. No, no, it isn’t even directly the government, but the related role of politics in Western Society.

For millenia, religion played an essential role in “glueing” a society together. It provided the moral underpinnings and demanded adherence to a single and universal set of morals and ethics, a single answer to “what is life about?”, “how should we conduct ourselves?”, and “what is the purpose of this community?”.

As an atheist, I certainly do not mourn the transcendence of secularism over religion in the Western world. That said, this transition from religious to secular dominance in Western thought has come at a price: there no longer exists a single set of ethics, beliefs, ideals or morality that bind people together. Without consensus in ethical, moral, and idealistic values (what kind of community do we want?), the basis for a community withers. Diversity, contrary to the liberal mantra, is not a strength in this regard; it is a severe weakness. If one does not believe that they share the same ethical, moral and idealistic values with those around them, those they feel compelled to share the same political space with, then the among the ramifications is a diminished sense of community and an ever increasing level of political distrust, conflict, and animosity.

The violent events of the past week in Washington DC are ample evidence that we are indeed a very, very weak political community, and that we are only getting weaker. It could be argued that political beliefs have replace religious beliefs as the central “faith” of the western world. It is no longer that one’s political opponent has a different opinion and is therefore as politically “legitimate” as oneself. My god is as fake as yours. Now, those who differ are “heretics” (the of calling ones’ political opponents Nazis or Fascists is reminiscent of the calls of “blasphemers” or “unbelievers” of the past), they are evil, their opposition must be malevolent and irrational (racist, homophobic, etc.) and as such any and all political opposition is “illegitimate”. I worship the one true god and you are heathen! We’re going down a well-trodden path.

History is filled with endless and bitter religious wars. The US is embarking on yet another– just a secular version– a revitalized community is likely not forthcoming.

Mark Crankshaw
Jan 25 2017 at 8:20pm

Russ Roberts said:

You know, these towns that you write about, some of them, particularly in the Appalachian Region and the episode just mentioned before: They are very depressed economically. The best jobs have left. A lot of the factories are gone. Why do the people stay there? Why don’t they leave?

To which Sam Quinones replies:

I mean, I not sure I understand, because rationally there is no reason why you would stay…I think there must be a lot of psychology as to why folks don’t leave horribly depressed economic areas. They don’t know anything–they don’t know anything about any other area. They don’t feel at home. They feel lost elsewhere.

As one who has stared down the barrel of that particular gun, I won’t dispute that there is a psychological component to the reluctance of people not leaving depressed economic areas. However, from my own personal experience there is a massive rational reason to stay unless own has deep pockets and a graduate degree.

I have a colleague at work who constantly bemoans ‘those Trump supporters’. Why don’t they just move, he implores.

Here’s the rub: these economically depressed areas don’t have jobs, but they do have affordable housing in areas where one is not the only white person in the area. Try moving to where the jobs are and you will quickly discover that there is a massive housing price differential between those rural depressed areas and the largely urban areas with all the good jobs.

I made the move from an economically depressed area to a major urban city when I was young, single, childless, had a graduate degree and a “good job” (at least it seemed to me good pay at the time). I quickly found that even the worst housing available consumed half of my gross income. The only “affordable” areas were in dangerous crime ridden dumps where you find yourself the only white guy in the neighborhood.

With substantial student loans to pay off, even an efficiency was un-affordable. I eventually left behind the low income barrio to which I initially moved, that seemed to contain an average of 15 people to a one-bedroom apartment, with the nightly arrests of my ‘no hablo ingles’ “neighbors” right outside my front door. While I did feel much taller in the barrio (they called me “el blanco grande”) I eventually grew tired of hearing “shots fired” and the police tape all over the place. Eventually I found a room in a house that I shared with six other people in Arlington VA.

I stayed there for 7 years, had over 100 “roommates” who rotated in and out every month, most of whom I never knew their name. My landlord charged $450 to some poor soul for literally a closet with a bed in it, and $600 for an unfurnished furnace room–and that was what he charged over ten years ago.

Now just imagine I was older, married, or like a lot of those in economically depressed areas, never married or divorced but had children (and end up with substantial child support payment that balloon as ones’ pay increases). Imagine that I only had a high school diploma and had some part-time or low paying job in the DC area. I wouldn’t even be able to afford the closet!

Granted, I didn’t like the DC area (and never will), especially the liberals who live there, and never felt at home there. Fifteen years later I’ve since married, moved as far as I can possibly commute, and own a home that allows me to send my children to a decent school (which one can not do anywhere near where there is ‘affordable housing’). However, if you don’t have a high level of schooling and therefore cannot get a high paying job, your prospects in DC, New York, LA or San Francisco aren’t merely extremely limited, they are absolutely wretched. They are actually much worse than staying put in an economically depressed area.

Jan 26 2017 at 10:50am

I found the discussion with Mr. Quinones riveting…until he started railing against the private sector at the end of the podcast seemingly without any basis.

The only ‘fact’ he threw out was that somehow the private sector has exported a lot of jobs overseas. As has been discussed here (and by myriad other economists), while there are some jobs that have been ‘lost’ to other countries, it’s technology/innovations in productivity that has caused the bulk of these jobs to no longer be needed. If his argument, then, is that it’s technology overall that’s driving ‘societal isolation,’ I wish he’d develop that argument thoroughly.

But when you look at the fact that the National Debt has grown by over $14 trillion in the past 16 years, I don’t think anybody can logically argue that the private sector has grown in influence over government, or that government has effectively been demonized. Yes, of course there are a lot of people/economists who continue to point out the myriad problems of Big Government….but if that line of reasoning had won the argument, government wouldn’t have grown this much, particularly in the short run (relative to overall U.S. History), when the pain-killer problems emerged.

Todd Kreider
Jan 27 2017 at 11:14am

That was a rant at the end of the show? As far as rants go, the guest was an amateur. For a true, professional rant, check out some Richard Epstein on Econtalk…

Robert Swan
Jan 28 2017 at 8:17pm

I enjoyed this talk, but have mixed feelings about it. On the one hand, the way the drug selling evolved into a sophisticated operation with marketing promotions not all that different from a McDonald’s (even free “balloons”!) was very much in keeping with EconTalk’s emergent order theme. On the other hand (and as noted by quite a few commenters) Sam Quinones’s demonising of opioids didn’t ring true. It flew in the face of what I’ve heard from several sources I trust, and of my small amount of direct experience.

My understanding is that it is perfectly possible to live an upstanding and stable life while being dependent on regular doses of heroin. This dose doesn’t have the “high” or the “rush” or whatever; it’s more akin to a dialysis session and simply satisfies the physical need. As noted by commenter Sam, this stable maintenance dose does no harm. Can’t say that of alcohol or tobacco. I doubt it can be said of marijuana either — called dope for a reason. Not sure where oxycodone stands on this but I’d have thought it’d be in the same camp as heroin.

Words are interesting things. Quite a few oxycodone users today would agree that they are “addicted” but might bristle if you called them “addicts”. There seems to be a taint of blame in the latter.

I think Sam Quinones is on very shaky ground saying that this is supply driven. There are numbers, but the usual thing about correlation vs. causation applies to those. Perhaps the clever marketing is making inroads, but is their marketing so good that they can convince people otherwise happy with their lives to opt for oblivion? Perhaps the real growth in supply is in susceptible clients. I’ll not settle deeper into my amateur philosopher’s armchair to speculate further, but I think it’s a more important question than heroin supply.

It was an odd moment at the end when the guest suddenly seemed to have become possessed. It passed quickly and his calm and urbane personality returned. He might think about consulting an exorcist if it happens again.

Jan 29 2017 at 10:56am

I had just read American Pain the week before listening to this episode. Then, after the podcast, I read the full Dreamland book and also Narconomics.

For those interested in the topic, I recommend both American Pain and Narconomics. Seems like Narconomics in particular would make an interesting EconTalk discussion.

Stephen Williams
Jan 29 2017 at 4:27pm

Interesting interview, the guest did exaggerate the difficulty of getting off heroin. I’m not that sure that any drug is hard to get off given enough reason. Chairman Mao made China almost drug free, the reason he used to convince people was death, when given that choice most stopped using, just saying.

Jan 29 2017 at 4:51pm

Just finished reading “Dreamland” courtesy of my neighborhood library, and a few thoughts:

* Mr. Quinones’ writing style made it both easier (via short chapters) and harder (via jumping around from place-to-place and from year-to-year each chapter) to follow the story.

* “Dreamland” refers to a community swimming pool in Portsmouth, OH, that Mr. Quinones represents as the ideal American town – one that existed in the 1950s, but doesn’t exist today. Misplaced nostalgia for the past has been a pretty consistent EconTalk theme for some time, and I’m surprised that this wasn’t discussed on the podcast. The book certainly seems to imply that the 1950s was the denouement of life in America.

* Mr. Quinones adopts the staid narrative of how Walmart has destroyed small-town America. At one point, he actually writes that while in Walmart he “imagined its aisles haunted by the ghosts of store owners who once sustained small-town America. On one aisle was the departed local grocer, down another the former hardware store owner, next to that, the woman’s clothier or that long-gone pharmacist.” Upon reading this (and other passages), I see where he developed his end message in the podcast when he railed against the U.S. private sector.

* While most of the book was believable, I found myself skeptical of Mr. Quinones’ reporting of the Portsmouth-area Walmart. Briefly, he details how area residents regularly shoplifted from the store to pay for their opiates – expensive electronics time after time after time. Further, he said the low-wage employees were complicit because they weren’t paid enough to try to stop it. I find it very hard to believe that this much shoplifting would go on without either the store manager cracking down the first week this happened because his/her job/bonus would be at stake, or Walmart simply closing the store because they’d be losing so much money. Of all these chains, Walmart seems to be the leader in tracking every dollar, every product, every component of profit…it’s very hard to imagine how they’d let people shoplift “DVD players, Xbox consoles, headphones, Tide detergent pods” regularly via a box-switching scheme. That store would be out of business!?

Aceso Under Glass
Jan 30 2017 at 1:05am

I was quite disappointed in this entry. Quinones seems to dismiss the idea of taking pain seriously without even having to justify it. He does no math on the people who were helped by easier access to pain medication and hurt by the recent crackdown. There was also no mention of how opioid deaths went down in states that legalized medical marijuana.

john penfold
Jan 30 2017 at 12:55pm

Fascinating discussion. Thanks. I see some here dispute the credibility of a number of points. Nothing is simple, but having been present at creation, Cali Colombia in 68 when nobody was interested in a report about the early organization of the cartels, Bogota in 75-78 when the drug warriors were hungry for information, and Tegcigalpa in late eighties when Mata Ballesteros resumed residence, I’ve followed the business. When I made the first estimate of the impact of illegal foreign exchange income on Colombia in 1976, I suggested that going after the supply not only could not work but would exacerbate all the problems. I called interdiction a non tariff barrier. Then when I replaced my knees, 30 years later and when my wife shattered a knee late last year, I saw the legal pushing first hand, and also learned that the staff had connections with more criminal elements. Its rampant. I find all his stories credible except non use among Mexican illegals. It’s also bad in Mexican communities across the country even if not among the clever folks selling the heroine.

Jan 30 2017 at 2:34pm

It would have been nice to hear Russ push back a little against Quinone’s view of addiction. Maybe it would have been inappropriate in the context of this interview; it might not make sense to start lecturing a non-economist guest about the theory of “rational addiction.” But I would have liked to hear something like this from Russ, given that he studied under Gary Becker. Maybe get Kevin Murphy to discuss this idea in a future program? I think a more standard view (than Quinone’s) is that people “grow out” of addiction as they age and acquire obligations and responsibilities. I also recall hearing that when taxes on alcohol increase, consumption decreases all around but the response from alcoholics is *larger* than the average response. This actually makes sense in the “rational addiction” framework because they correctly sense that their expected future costs have changed *more than* that of the average drinker; this result makes little sense in the “addiction enslaves the mind” framework. (The alcohol tax example is lifted from Tim Harford’s “The Logic of Life,” but I believe he is discussing work by Becker and Murphy.)

Marilyne Tolle
Feb 13 2017 at 11:37am

On supply-side policies, this new NBER WP finds that programmes that monitor the prescription of opioids in Medicare lead to better curbs on utilisation when they’re compulsory.

A big caveat though is that, even when compulsory, these programmes seem to have no effect on opioid poisoning incidents.

The authors hypothesise that may be because opioid users 1) substitute into other opioid sources (out-of-state or street level) and 2) reduce the amount of opioids they sell to others and keep more to themselves.

Another hypothesis is that the compulsory programmes reduce the rate at which people become addicts, which delays the effects on poisonings beyond their sample period.

Comments are closed.


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Podcast Episode Highlights

Intro. [Recording date: December 12, 2016.]

Russ Roberts: I want to remind listeners to go to where you'll find a link in the upper left-hand corner to this year's annual survey of your favorite episodes.


Russ Roberts: Now for today's guest, author and journalist Sam Quinones. His latest book is Dreamland: The True Tale of America's Opiate Epidemic, which is our topic for today's conversation. Sam, welcome to EconTalk.

Sam Quinones: Great to be here, Russ. How're you doing?

Russ Roberts: Doing great, especially after reading your book--more or less. Dreamland is one of the best nonfiction books I have read in a long, long time.

Sam Quinones: Well, thank you.

Russ Roberts: I couldn't put it down. It was deeply disturbing in many ways, but incredibly illuminating about an issue that we have touched on a number of times here on the program, which is the opioid epidemic. But I want to start at the beginning, which is actually heroin. So, I want to start with the revolution in the production and distribution of heroin out of Mexico that you describe. And I want to start with the business model of what you call the Xalisco Boys (The "x" is pronounced like a guttural "h" or "ch", or like the Spanish "j": ha-lis'-co or ja-lis'-co). Xalisco being a small town in the Province of Mexico on the Pacific Coast, Nayarit. And it's spelled with an 'X': X-a-l-i-s-c-o.

Sam Quinones: Right. Not to be confused with the state of Jalisco, which is a very, very large state with Guadalajara as its capital.

Russ Roberts: Talk about what came out of Xalisco.

Sam Quinones: Right. These guys back in the early 1980s, families from this town, a town of about 20,000 people, landed and had then migrated to the San Fernando Valley of Southern California--Canoga Park, [?] area. A few of these families had figured out how to cook black tar heroin from the opium goo that grows in opium poppies. Opium poppies, you should know, grow very nicely and have about a century in the mounts of the Northwest of Mexico. And so, Nayarit is a state right on the Pacific Coast of Mexico, northwest. And so they had access to that. They began to learn how to cook the goo into what's called black tar heroin. Black tar is a kind of a sticky, gooey, semi-processed form of heroin. It's like a tootsie-roll kind of--every bit heroin just like white powder is. It's just not as processed and filtered and so on. And they began to sell this heroin in parks in the San Fernando Valley. A few of these families. Not very many. They would chip off little pieces; the addicts would come up and buy it from them. But in time, a couple of things happened. One was, the cops began to get wise to them. They got wise to them because more and more families from the town began to see this is as a viable business and began to get involved in it. That saturated the market. Now, these guys were different, though. Most times, you find in the underworld, people develop or grab market shares at the barrel of a gun. Al Capone started that, I think; and ever since, that's been the way people in that economy and market share. But these guys couldn't do that because they were all from the same town. They all knew each other. A lot of them were related. Sometimes they had gone to school together. Everybody knew where each others' mothers lived. So, they couldn't use that method. So they developed another method, and this really led to the system they developed, which was a form of selling heroin that resembled very much pizza delivery. So, you, the addict, would call a number. The operator, who was standing by to take your order, would then dispatch a driver. A driver would meet you at some predetermined place and sell you your heroin. And this got them out of the parks. The cops couldn't find them as easily. They also got access to a much larger market of heroin than they would have if they were just a stationary, in a park. And in time that process replicated itself. Even with cars: more and more guys come up from this town; more and more people get into the business. And so they have to move beyond even San Fernando Valley--they kind of saturate that, given the number of addicts that are in the area, they need to set the business model kind of saturates the market and they have to move to other cities. So, first there was Pomona, Ontario, which is about 30 miles east of LA (Los Angeles). I think they went to San Diego. Portland. Denver. They began to expand, very, very much like any capitalist small business or franchise would.


Russ Roberts: Now, talk about the ways they avoided detection. The first thing as an economist I noticed is they were very price conscious. Similar to the crack cocaine distribution, which was really an innovation in the magnitude, the size of the dose--what we're talking about here with the black tar is a tenth of a gram. And talk about how it's sold in balloons and how they use that to avoid detection.

Sam Quinones: Sure. They were not cartel-killers. They were not full-time drug traffickers. They were kind of guys who thought that they'd get some extra money. They were very aware of not wanting to go to prison. And so, the way they began to do it was--they also were retailers. Which is really rare in the Mexican drug-trafficking world. Most cartels, most drug-trafficking groups, they sell wholesale. These guys developed a retail--they realized that they had, that the profit was really in retail. And they began to put the dope in small, little balloons, tie them off; and they would put these ones in their mouths. So, you could--I've talked to guys who actually could put 20, 25 balloons in their mouths.

Russ Roberts: They are not inflated.

Sam Quinones: Not inflated. They are balloons that are just wrapped around, just to protect the dope in case the cops stopped them. And that's why they also carried a big jug of water. The cops stop them; they begin to swig on the water and they swallow the balloons down; and the cop doesn't find any dope on them. And that's one way they avoided detection. Very important in this was also: They never used guns. They, I think, learned or saw the Bloods and the Crips fighting it out for territory in those years for crack territory in Los Angeles. And heavy, heavy police attack on those folks. The Colombians were the same way--when they brought their dope into Miami they were very much given to shoot-outs and killing lots of people to kill one target. Of course, Al Capone, etc. These guys eschewed guns and completely understood--first of all, that they were not gunmen. But number two--an illegal immigrant. They were all here illegally in the country. An illegal immigrant with some dope would be deported. An illegal immigrant with some dope and a pistol would get 10 years in prison. This was very clear to them. So they really formed a system that relied far more on marketing, on customer service; on making sure that your dope was potent and that your customer got it on time. They were also, during these early years--the 1980s into the early 1990s, they were marketing, they were working during a time when the numbers of addicts--the demand was really small. And so they would go to one new town--say, Salt Lake or Portland--and a few of these crews would get there. They'd compete among each other. But in order to take customers from each other, they couldn't kill each other. So they had to out-market and do a better job of customer service, because they couldn't kill each other. So they became master marketers first, very early on. And this was also part of their way of developing a market. They developed personal relations; they'd give you 50 free balloons if you brought them 5 new customers. If you bought from me 6 days or a week I'd give you a free one on Sunday. These kinds of come-ons and gimmicks--

Russ Roberts: Free samples--

Sam Quinones: and that kind of thing were part of their business.

Russ Roberts: They gave away free samples. They'd go to a methadone clinic[?] and hang out[?]

Sam Quinones: They gave away free samples; they'd hang out in front of methadone clinics and give away free dope there. If they knew a guy well enough, he got out of jail, hadn't been using for 3 or 4 months they'd meet up at his house, give him free dope there, get him using again. There's a whole range of ways that they had of marketing and retaining market share that way instead of through the barrel of a gun.

Russ Roberts: So, as a hardcore free-market guy, there's a certain respect you have to have for that. But there's a really dark side to it, which is: Heroin addiction is not easy to get out of. In fact, you seem to suggest that you can't. Period.

Sam Quinones: Well, I'm not sure I would say you can't. I have known people who have. It's just a torment. It's a torment unlike any drug. It's a drug that deprives you of rational free will, I believe. I don't believe that when you are fully in addiction you have that free will, particularly, to heroin. So, these guys knew that. They knew that they were marketing a very potent drug. The other thing that I think they knew, too, was this: Heroin that used to come to the United States from the Far East--you know, the French Connection-type dope, and well, for most of the 20th century a lot of it came from Turkey or from Burma or from Vietnam or what have you--a lot of that dope had to change hands many times. By the time it got to the street it was pretty well diluted. Each time it changes hands, the guy, to make his money, he cuts it and he sells it for double. He makes 1 kilo into 2, or 4, and sells it for double and makes a lot of money that way. That's how you make your money. And so, for many, many years, the DEA (Drug Enforcement Administration) always found, when they did their tests on heroin that they would seize on the street, that the potency was 6 to maybe 15 to 18 percent. Something in that ballpark. These guys were making the heroin, their family members were making it; they were taking it themselves up through the border. Heroin is very, very easy to smuggle across because it's so condensable. And it would get to the United States in very, very potent form. They were not diluting it so much as the dope that would come from, say, Burma or someplace. It didn't have as far to go. Heroin is a commodity. It's not like a red wine or marijuana which has a lot of varietals. It's one thing. And the price really depends on how much you diluted it, and how far it had to travel. And in this case they didn't dilute it very much at all. And it had only maybe 2000 miles to travel instead of 12,000 miles, say. And so it got here much more potent and much cheaper, and that's what made their heroin very, very popular.


Russ Roberts: So, I have a couple of prices in the book: At one point you mentioned 25 doses for $100; 5 doses for $100--obviously it depended on the city and what level of competition there was.

Sam Quinones: Completely.

Russ Roberts: How many doses would a user who is in bad shape be using a day?

Sam Quinones: Usually about a gram to a gram and a half--so it could be 6 to 8. It depends. I would say 6 to 8 doses a day, perhaps, something like that. I found different people in different states, honestly, in my book, per person. So, that's the thing about heroin. That's what makes it a magnificent drug for drug traffickers. It really has no medicinal use, compared to other opiates from the same opium poppy: heroin is extraordinarily addictive and has more or less the same pain-killing qualities as others but it's far more addictive--because it takes you up and down: euphoria and then you crash very quickly. So, you need to be doing it 2, 3, 4, 5 times a day sometimes, and that's what leads to the addiction. That's what makes it very, very appealing to a street trafficker, because you've got a customer who's going to hit him up every day. There's no day--on Christmas, on Sundays, you're not saying, 'Maybe I won't use today.' No. You're using every day; you cannot not use this drug. And sometimes it's 3, 4, 5 times a day. And it also drives people to extraordinary ends: they are willing to sell anything; they are willing to find any client if they'll get them more free dope, they'll do it. A lot of these guys spread. The way they spread, the way they expanded to other cities was really with guides who were addicts. Addicts were their guides: they told them, 'Man, you bring this stuff to Reno, I know where the methadone clinic is there, and man, we could make a killing there. And you just give me my free dope; that's all I care about.'

Russ Roberts: Can a person hold down a job as a heroin user?

Sam Quinones: You can. And what I found was these guys changed that, though. I met guys, for example, addicts who would say, 'Back when it was hard to get, back when heroin was more difficult to get and was far more expensive and far more diluted, I was able to do more with my life. I was able to hold down a job, more or less; more or less handle family responsibilities and this kind of thing. Because it was hard to get: it was either really expensive or the places that I had to go to get it were dangerous, like some forbidding little bar or some strange, unappealing motel or housing project or what have you. But these guys made it easy. That's when it just went off the rails for a lot of these guys. So it made it easy in several ways. First of all, they made it cheaper. They would give you free dope from time to time to keep you using. And, all it was, was a phone call away. I remember I talked to one guy who had no legs. He had, because of his long addiction he had one day frozen, almost frozen to death in a storm, had lost his legs. And so, before these guys showed up, he had prosthetics: he had to hobble around downtown Portland 3 times a day to get his dope. And he didn't know what kind of quality it was going to be; people would rob him occasionally. It was just a torment. 'These guys show up and it's magnificent: these guys, they are a phone call away; I don't have to walk out of my motel to go hobble downtown Portland. They are cheap and frequently they give me free dope; they are clean; they are not going to rob me; they are nice guys; they are polite.' On and on like this. 'And it was almost like as if I'd died and gone to heaven: these guys were the best dealers I've ever seen. They gave me free dope; I could con them out of free dope.' Etc. And so his use kind of went off the rails. The convenience, the access to easy availability and cheap supply is what really, really pushed people over the edge a lot of times.

Russ Roberts: And of course as you mention in the book, none of these drivers, who are typically young kids, young men from this one town, they're not using. They are not--they don't sell to black people. They are afraid of them, for whatever reason--they are racist. They only sell to white people. Do they ever sell to fellow Mexicans? Because they need a Mexican community to hide among?

Sam Quinones: No. No. No--

Russ Roberts: And why not?

Sam Quinones: First of all, in the Mexican community, the level of heroin addiction is microscopically small. I don't know too many. Now, the Mexican-American community is a little bit different. But even so, this is a white person's problem all across the country. The pill problem, opiate addiction problem is really white people. No, they are a rare breed in the heroin world, the heroin retailer world, because most of the time, up to then--and I've had many cops in different cities tell me this--your typical heroin dealer was an addict. He was stationary: he was in a house; he was in a bar or a motel or someplace. And he was very easy to arrest and very easy to investigate. The only problem was back then no one bothered because it was such a small problem. These guys come along and they don't use. They are in and out; they are very quick; they are not hanging out; they are not partying; they are not causing a ruckus; they are not calling attention to themselves. And they don't hang out in one place. They don't have a bar or a house or something like that where they sell their dope.


Russ Roberts: So, as you point out, there's a poignance, an incredible poignance, to the fact that it's culturally repugnant to these folks to be a user. The idea that they are helping--often children, high schoolers and teenagers--get heroin is repugnant to them, because they would never want their own children, of course, to be doing this. And yet they come anyway, because it's very lucrative. And they come for very short periods of time. So, talk about the motivation of the young men who come from this one town--their cultural aspirations, their alternatives, a little bit about what life feels like in the town. Because it's incredible.

Sam Quinones: Yeah. Very interesting stuff. That's what I--I knew most about that when I started this book. They come from an area--a lot of these folks--immigrants in general, when they come to the United States, they are not the poorest of the poor. They are people who have--they are kind of working class folks; they have some resources, some assets but not a lot. And all around them they are seeing people who are doing better by going north. In the immigrants' case, work as landscapers; say, in this case, 'You guys come north and sell heroin.' But when these guys come back home, the guys who have gone north, they set a new standard for achievement: That, in order to be seen as having overcome poverty, you now need to be building yourself a house. For immigrants--Mexican immigrants--all across Mexico, they build houses. Hundreds of thousands of houses, maybe millions of houses, all across Mexico, because of that. And that becomes the norm, the standard by which you are judged, because you are not interested in becoming American. You are not interested in doing anything more than going home and showing the people who humiliated you when you were young that, 'This is what I'm really capable of. This house that I'm building is what I'm really capable of.' Now, that's the immigrants' impulse all across Mexico, I would say--I've studied this many years, wrote two books about it. I think this is a very, very important impulse. When it comes to drug trafficking, the impulse is the same; it's just that the risks and the rewards are many times greater. And so, you go north to sell dope, and you come home, and you build a house that might take a regular 9 years to build--you do that in 9 months, because you have the wherewithal, you have the capital. You don't have to build room by room, one room a year. You build it all in 9 months, and you build nice things like wrought iron and automatic garage door openers. And that kind of thing. What that does then is set the standard, set the bar very, very high for the other kids who are still poor in your town, are still kind of scuffling and wanting something--who no girl will talk to, who is not respected: their dad is an alcoholic, their dad is just a scuffling sugar cane farmer. These guys now have to reach this level, not the level of a house that it takes 9 years to build but one that it takes 9 months to build. And a lot of these guys have available to them only the most dead-end work in Mexico--sugar cane farming, bakery work, butcher, construction, avocado farming, etc. These things lead nowhere in Mexico. And they are not viewed as jobs that people really love to do. So, these guys all became--basically, two generations of this town, I think, became heroin traffickers up in the United States. And they all then went back home. They all brought their money back home. They all built houses--not lavish mansions. We are talking about middle-class houses. This is a system deterring you, transforming you from making you a poor person into a middle-class person, not into some drug kingpin. And everybody then, they would come home and they would be the kings for 6 weeks or 2 months or whatever. It wasn't all the girls then wanted to talk to them; and they could buy a good used truck; and they could build a house, a small house in 9 months instead of 9 years. And this became kind of what drove these kids forward. And then, also, once--the other thing, amazing to me, I thought, so fascinating--was that once they'd already done this--they'd done this once--they'd come back. They, too, would get addicted. Except it was not to the drug. It's to the feeling of coming home a king. Coming home a man of respect. Coming home a man with a trunkful of Levi's 501 Jeans and passing them out among your nephews; and your brothers-in-law, what have you. That was their drug. And so they'd spend their money and they'd be like a junkie without any dope and they'd have to go back to the United States to earn more money to come back and be the king for 6 weeks again. It was a fascinating peek into what really drives people. A lot of it is really psychology and aspiration.


Russ Roberts: And these are young--young men, typically. And a puzzle I had reading it--so, the profits--at one point you mention it takes about $2000 of time and equipment to cook a kilo of black tar heroin; about $50,000 to maintain the apartment and the car for the people and pay the drivers. So, for the person who is the distributor to the driver, sort of manager of the town of a certain number of drivers, there's $150,000 roughly of revenue.

Sam Quinones: Mmmhmm.

Russ Roberts: So there's a huge profit. It's $52,000 in costs; about $100,000 in profit. So, normally competition will drive that down. Of course, if it's dangerous, it doesn't drive it down very far. But I'm wondering why other towns didn't compete?

Sam Quinones: That's a very good question. Yeah. I'm not sure--

Russ Roberts: Is it just the technology of cooking it? Is it what they figured out that no one else has figured out?

Sam Quinones: No. That's more like a folk craft. You can cook black tar heroin from opium, the opium goo that you harvest from the opium poppy, and cook it into black tar heroin. I've seen film of this. The DEA actually has a confiscated film that I have in which a guy is cooking as if it were a barbecue. It's like a big barbecue grill and he's got a couple of pots going. And, no, it's not hard at all. I'm not sure exactly. In those areas, a lot of people were already going north to work. This is an area of very heavy immigration of the United States. They [?] were already involved in other jobs. Heroin is viewed, again, get back to kind of the way it's viewed in Mexico, is that the lowlife, most low-life, scuzziest, back-alley drug. And so getting involved in that is--you know. And it does take, I think, a fair amount of knowledge--a kind of breadth of knowledge that is developed over many years: trial and error. There is no book. They didn't use a book to figure out this system. It's: 'When it will get you arrested, let's not do that any more.' And, 'Let's try something else.' You know. I mean, it was--so, I'm not sure I know. I do know, though, that at a certain point, what started with a few families had to expand to many, many other families. So, for the first 15, 20 years of the life of this thing, a lot of these guys, there was the same last names: [? Hernandez, Tarjeta, Garcia-Langarica, sp?], a few others [? Diaz-?]. These kinds of last names. And they all were kind of connected and they all were related to each other. Sanchez family was a big one. But then they had--the DEA first figured these guys out in late 1999 and 2000. And they held the first big, nationwide bust. It was the first time in fact, that when they busted these guys, in I think in a operation called Tar Pit, it was the first time that the DEA and the FBI (Federal Bureau of Investigation) had actually worked together on a, and found a drug ring that went, literally, coast to coast, from North Carolina to Reno and Los Angeles and Phoenix, etc. And they arrested--I can't remember now as I talk to you, maybe 200 people. And with that, the families that ran those crews had to find more labor. A lot of those people went to prison, Federal prison, some for significant sentences--10, 15 years. So, what they began to do was expand to new families, families that had never been involved. And at 2000, the year 2000, just as the United States was developing a very healthy appetite for opiates of all kinds, they have to now expand throughout--so it's not just police go in a few of the little villages around there--they sometimes have to take labor from towns in other counties and people that they know, and I [?] a few of those as well. But it happened because their labor source, their labor supply, was in one fell swoop sent to prison. And so they needed to kind of fill the ranks with new folks.

Russ Roberts: And you went to Xalisco under cover, pretending you were not a journalist.

Sam Quinones: Right. First time I've ever done that, by the way. Any time people asked me, I'd say, 'I'm a journalist'--except for there.

Russ Roberts: You were scared.

Sam Quinones: I was not going to do that there.

Russ Roberts: Reasonably. So, you went to Xalisco. You've talked to these drivers--I think. You've talked to users. It's an incredible bit of reporting. And that's half the book. That would make a fantastic book. But it just gets more interesting, because there's an intersection with the opioid problem.


Russ Roberts: So, let's switch gears. Let's talk about painkillers. How did painkillers become a problem? It seems like there was this great new set of painkillers out, oxycontin and others. Why did they end up getting misused and abused?

Sam Quinones: Yeah. That was the--I backed into this story. Because of my background in Mexico, I really focused first on the heroin traffickers. But then, of course, I was left with the question: Why is it that they have so much new demand? Because they were now, by then, by the time I doing it, they were now in Ohio, West Virginia, places like that. And so that got me on to this other story that was really the first story, a really far larger story. And that begins, really, in the 1980s as well, about the same time, when pain management is just beginning to be kind of a new discipline within medicine that you study, and a whole group of pain specialists began to form a collective consciousness and believe that we were not treating pain correctly--that there were these pills, opiate painkillers out there, and doctors all across the country were unwilling to use these, and that this was not a reasonable proposition. That these pills ought to be far more liberally used. And at first they made the argument, 'We need to use these for hospice care folks, people dying of cancer, whatnot, in order to improve their last months on earth. What does it matter if they are addicted to these pills? Who cares if they are addicted to these pills if they also live the last 3 months of their lives pain-free?' And that made a lot of sense. That was a very logical argument: that folks would die in utter pain because doctors were afraid they would be addicted. But these folks made a different argument. They, however, kept pushing; and that's why we're here today. They didn't stop with just hospice care. They began to make the argument that virtually all of these pills, 'We now know--science now knows--that, you know, 5000 years of experience with the opium poppy be damned, we now know that these pills are virtually non-addictive when used to treat pain.' And they began to push. They were joined in this after a while by certain pharmaceutical companies who were producing some of these pills, main one being Purdue Pharma, which makes the pill Oxycontin. And they took up the call of these guys. I had one doctor say, 'If it hadn't been for the pain specialists, the pharmaceutical companies would have had nobody to footnote, to use to say this is why we're doing these, we're producing these pills.' But had it not been for the pharmaceutical companies, these pain specialists would have been without a megaphone. And so the combination of those two together, particularly as the 1990s progressed, becomes very, very potent. They begin to argue that we are a country in pain; virtually non-addictive now when used to treat pain to revolutionize our treatment of pain. And then, the game-changer comes with oxycontin. Oxycontin was a game-changer for a couple of reasons. The main one was that it was promoted by Purdue Pharma almost the way you would promote an over-the-counter medicine to doctors, with lots of giveaways and discounts--very much, as I got into my research, very much reminiscent of the come-ons and discounts that the Xalisco Boys would use to sell their heroin to their customers. And so a lot of these kinds of come-ons and this kind of thing; and they had a CD (Compact Disc) they gave away called "Swing in the Right Direction with Oxycontin." It was a bunch of swing band tunes; it was this kind of a new approach to marketing a drug. But it was an opiate--highly addictive; but they were using the idea that these drugs were virtually non-addictive, which was gaining credence in medicine. They were helped also by medical establishments--JCAHO (Joint Commission on Accreditation of Healthcare Organizations) that accredits hospitals came up with the idea that now doctors should use pain, should consider pain to be the 5th vital sign. So, they used to treat it just like you used to treat pulse or that kind of thing. But all these things should be treated the same and therefore pain is something you should always treating. There was a patient evaluation. So, there was this whole culture around the idea that we were, first, a country in pain; and what's more, that we were not treating it properly; and finally, that we had the tools but we had just been afraid to use them. And that was these opiate painkillers; and of the new one was oxycontin.


Russ Roberts: And as you point out, millions of people, who were in horrible pain weren't any more. So that was the good side. The bad side was the promised non-addictive aspect of oxycontin, which was the slow-release part--the idea that oxycontin was continuous was supposed to dampen the addictive part. Two things happened. One, people figured out a way to get around that by sucking off the coating that slowed the release; or hitting it with a hammer. So that was problem Number One. Problem Number Two is--I think; correct me if I'm wrong--that there were people who got addicted anyway, even though it was slow-release.

Sam Quinones: Yes. Right. They were following doctors' orders and they would still get addicted. And part of the problem, too, was that along with the idea that these pills were no longer addictive when used to treat pain, came the corollary which was then that there was no limit on dose. So, you began to see all across the country doctors prescribing enormous quantities of these pills for patients to take home with them after acute surgery, for acute pain after surgery. Now, this is pain that is probably going to last you, oh, no more than 3-5 days. If it lasts more than 5 days there's something else wrong. But, they would prescribe 30 days' worth of Vicodin or Oxycontin--these are common--Vicodin is another common opiate painkiller. And so what happened is--and then--and this was happening all across the country--an enormous new supply of opiates was created across the country; and a fair amount of that, a good amount of that leaked out into the black market. I believe this--when I was in Mexico, I believed that all drug stories were demand-driven, and that drug scourges were created by demand for those drugs. Now, when I did this book, this changed my mind, honestly: I came to think that really most drug problems begin because of excess supply--easy, cheap availability of a drug. And that's exactly what happened here. We have a new, a massive new supply of opiate painkillers from coast to coast, all across the country, because it's doctors who buy in to this idea. A couple of generations of doctors buy into the idea that they now need to very aggressively prescribe these things to treat our pain. And some are pushed or pressured. Legally you have to do this: If you don't treat pain, you can be sued. Some, it's insurance pressures; if we don't push people through our clinic we won't be able to reimburse enough to keep the lights on. But, whatever the case, doctors all across the country come to this idea that they need to do this. And that is what creates a massive and continuous new supply of opiate painkillers for the last 20 years, from coast to coast.

Russ Roberts: So, a couple of important footnotes. This same molecule really is heroin, correct? All of these are just variations--

Sam Quinones: All of these drugs are derived from the opium goo, the opium poppy, the goo that the opium poppy produces. So they all have molecularly--their molecular structure is more or less the same. They do a very good job of killing pain and they are extraordinarily addictive; and they have what--when you get off of them, they cause withdrawals. They have the same effect on the brain chemistry, no matter whether it's hydrocodone, oxycodone, heroin. There's some differences but by and large they all come from the same poppy. They are derived from the opium poppy.

Russ Roberts: The idea, which sounds reasonable, was that if you are in pain, the drug merely covers the pain and doesn't produce euphoria; if you continue to take the drug after the pain, then you can get addicted. But it turned out, of course, that we really don't understand why people get addicted in the first place. So, pain is not sufficient to avoid addiction to these drugs, evidently.

Sam Quinones: It is for some people. And for others it isn't. This is the problem. We applied the fire hose approach: You just blast everybody with opiates. And for some, that's fine; and a lot of our listeners they are now going, 'Yeah, I didn't have any problem.' And it's probably true. But there are an awful lot of people who do. And it's figuring out who is who beforehand that's the tricky question. Like, 'Is this a person who ought to get this much?' And doctors were not doing that. A lot of doctors didn't have time to do that. Time is the crucial thing that we have lost in modern American medicine. You do not have time as a primary care doc in most parts of America to sit down and ask a patient all the questions that really will allow you to come to a really clear idea of whether or not this person should get this quantity; and then, if that person should get that quantity over a period of time. They have shown, I think--there are studies that show that there is a very high incidence, risk of addiction, if you are given these drugs, exposed to these drugs no matter who you are, over--I believe it's 90 days. You get 100 milligrams a day, more than 90 days, something like that, I don't have it in front of me right now--but the risk of addiction is very, very high no matter who you are. But the problem is, we apply the fire hose approach. This is a very nuanced problem. Pain is a very nuanced issue, and you've got to spend time. It's individual. Every person is different. And when you try to apply a fire hose to everybody, things just don't go well.

Russ Roberts: So, just a couple of data points from Wikipedia, which you can--I think are consistent with the ones you mention in the book. It says

In the United States, more than 12 million people use opioid drugs recreationally. In 2010, 16,652 deaths were related to opioid overdose....

In 2007, about 42,800 emergency room visits occurred due to "episodes" involving oxycodone.

So, it's a serious problem. And in particular, particularly tragic, young people in particular geographic areas where usage, access was much easier, just thousands of lives were ruined. And eventually--

Sam Quinones: And continued to be--

Russ Roberts: And continued to be--

Sam Quinones: By the way, this is something--you know, the CDC (Center for Disease Control) just put out information that shows that we have now more heroin-related deaths than gun homicides, in 2015 as a country. That's a spectacularly--

Russ Roberts: Tragic--

Sam Quinones: It's a tragic thing. It's just blows my mind.


Russ Roberts: So, talk about how the heroin distribution started in Iraq with the opioid distribution.

Sam Quinones: Sure. The reason I write about the Xalisco Boys, as I call them--these guys who developed this system for selling heroin a lot like pizza delivery, is not because they are the only heroin traffickers from Mexico. Nor is it really that they are the only black tar traffickers from Mexico. The reason I wrote about them was--two reasons. One was that, really, they developed this kind of new way of trafficking that was based on marketing now. Very heavy on marketing. Almost no violence. No violence at all. 'Violence, bad; can get us a lot of prison years. We forget about that.' But the other reason is because they--as they expanded, as they were going through this kind of capitalist expansion mode, through the 1990s, they jumped the Mississippi River. They are the first ones to bring black tar heroin east of the Mississippi River in the history of that drug--according to the DEA. They are the first ones to jump the Mississippi River. And they do this--one guy in the book does this in 1998. Now, that's a crucial year because it's just at that moment when this pain, this revolution in pain management is really taking hold, and when, in that area of Columbus, Ohio, to the north--Cincinnati to the west, West Virginia, eastern Kentucky, that very, very roughly-drawn area--that is the area where Purdue Pharma is first very, very aggressively promoting and marketing Oxycontin. And you are finding now lots of people beginning to get addicted. And all of a sudden they land in an area--pure coincidence; there's no conspiracy here--they just happen to land in an area where for the first time they find a huge number, a growing population of addicts. And then a growing demand. And so, they are the first ones to recognize and then systematically exploit the coming market for heroin that this massive, kind of fire hose approach to prescribing opiate pain pills implies. And they just hang out in Columbus, Ohio. And this guy tells me, 'At first it was amazing. I was just doing this business; I had two kids up there driving for me; and I was lying to all my friends back home. I was saying, no, I'm in New York City; or I was telling them all kinds of lies about where I was. Last thing I wanted them to know was that I was in Columbus, Ohio. But then these kids go back home; they come back home with lots of money for the parties; they are showing off from the girls. And pretty soon everybody gets the idea of Columbus is the place to go.' And within a year or two, I think about two years of his first arrival in the summer of 1998, you know, Columbus is beginning to get one crew after another. And I think lately--it comes and goes--but I think they've got 10 or 12 crews working from this one town in Columbus, or had, the last I heard, anyway. And they begin to bring--you know, it's a fascinating story. Oxycontin is a game-changer for another reason, not just how it's marketed. But, because before Oxycontin, people would mess around with low-dose Vicodin, Percocet. But those have acetaminophen in them. They have Tylenol in them. If you develop a large addiction to those, you will destroy your internal organs. Oxycontin has none of that. So it takes people up to very, very large addiction levels, daily addiction levels, so you have to be doing 100, 200, 300 milligrams a day of these pills--that's $1 dollar a milligram on the street. So, it's 100, 200, 300 milligrams a day. Well, you can't sustain that. There's no way you can continue with that. So you begin to look for something very cheap and just as potent. And cheap Mexican heroin fills that bill perfectly. And their heroin fills that bill absolutely. And it's easy to get. And it's available. And they'll give you free come-ons and discounts, etc. And so it's that kind of encounter, between the heavy marketing of pain pills and Purdue Pharma, and the pill mills were beginning in that area as well; and then the encounter of these heroin traffickers with this new system and this very cheap, very potent dope that creates the first examples of what we're now seeing all across the country, almost in every state of the union. Which is: people getting addicted first to pills, and then transitioning to very cheap Mexican heroin. It's not always the Xalisco Boys doing the selling in every state. But that's where you first see it. That's Ground Zero, that whole region, south of Columbus, Ohio.


Russ Roberts: So, there's a lot of things to talk about here, but I just want to make sure I get this question in, because it's haunted me, reading your book. Which is: I have very limited experience with opiates of any kind. And so I can't really--I once had a root canal, and I had codeine afterwards, with Tylenol. And it was really pleasant; I really--it was blissful. The pain went away. I slept incredibly well. That's really about it for me. So I'm really not a very good data point. But after I read your book, I did find myself--because there's so many teenagers and young people whose lives are ruined or who died tragically, in this book. And I'm going to tell listeners: It's not a sensationalist book at all. One of the great reasons it's such an effective book is that it's not sensational. Your imagination does a lot of the work. And it's really a--it's a police kind of book--what's the right word? It's a--I can't remember the word.

Sam Quinones: Well, I try not to use adjectives.

Russ Roberts: Yah. Exactly. It's a procedural book. So, I found myself calling my kids--off at college and telling them, 'Try to avoid these drugs if you need them.' And my question is-- 'And certainly stay away from, if somebody offers you a balloon of black tar heroin for free, don't take it.' Which is obviously pretty good advice. But I found myself wondering, if they had surgery of some kind, and you give many examples of this where some kid in the football team gets shoulder separation and he gets prescribed drugs by a doctor to take care of the pain--and he ends up dead. And so, would you counsel your children? Would you, yourself take these opioids in the aftermath of surgery?

Sam Quinones: Well, look. First of all, it's incumbent upon doctors to know the person. And know--and so that is a big thing. And parents, for them to know their kids. With regard to athletics, you are absolutely right. This pain revolution has transformed football into a gateway to heroin addiction, because football is a sport that creates chronic pain, creates pain. And also, along with that, though, there is very often the intense desire to get back on the field. And this is not just the coach. This could be very easily the player. And could be very easily the friends and the parents, the siblings, and all. And my feeling is, if there is that kind of injury, your body knows. We all know. If you get a shoulder separation, there's one way of curing that; and that is time. And you just have to make sure that you understand that you cannot continue for a month to take these pills. They are not pills to be taken for months. They are magnificent--I think doctors will tell you--they are magnificent for post-surgery pain that lasts 3 or 4 days. That's what they're made for, really, if you ask me. And for hospice care. And some, some small part of chronic pain. But if a doctor is saying, as somebody told me when I had my appendix out, 'Here's 60 Vicodin, 30 days' worth of Vicodin. Take as needed,' you need to ask questions. You need to say, 'What's in Vicodin? Tell me that, Doctor. Would you know? And why the 60? Why not 6? If this is acute pain, why not 3 day's worth instead of 30 days' worth?'

Russ Roberts: I want to emphasize that this is not a medical program, of course. Anything we are saying here, for folks out there, take with many grains of salt. But I would counsel everyone listening to be careful and to ask questions and to not take anything for granted. It's a chilling--

Sam Quinones: And to also understand that we need to be--one of the great things about this story that I learned was, this story, doctors get a lot of blame for it. But, you know, a big part of why this happened was because we Americans didn't want to be accountable. We didn't want to be accountable for our own consumer choices, for our own behavior. Doctors would say--talk to any doctor, any primary care doctor will give you some amazing stories on this. People come in: 'Well, I have pain, Doc.' The doc says, 'Well, you need to eat better. You need to exercise more. You need to start swimming. You need to stop smoking.' Etc. It's a bunch of things like that. 'Do yoga.' Whatever. And people do not want to do that. That's why pills were so appealing.

Russ Roberts: Magic.

Sam Quinones: These opiate painkillers are so appealing as a solution because most of the patients wanted the easy way out. And we need to be accountable.


Russ Roberts: So, I want to talk about another part of the problem. And yeah, I certainly agree that we have a certain cultural problem here with suffering, delayed gratification, here--you name it. We want to avoid it. Which is human. We all understand that. It's one of the curses of being wealthy. But there's a piece of the story that was just extraordinary to me. I'm going to try to spin it out, and you can then fill it in. So, there were these doctors--and by the way, I felt I could have done this interview by myself, Sam. I've told this, excerpts from your book, to way too many people. Ask my family about it. They are getting a little tired of Dreamland. But, so you've got these doctors in what are called pill mills, particularly in areas--Ohio, and Kentucky, West Virginia--depressed areas economically, people having trouble finding work. And the doctors set up shop; they are going to dispense a prescription every 3 minutes, because they want to make money. They are not reliable, honest doctors; they are just going to write prescriptions. They are going to say, 'Are you in pain? Yes. Good; here's a prescription.' It takes 3 minutes. So, you are going about 20 patients an hour. People are lined up. Addicts and others are lined up to get at these drugs. To see the doctor--I just want to talk about the financial side--to see the doctor, it's a $250 cash payment.

Sam Quinones: Right. No insurance accepted.

Russ Roberts: Correct. So, you show up. You give the doctor $250 that maybe you've stolen or fenced, whatever, from whatever. And then, that gives you the piece of paper. The doctor gives you the opportunity to buy oxycontin, a supply. It's going to cost about $1000--I forget how long a supply. Is this a month or 3 months? I can't remember. But a long supply.

Sam Quinones: Could be a month.

Russ Roberts: A month. Let's say $1000. But you don't have $1000. You do have a Medicaid card. And the co-pay for Medicaid is $3. Which seems like a very nice, thoughtful thing. But what it means is that the taxpayer is going to cover $997 of this. The addict is going to cover $3. And then the punchline--that's interesting by itself and as an economist who has often talked about the value of cash, I can't help but note the irony that we give people Medicaid because we don't want them to have cash as a way to use it on drugs and alcohol. So there's an incredible tragedy here. So, they take the $3 co-pay; they $1000 worth of drugs; and it's worth $10,000 on the street.

Sam Quinones: Something like that. Right. Exactly. This is what happened in many parts of that area that I talk about as ground zero--rustbelt and the Appalachian area. And I believe one of the reasons for that was because Purdue figured out that it was in those areas, when they were first starting to market Oxycontin, in those areas, doctors were already prescribing a lot of drugs. And the reason for that was because doctors had become the connection, the crucial element in navigating economic catastrophe. You needed a doctor to get Workers' Comp (Worker's Compensation).

Russ Roberts: Disability.

Sam Quinones: You needed a doctor signing off on--Disability, all those forms of Disability. Now, for a long time, Disability was desirable because you got an SSI (Social Security Income, or SSDI, Social Security Disability Income), desirable because you got a $500 check every month--so it was not a lot of money but I mean that's what people had done. The pill revolution transformed the calculus of why you would want SSI or SSDI or what have you, because it gave you, as you said, the Medicaid Insurance Card. And all of a sudden, if you could find a doctor to prescribe you a long list of drugs--Vicodin, Oxycontin, Xanax, etc., etc.--it went on and on--that you could make a ton of money and get high a month[?], too. And yes. It was--the taxpayer money was kind of funding this in certain areas, among certain people. It was a big way that it began to spread early on. I think it's still used in some areas. But it was because doctors were so used to--they were almost economic counselors--themselves, or job counselors themselves, doctors, in a certain point. Because all the people that were coming to them were being laid off, or were being threatened to be laid off. There was all these, this grave concern about, 'How am I going to navigate economic disaster and catastrophe in our region?' Well, doctors were it. And they were already used to prescribing a lot of drugs. And so, when Purdue came along, it met a very fertile, you know, tender terrain in there. And that's why that area, I believe--that's why that area was kind of Ground Zero for all of this.


Russ Roberts: And this--you mentioned earlier that these drugs were cheap. Like, the heroin. They were cheap to the user. They weren't cheap. They were expensive. But, so there was this really unhealthy, symbiotic relationship between the drug company and the doctors who were benefiting from this, and the users, who were basically funding this habit out of this structural process of Disability/Medicaid payments.

Sam Quinones: Right, and all of [?] came primarily in my opinion, dealing with economic cataclysm. I mean, these are areas where we are losing mainstay jobs, never coming back. And this was a way of navigating that. I would also say this was--what was interesting about this, too, I thought, was that these pills were first presented and marketed as a boon to doctors: 'Doc, here's the solution to those patients that you take up your time that you don't have.' And 'This is going to be a great thing for you guys.' And it turned out really, that in the long run that it was horrible curse for doctors. First of all, in a lot of cases it made doctors lazy. Just throw pills at the problem and get them on their way and forget about it. That kind of approach. But also, it really, really did, after a while, particularly in some of these areas that we're talking about, undermine any scruple the doctor brought to his profession. And so, at a certain point you find docs, you know, kind of taking a horrible advantage of these very vulnerable addicts. Because they can. You know? And it's just available to them. And you find people getting into very, very sticky legal problems. We just had a woman out here convicted of murder, a doctor out here convicted of murder for this. So, it turns into a curse. It seems like a simple silver bullet solution to all these very complicated problems of how do you treat patients' pain and what it really turns into, as most silver bullets do--in my opinion--a horrible curse that ends up destroying lots of careers. And really--you know, you do make a lot of money, for a while. But after a while, everyone knows you are quack. And you really not--the reasons you may have gotten into medicine are somehow clouded in this big fog of money and dope and very desperate people.

Russ Roberts: But you point out--a lot of them went to jail--

Sam Quinones: Yeah--

Russ Roberts: Fraudulently dispensing--

Sam Quinones: Yeah, and they still do. They are still--there's two doctors--there are several doctors in the Los Angeles area I can point to who are going to jail or about to go to jail because of this. You know.


Russ Roberts: One of the most poignant, just heartbreaking parts of this book, is you talk about the fact that after a while the local pharmacy might not take the doctor's prescription because they know it's not real.

Sam Quinones: Oh, yeah.

Russ Roberts: So, the users have to start driving 200, 300 miles to get their fix of legal, destructive drugs, these opioids, these pain-killers. And on the way, they are fantasizing about the fact that that $3 payment is going to get them $10,000, because they are going to be able to sell it on the street. But they end up, of course, using it on the car on the way back and never getting out of the cycle--

Sam Quinones: Right. This is the most, the most complete form of personal slavery, opiate addiction, that I think we know, in America today, apart from just prison itself. You know, if people think, have all these dreams, and then what's really true is that this is, this just deprives us earlier of all rational free will, and so you have the dope in front of you. You just kind of use it. You know, it's the only way to really explain how a kid who would complain while sober, before his addiction, would complain about doing the most minor household chore, gets addicted and thinks nothing of walking 2 miles in a snowstorm to get his dope. You know, it's an amazing depriver of personal liberty, unlike any other substance that I am aware of.

Russ Roberts: So, we had Chris Arnade on the program talking about some of these depressed areas in Appalachia and elsewhere. And we had Angus Deaton on, as well, talking about the rise in the death rate, which is for the first time in American history for a long, long time anyway, since it's been measured, probably, the mortality rate for certain age groups has been rising. Particularly, the most surprising one recently was women, 45-54. And yet your book is--maybe it's because it's the most heart-wrenching part--is young people dying. And I raise the question for listeners who remember those episodes: I said, "Are these people killing themselves out of economic--you know, malaise?" What's it mean, a drug overdose? It's pretty clear from your book is a drug overdose is people who are trying to get high and don't realize how much they are taking. And eventually it just stops your heart. And of course there's a coroner problem. Some of the coroners don't recognize it; they'll say a heart attack is cause of death when it really a drug-induced heart attack. There's a lot of science around this. But, talk about what you think the significance is for our assessment of these economic problems. I want to throw in one more variable, which is: You know, these towns that you write about, some of them, particularly in the Appalachian Region and the episode just mentioned before: They are very depressed economically. The best jobs have left. A lot of the factories are gone. Why do the people stay there? Why don't they leave?

Sam Quinones: Wow. Yeah.

Russ Roberts: They stay. They stay, they find this comfort. And some of them, I assume, survive. But it kills some of them. It's a terribly sad story.

Sam Quinones: Exactly. I mean, I not sure I understand, because rationally there is no reason why you would stay. But there's more too--just like I learned about Mexican immigration--there's more to Mexican immigration than pure cost/benefit analysis and dollar and sense. There's a lot of psychology that goes into it. And what makes me feel like a big man when I go back home, that's a big part of it. And I think there must be a lot of psychology as to why folks don't leave horribly depressed economic areas. They don't know anything--they don't know anything about any other area. They don't feel at home. They feel lost elsewhere.

Russ Roberts: They miss their sister.

Sam Quinones: A lot of that, you know, goes into why they stay, I think.

Russ Roberts: Yeah, they miss their family. But do you think this is a problem? Is this particularly a female problem of 45 to 54? Your book doesn't seem to suggest that.

Sam Quinones: No. I think this is a white problem. It's not--we've been talking a lot about Appalachia. But really the places where you find this mostly I would bet are in very nice, well-to-do areas like Charlotte, Portland, Salt Lake, Indianapolis, Minneapolis. These are areas that have done really, really well in the various economic expansions and booms that we've had over the last, say, well, since the mid 1990s, basically. And so, no. I think this is a white problem. That study that you mentioned by Professor Deaton--

Russ Roberts: Yeah, it's white women[?]--

Sam Quinones: Yeah, it's white men and women. It's basically--if you'll note that--that upturn begins in 1998. 1998, there's only one thing really that happened about that time in the United States that affected white people all across the country that would create a new increase in mortality among folks, and that is the expansion of opiate painkillers as the go-to pill for almost any kind of pain. Massive supply of new opiates, a big black market and a very, very scary rise in opiate addiction that we're now seeing. I mean, if you look at that study, it's, 1998's the crucial year. And there's only one thing that happens. But that is not just in Appalachia. That is not just in, you know, the poor rustbelt areas. Many, many well-to-do areas are the same way. It's a white problem.


Russ Roberts: Well, let's close on a somewhat optimistic note, as your book does, which is the following: The war on drugs has been remarkably ineffective. It has, it brings with it, many, many negative things, besides the fact that it fails. And so it's very difficult to stop people from doing what they want to do. And it's very difficult to stop entrepreneurial folks from doing what they can do. And so the supply of black tar heroin is still out there. The opioids on the street, it's not quite--they are not as available as they were before: there are new formulations being created that are trying to reduce the likelihood of abuse, breaking them open as I mentioned earlier, etc. It's all kinds of efforts to try to make the magic of, the holy grail of the non-addictive painkiller. Which, of course probably doesn't exist; and you mention that in the book, that it's probably just a pipe dream--to use a bad metaphor. But, the optimistic side of this is that there's a cultural problem, too. It's not just that there's drugs available or that there's painkillers available. That, we have a certain emptiness at our core at times as human beings. And this fills it. And, what's, again, poignant and moving and inspiring at the end of your book are the--what we would call Civil Society--the attempts of parents and others to band together to try to create efforts to rehabilitate, to get their kids out of this problem, to try to get their kids from getting started on the problem. Talk about some of the things that are going on that you see as hopeful, even in these depressed areas, that [?] the end of the book I think are somewhat cheerful.

Sam Qunones: This is a story about isolation versus community, really. These drugs are the most isolating drugs. They thrive on, because we are, as Americans, are culturally so isolated from each other. Whether in poverty or in wealth--doesn't matter, I don't think, really. And so these drugs are almost like--heroin, certainly, the poster drug for our era. Era in which we are superficially connected to each other through social media and Internet and truly not connected in any human sense; or disconnected very, very widely, I would say, across this country. And so, I say at the end of, the Afterword to my paperback book, that if this--you know, heroin may be actually a call to a kind of a community renewal. We have spent 35 years in this country exalting the private sector, destroying community, allowing the private sector, in my view, to destroy community in many, many areas. Jobs go overseas. A variety of things. It's a complicated story. And we could talk about that. But I think what's happened in the last 35 years is we have seen communities destroyed. We have built up a brand new suburbia that's extraordinarily isolating. We call that prosperity. We have demonized government and laughed at government and called it incompetent, not paid taxes to support it. And we have a situation now, in my opinion, where--having done all that, having solved[?] that the private sector, demonized government, what we now have is a story that the private sector has visited upon the United States of America and its people the most devastating threat to personal liberty that we know today, which is opiate addiction. And for a long time the only ones who were fighting that were government officials--coroners, jailers, cops, public health nurses, etc. That's changing now--

Russ Roberts: But, Sam--

Sam Qunones: so, what you're seeing is that heroin is forcing us to kind of recognize our own isolation, our own lack of community. And actually, in those areas where it's hit hardest, in some of those areas where it's hit hardest, has pushed people to begin to create those bonds of community again. They are halting attempts; they don't always work. The people seem to be up against very potent forces that are keeping this from happening. But nevertheless I began to see this, as I've been traveling around, talking about Dreamland to various small communities in America. I begin to see this kind of idea that we need to kind of get to know each other again. That we need to do things in public: not always be afraid of what's outdoors and outside. But get them outside. Let them skin their knees. We've been so afraid of the kids' feeling any pain at all, for a decade--a couple of decades, now. And all it leads to is these kinds of problems. So, in the town of Portsmouth, Ohio, I spent a lot of time for this book. I mean, you know, people--there's a new cafe; there's workout spaces that people are developing. There's a new recovery movement in that town after years and years of so many people being addicted. A lot of them right now in recovery. Doesn't mean that there's no problems. And Portsmouth still faces a lot of economic hurdles and bad jobs, basically. But you kind of find, in those areas that heroin has really visited and pummeled, and opiates have pummeled, that there is this recognition that, 'Yeah, our communities have been devastated and it's now time to work back towards a feeling of community and getting to know each other once again.' That's the positive, I guess, that I would take out of all this.

Russ Roberts: Well, I don't think--you might not be surprised to know that I don't agree with much of that. I agree with the last part a lot. And I would say to listeners that I only found about two paragraphs in this book that I didn't agree with. Which is a very small number for the average book I read like this. So I would just add that, I don't think the exaltation of the private market and the disrespect for government is the root of the problem. It hasn't stopped government from getting bigger over the last 30 or 40 years. And I don't think it's really the cause. I think the deeper problem is the cultural problem that you suggest. And I don't think we should look to Washington, or Columbus--which is the capital of Ohio--for that feeling of community. I think we have to create it ourselves, from the bottom up rather than from the top down.

Sam Qunones: No, I would agree with that, as well. I think that that's certainly true. I was just telling a woman who wanted to come have me speak, in a part of Ohio, in fact, saying, 'You know, my feeling is that people in these counties, they have the answers. But for so long they've been laboring alone or unaware of who else is working on these things. Or maybe not with the proper budget.' Or a variety of issues. And coming together, kind of finding that common ground is crucial. And the community feeling. Getting to know--sometimes, for example, public health and cops don't know each other. That's crazy. In one county, you'll find people who just don't really know each other that well or won't know how to work together. Well, clearly there's ground for those folks to come together and work on this topic, and really--and they are aware where the solutions, I believe, are--are already there. When I give my speeches, I make sure I don't say, 'Well, if you want to solve this problem, my policy prescriptions are 1, 2, 3, 4.' I don't ever do that. I just say, 'Look, it seems to me that a drug that is created and thrives on isolation, that the way to attack it is defeating it through community.' And this is a problem we have; and our own isolation is a problem that we have created for ourselves over many years now. And forming a community to fight it can actually lead to enormous benefits, not just in the fight against dope, but in many other ways. That's my message frequently when I'm out in these areas.