June 2, 2017 · 6:54 am

Porter & Jick, Dreamland, and The New England Journal of Medicine

The New England Journal of Medicine startled everyone this week by a posting a one-sentence warning over the so-called Porter & Jick letter to the editor that the journal published in January of 1980.

The warning note reads:  “For reasons of public health, readers should be aware that this letter has been `heavily and uncritically cited’ as evidence that addiction is rare with opioid therapy.”

I find it remarkable that the NEJM did this, particularly so long after the letter itself was published in the journal. Apparently this kind of note is very rare.

But I think it confirms what I wrote in Dreamland – in which I interviewed the main author of the letter, Dr. Herschel Jick.

I think it’s important to reiterate the impact, as well as the intent, of the letter.

As written, it is entirely correct. That a data base of hospital patient records, that Dr. Jick ran, and still runs, found the following: of 11,800 patients given narcotic painkillers while in hospital, only four developed an addiction to those drugs.

Remember this was data taken from the 1960s and 1970s, a time when narcotic painkillers were rigorously controlled, and never given to patients to take home with them. So it stands to reason that patients, under such strict controls and administered the drugs only in hospital, would rarely develop addictions – as the letter’s headline in the journal read when it was published: Addiction Rare in Patients Treated With Narcotics.

They simply didn’t have access to large supplies of narcotics, and especially drugs to take home with them, as patients routinely do today. Hence they didn’t run much risk of addiction. (The whole thing, btw, helped change my mind about what ignites a scourge of addiction, which I now believe is not demand, but supply. Supply first sparks demand.)

The problem came not with how the letter was written, but how it was interpreted, then used, by others. Through the late 1980s and 1990s, it was widely cited, quoted, footnoted – as my research in Dreamland made clear and as a recent letter to the NEJM from the Canadian doctors confirmed. It was deemed to be proof that somehow science now knew that addiction was rare when opiates were used to treat pain. Through the years, it became known, through a process similar to a game of telephone, as some kind of “landmark study” that presumably refuted much about what we know about narcotic painkillers and addiction.

The Porter & Jick letter – 101 words – neither did, nor intended, anything of the kind.

It was also used, of course, by pharmaceutical companies – especially Purdue Pharma, manufacturer of OxyContin – as proof that their drugs no longer caused addiction when they were used to treat pain. The company used the statistic that “less than 1 percent” of all patients administered opiate painkillers drugs – especially OxyContin – grew addicted to it. This was not true nor supported by any science. It was not supported by Porter & Jick, which was making an entirely different observation. Yet the letter was used to convince a generation of doctors that science now knew new things about narcotic painkillers and one was that they were “virtually nonaddictive” when used to treat pain. A claim that, again, has no basis in science or the letter.

All this I wrote in Dreamland, which came out two years ago. I found the whole story to be an unsettling episode in how scientific thinking changes based on no evidence at all, but due instead to deft and relentless marketing.

I’ll add one more thing. The NEJM’s warning note was prompted, as I said, by a review of the letter and its influence in scholarly studies that was published by some Canadian doctors in the journal this week.

I read the letter these doctors wrote and I don’t see Dreamland credited or footnoted.

I’m trying to take it all in with equanimity. Yet I’ll admit to some frustration to have done so much research and storytelling that brought this to light as part of Dreamland’s larger story of how this opiate-addiction epidemic spread, and which others have read and learned from, and then not have it reflected in the work those people do. On the contrary, the Canadian doctors’ letter is presented as some new revelation, which it is not.

So I’ll just say that it would have been nice to see my work credited in the recent NEJM report by those Canadian doctors, as well as media coverage of that letter. I’ll leave it at that.

 

 

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June 1, 2017 · 11:38 am

Happiness & Heroin

One important thing my mother told me when I was growing up was that first I should find the work I loved to do in life. That if I did, or didn’t, it would affect all the other aspects of life: sleep, romance, family.

I’m lucky. I love what I do. I’ve been a journalist for 30 years and when I’m on my deathbed I’m quite sure I’ll be making deals with God, saying, I’m happy to go but just let finish this one story first. Nothing I’ve done in the last 30 years has been drudgery, tedium. It has been exciting, mentally stimulating — and it paid the bills.

That didn’t happen by chance. I worked at it very hard for many years. I was helped by several great editors who pushed me to learn the craft and forge a writing style – sometimes not so politely.

I was helped above all by my parents who did not give us what we wanted growing up. They gave us what we needed. They gave us education and experience, above all. They gave us far less stuff than other friends I grew up with were getting from their parents. Later in life, I was very happy that was true.

I bring this up because I believe it is relevant to the opiate-addiction epidemic we face as a nation and a culture.

Recovery from addiction, I believe, means finding fulfillment in some project, endeavor or work. Finding something you love to do, something that means more than dope, that stimulates your mind more.

One way we, as a culture, have failed our kids is that too often we believe the stuff they get (and have demanded) without working for it, and that we give them, is somehow going to help them be happy. We as a culture have avoided pain, run from it. And we want our kids to be spared any pain at all – even hard work. But no one find’s his calling in life without hard work, sometimes demeaning work.

I hated all the years I spent washing dishes in cafeterias and restaurants while I was in high school, but I’m plenty happy I did it for it taught me to do things I didn’t want to do, taught me how important education is, and that fulfillment comes from finding the work you love and spending your life trying to get good at it.

So many kids I see have been given far too much without working for it. Too many haven’t learned that through hard work, pushing yourself to seek that calling, you actually learn and achieve and feel good about what you’ve done.

On the other hand, heroin, seems to me, is simply the final “stuff” for a culture that believes that more stuff leads to happiness. (Writing about heroin these days is really another way of writing about America, who we are and what we’ve become, I’ve grown to believe.)

My mom was right. It’s through hard work in something you love that you achieve fulfillment.

I began to think about all this again when I read snippets from the philosopher John Dewey about how we find happiness.

Here are a couple:

“To find out what one is fitted to do and to secure an opportunity to do it is the key to happiness. Nothing is more tragic than failure to discover one’s true business in life, or to find that one has drifted or been forced by circumstance into an uncongenial calling.”

And …

“The opposite of a career is neither leisure nor culture, but aimlessness, capriciousness, the absence of cumulative achievement in experience, on the personal side, and idle display, parasitic dependence upon the others, on the social side.”

Interesting stuff, and relevant more than ever to today’s America.

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May 21, 2017 · 8:51 am

Grunge, Heroin & Conformity

The passing of grunge rocker Chris Cornell this week means that of the five major bands to emerge from the early 1990s’ grunge scene, Soundgarden, Alice in Chains, Stone Temple Pilots and Nirvana all have lost lead singers to early deaths.

Only Pearl Jam has not. 

Mostly, these were singers whose lives were mangled by heroin/opiates, whether they died from it or not.

As I read the news, it occurred to me how deeply the grunge scene of the late 1980s and early 1990s swallowed the greatest drug scam ever sold, which is that heroin use is somehow a sign that the user is a rebel, an outsider, an artist finding his own tormented path on the margin of a claustrophobically conformist society.

The reality is that the drug, more than any other, is about commerce – about cold, hard business — and about enslavement to consumption. All of which, needless to say, is about as low-brow conformist as it comes.

Heroin should have been forgotten not long after it was invented for it has few medicinal benefits that other opiates don’t provide with far less addictive risk. It survived because it was a great drug for traffickers. It was easy to conceal, easy to cut, and it created customers that had to buy the product several times a day. A businessman’s dream.

The drug got its underground cachet beginning with Charlie Parker, the legendary saxophonist in the 1940s, who died in 1955 at the age of 34, having wasted much of his prodigious creativity in the pursuit of smack, while bringing an entire generation of younger musicians to dope. (Trumpeter Clifford Brown was staking out another path for jazz musicians – one of great devotion to art and improvisation combined with a sober lifestyle – when he was killed in a car accident at age 25.)

Beat writer William Burroughs helped solidify the drug’s reputation as an outsider’s substance.

Heroin got a bigger cultural boost from the Velvet Underground’s first album in 1967 and Lou Reed’s “Heroin,” followed as the years passed by notably addicted rockers like Johnny Thunders, Sid Vicious and, of course, Keith Richards. So that by the late 1980s, heroin was fully established as the go-to drug for anyone – often a pasty-faced white kid with a rocknroll heart — wanting a personal image as a non-conformist.

To the extent of few others before it, the grunge scene bought this fiction with gusto. Heroin, moreover, seemed the perfect drug for grunge’s nihilistic, dirge-like sound. So an entire scene was created that seemed to emerge from the swamp of the Velvet Underground’s first album. Many others died from it. Grunge did, too.

My music was punk rock and the grunge thing happened later. My focus in life was by then on writing and storytelling and not so much on the latest wrinkle in rocknroll. Grunge was too slow, too hopeless and depressing. Also, I lived in Seattle during this time, and didn’t like the city and left as soon as I could and moved to Mexico. So all in all, grunge didn’t do much for me. (Stone Temple Pilots were a bit different, and appealed to me more, in that the music was less grungy and they weren’t from Seattle, though their singer’s story is the same.)

There was, nevertheless, a do-it-yourself ethos to the scene that I found attractive. Bands were especially afraid of “selling out,” thus many of them first signed with the local Sub Pop label.

It’s a sad epitaph to the scene that the folks who created it fought mightily to avoid the taint of commercialism in their music and conformity in the way they lived — and ran, as they did, to the embrace of a drug that embodied everything they were fleeing.

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May 17, 2017 · 9:51 am

The proper use of `awesome’

    Lately I’ve been looking for some inspiration that only human achievement can provide, given the news of the last few days.
     So I was thrilled when my old friend from Claremont High School, Scott Edwards, sent me youtube clips of his son, Andrew, playing piano.

    The problem with the way we use the word “awesome” is that when you use it to describe the color of your new car or a new iPhone it doesn’t leave you with much to describe something that is truly awe inspiring. Such as when you see your old high school friend’s son playing piano like this.
    I first met Andrew Edwards when he was an infant. Now look at him. He’s entering college at USC next fall Scott tells me. (Bears mentioning that Andrew’s mother, Alison Edwards, is a piano professor and concert pianist of astounding talent.)
    So many kids seem to expect something for nothing, or can’t see the deep benefit that comes with prolonged pursuit of talent or knowledge.
    In our culture, we spend so much time thinking about how to be “happy.” We’re bombarded with easy paths to what marketers want to tell us is “happiness” – which is usually something more akin to amusement or distraction or titillation.
    Seems to me that the kind of dedication displayed in these youtube clips brings a fulfillment and satisfaction that is real happiness. Amazing to see what kind of achievement true hard work, focus, and devotion brings….

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May 4, 2017 · 11:24 am

Writing Better Stories For Ourselves

Two weeks ago I had a heart attack at a high-rise hotel in Atlanta on the morning I was supposed to deliver a speech at a large conference on prescription-painkiller and heroin abuse.

Turned out one of my major arteries was completely blocked. I’ve written elsewhere about what happened that day and you can read it here.

I rebounded quickly because I was near help, and also because of an outpouring of prayers and good wishes sent from many you, which I greatly appreciated.

My wife and I were teary-eyed for days reading your posts and comments.

I went to visit my new cardiologist when I got home. I had never thought of what was happening during a heart attack.

“What you were feeling is the pain of the heart dying,” she told me.

This hit me much harder than anything else I’d heard from a doctor. I began to understand more deeply the enormous good fortune I’d had in being where I was when this happened. Another two or three hours without help, “and you’d have been in serious trouble,” she said.

I’ve spoken a lot about personal accountability in my talks about Dreamland. I believe it’s one of the lessons we ought to learn from our opiate-addiction epidemic: that as a culture, we almost demanded doctors cure our pain quickly and completely and we weren’t going to do much to help them do that – like eat better, exercise more, avoid processed foods. Opiate painkillers were quick, cheap and those were the tools doctors turned to.

So midway through writing the book, I stopped drinking sugary drinks; lots of junk food I’d already eliminated from my diet. I don’t buy food that’s advertised on TV. I’ve always walked a lot, but I added swimming. I had no clue that I had a blocked artery, or ought to believe I had one, because I thought I was doing a lot right. (My cardio rehab nurse said she thought the swimming had saved me, because through it my blood had found new ways of circulating around the blocked artery and used those when the attack came.)

Still, I’ve come to believe that our heroin/pill epidemic has a lot to say about who we are as Americans, how we do live and how we should live. I think I felt that a bit more deeply following my heart attack.

As part of that, I came across a discussion of the work of Viktor Frankl, a great philosopher and Holocaust survivor. It reads in part that what gave him the ability to survive Nazi concentration camps (four of them) was the search for meaning. That life is more than the pursuit of happiness; it’s the pursuit of meaning and with that comes fulfillment.

“We all said to each other in camp,” he writes, “that there could be no earthly happiness which could compensate for all we had suffered.” But it was not the hope of happiness that “gave us courage,” he writes. It was the “will to meaning” that looked to the future, not to the past. In Frankl’s existentialist view, we ourselves create that meaning, for ourselves, and not for others. … We must acknowledge the need to make sense of our lives and fill what Frankl called the “existential vacuum.” And we alone are responsible for writing better stories for ourselves.

That last sentence is the most important one.

Frankl’s work, I think, is hugely relevant amid this opiate-addiction epidemic.

I’m just beginning this new life – renewed approach to exercise, avoiding stress, and thinking of food differently than even I had. Feeling very fortunate to be alive and be around people who care – like many of you.

Hoping to continue writing a better story for myself, and wishing the same for you.

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March 30, 2017 · 6:52 am

Big News From Nayarit: Edgar Veytia arrested

In fascinating news from Mexico’s heroin world, Edgar Veytia was arrested Wednesday at the San Diego-Mexico border.

Veytia is the Attorney General for the state of Nayarit, and a figure bigger in the public mind than the state’s governor – which is rare in Mexico.

He was charged under an indictment out of New York alleging that he conspired to smuggle heroin, cocaine and methamphetamine into the United States.

Those who’ve read Dreamland know the importance of Nayarit in our heroin supply. Many have alleged that Veytia protected the heroin trade, in an alliance with a large and new cartel known as Jalisco New Generation, who has taken control of the region over the last six years.

Proceso, the Mexican new weekly, recently published this article calling him the “dark Prosecutor,” and repeating allegations that he had protected the drug trade.

Veytia began his career simply enough, as an attorney handling the taxi concessions for the city of Tepic. But in time, he was place in charge of the state’s anti-kidnapping squad and from there elevated to Attorney General.

(Stay tuned for a blog post later today about my own (brief) encounter with Edgar Veytia.)

In Nayarit, he has promoted an image of himself as a tireless, almost God-like, fighter against crime, subduing the violence that racked the state during 2010 and 2011. The governor of Nayarit named him government official of the year.

Veytia has several corridos – ballads – written about him, promoting this image. The words to one song read, in part:

“Nayarit was a war zone, body mounted and the state needed a miracle sent from the Lord above.

Edgar Veytia is the name of this miracle, who returned peace to the land, risking his life

He’s been able to let people feel better, in a peaceful state and for that I thank God.”

In February, the Mexican Marines shot it out with – and killed – a wanted leader of the Beltran Leyva Cartel — Juan Francisco Patron Sanchez, aka H2 – who lived a few doors down from Edgar Veytia in the city of Tepic, Nayarit’s capital.

A businessman in Los Angeles who is from Nayarit, in an interview in 2014, told me Veytia had him kidnapped. (More on that interview later.)

So far, it’s unclear how Veytia was at the border and able to be arrested. I suppose we’ll hear  more on that as the case unfolds.

Leaving aside the charges against Veytia, the Mexican drug trade since its origins in the 1970s has depended on political protection, collusion and corruption.

More later today when I have time to write.

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March 28, 2017 · 8:47 pm

Can We Treat Our Way Out of This?

I was reading the obituary of a young woman named Isabella Sammartano from suburban St. Louis, Missouri, who died from a heroin overdose suddenly after being clean from opiates for 16 months.

Her obituary doesn’t provide a lot of detail, but it does provide some. It sounded as if she spent a lot of time in rehab, then relapsed each time. Finally, when she looked to be putting the worst behind her, she relapsed again and overdosed and died.

It’s an extraordinarily sad story – and it must have been very difficult for her parents to write the obituary.

It made me think of what her death can tell us. First, all addiction seems to involve relapse. I quit smoking (and started again) nine times before I finally quit for good – at 37.

But I lived through my cigarette relapses. With opiates, particularly given the amount of supply of dope on the street, getting out of treatment is like Russian Roulette. People go in, detox, get clean. Their tolerance to narcotics drops. They leave rehab and do well, then they relapse. With these drugs, and their prevalence and potency on the street, relapse too often means death.

It feels good to say, `We can’t arrest our way out of this.’ I agree. We do need expanded treatment. But, frankly, that also feels too easy.

My feeling is, when it comes to opiates, we have to arrest our way out of this before we can treat our way out of it. That’s a bit discombobulated, I know. What I mean is that we need to address supply on the street. That comes only with arrests. It seems to me dangerous to assume that in modern America people can get out of rehab and go home to areas awash in dope and be expected to stay alive, given the likelihood of relapse and the potency and controlling nature of opiates. It’s not cigarettes people are relapsing on. It’s pain pills and, especially now, heroin and fentanyl.

This is a supply story and has been from the beginning. Huge amounts of very potent opiates were unleashed on the country – first in the form of prescription opiate painkillers. When millions of people grew addicted to these pills, a lot of them looked for cheaper alternatives. Heroin traffickers, mostly from Mexico, slowly realized that these folks were a growing market and expanded their offering.

But it all has to do with supply. No treatment has much chance against a cheap and plentiful supply of potent dope.

It’s why doctors and the medical establishment need to continue reassessing how they prescribe opiate painkillers.

It’s also why we need to make Mexico a sustained priority. I’ve written elsewhere that I don’t think building a wall — or rather, more walls — at the U.S.-Mexico border is likely to do much to slow heroin trafficking. That doesn’t mean we shouldn’t seriously address Mexico’s continued production and exporting of this drug. Ninety percent of our heroin comes from Mexico, according to the U.S. State Department. It’s unconscionable that one country should export so much of this junk. China fought a war with England in the 1800s, twice, over this issue. We don’t need wars with Mexico, but it does seem to me that we need to make this the priority it deserves to be – and walls are a distraction from the real work that needs doing.

This young woman’s death also shows why we probably need to make much greater use of what’s known as medically assisted treatment – the use of drugs as replacements, as shields. These include methadone, Vivitrol and Suboxone – they either take away the craving for heroin or block overdoses.

It’s unreasonable, I think, to assume that addicts can go back to these same neighborhoods, where opiate supply is plentiful, without some sort of protection, some kind of shield.

The last couple years have shown how dangerous that is.

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March 26, 2017 · 9:02 am

House Republicans & Heroin

Governing is the opposite of dope.

It’s real world. It’s working the program. Accepting blame and accountability, breaking with fantasy. It’s hanging out with people who don’t think like you. It’s reminding yourself that life is full of constraints and you can’t just do whatever occurs to you. It’s realizing that you are not perfect and there are others whose opinions matter in this world.

That said, the recent health-care fiasco displayed House Republicans behaving like heroin addicts.

It’s easy to go on Fox News for years, blame someone else for everything when you don’t have to be accountable for finding solutions. It’s easy to rant about the endless failures of those people who do. Ranting is a narcotic; so is outrage; so is complaining and destroying. It gives us a big blast of dopamine to the brain. As does spending a lot of time insisting on all the nifty ways you’d do things better when you are king of the world. Feels so luxurious. Feels a lot like heroin, I suspect.

Being an opposition party means never having to put an idea to a constituent smell test. You get used to it – your tolerance for fantasy rises like an addict’s tolerance for a narcotic. Like addicts, you hang out with folks who think like you, talk like you, and never force you to face anything resembling reality, or the necessity of compromise.

Living without compromise is a nice idea in theory, but it’s possible only when you’re high on, and surrounded by, ideology — or dope.

A heroin addict brooks no compromise. He wants a world his way only. No messy complications, no one telling him no. Ask any parent of an addict.

What I think we saw was people addicted to a warm, euphoric ideological fantasy world in which they’ve lived for the last several years. Addicted to the idea that they could do it alone, didn’t need anybody, didn’t need to compromise. This Freedom Caucus seemed dead-set on depriving anyone but the wealthiest of what most would deem civilized health care: maternity care, ER visits, not to mention addiction-treatment coverage.

It was bizarre to watch them line up to take away benefits needed by so many who had just elected them and their president, and give them to our aristocracy.

Harold Pollack noted in this article in Politico that Democrats working to forge Obamacare held hearings over months and accepted more than 150 Republican amendments to the bill they passed. House Republicans this time took 18 days and “the payout to the top 400 families [in America] alone was estimated to exceed total ACA subsidies in 20 states and the District of Columbia.”

How do you come to the conclusion that thinking like the upper classes of pre-revolution France is okay?

Well, perhaps because House Republicans lived in a bubble for seven years, voting to repeatedly repeal Obamacare knowing it would be vetoed. Then the fantasy ended and they finally had the power to do it. They had nothing to replace it with. (John Boehner is, I’m sure, happy to be away from all that.) What they came up with would have savaged the very people who put them in office.

The word `compromise’ gets a bad rap these days, but it’s actually another way of saying something else. It’s saying, we’re behaving like adults. We’re not going to act like petulant children who want a world run according to their whims alone, which is, in turn, another way of describing how a heroin addict thinks.

Something like this, I suspect, is what Ryan was referring to when he spoke of House Republican “growing pains.” Getting off the dope of viewing compromise as a dirty word.

A big part of addiction recovery is relating to others again, accepting that your views are not the only ones that matter, that you have to modify your behavior, answer to others who may not think like you.

It’s like governing.

It’s messy and ragged; it’s hard and far from perfect. It’s adult, in other words, and it’s the opposite of dope.

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March 23, 2017 · 8:54 pm

Saints and Sinners: Growing up in Portsmouth

A letter from a reader of Dreamland:

I was living in South Shore when Dr. David Proctor arrived in 1978.  I had just come back from college and was working at the local brickyard.  For a few years I was still apart of the local drug crowd but slowly moved away from it because I found it scary and upsetting.  I did not like buying from biker dudes I did not know and I did not like the small dealers that sold drugs to kids.

In small rural towns there are the “saints” and “sinners” and the doctors in any town normally are in the “saint” category.  One of my local small dealer friends went to Proctor while he was still apart of Dr. Riddle’s office. Proctor told him he would write him a script for any drug he wanted.  When my friend told me this I will never forget the stunned and serious look on his face, even though he got a prescription for Black Beauties.  My friend knew in the back of his sinner brain that something was very wrong.

Once my extended Pentecostal rumspringa was over, I returned to church.  I got married and left the area.  However, my husband was an abusive man and I returned to my mother’s home in South Shore with a small child.  It did not take me long even in my state of mind to see that Dr. Proctor along with another doctor had done major damage to my small town.  Even in my mother’s church there were five people that I knew about that were addicted to prescription drugs.

 Your book focused on the opiates but there was a doctor who ran a “diet” clinic who was free with the amphetamines. I would walk around the corner to see his lot filled with cars from Hamilton, Franklin, Pike and other counties in Ohio plus cars from counties in Kentucky and West Virginia.  The people I saw were lean not obese.  So South Shore was a one-stop on the small time dealer network for both opiates and amphetamines.

 There is one thing I would like to say about kids raised in fundamentalist churches. This is about the saint and sinner perspective.  They will be zealously saint or zealously a sinner and there seems to be no middle ground. This especially applies to rural areas.  If you are trained to live your life a religious zealot then when you turn away from your religious upbringing you live your worldly life just as fervently and passionately in the negative. However, when these same people turn back to their religious roots from the addictive life they are not ashamed to help others to do the same.

I left South Shore in the middle nineties with my middle school aged daughter.  I went back to Morehead State and cleaned up my mess from the 70’s and graduated with honors just in time for my daughter to start college. My daughter went on to get her masters at UK.  After reading your book I am glad we left the area for I can see decades of destruction manifest in South Shore when I go back to visit.

A positive note:  I loved your description of Chillicothe Street especially during the holidays.  I was not part of the middle class but was raise by a single mom with three children and no welfare. We would take a taxi to Portsmouth to shop on Christmas Eve.  I can remember the Salvation Army Santa ringing his bell in front of Kresges’ and my mom singing “Silver Bells.”  We would go to Kresges, Greens Five and Dime, Kobacher’s and to Martings to see their window display and buy hot peanuts from their candy area and play on the escalators.

All of this is etched into my childhood mind as well as all the great times swimming at Dreamland with my brothers and the neighbor kids who took us with them.  I thought all city pools were like Dreamland.

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March 2, 2017 · 11:41 am

Our Heroin: From Afghanistan or Mexico?

While speaking on the topic of heroin in America, I’m often asked how much of our supply comes from Afghanistan, as we’ve been in a war over there for many years.

My answer, from interviews with traffickers, cops and DEA agents, is that most of our heroin comes from Mexico.

That view was confirmed this morning by William Brownfield, the U.S. State Department’s assistant secretary for International Narcotics and Law Enforcement Affairs.

In a conference call with reporters, Brownfield estimated that 90 to 94 percent of the heroin consumed in the United States originates in Mexico, with another 2 percent or so coming from Colombia and the remainder from other countries around the globe.

That represents a massive shift in our heroin supply since roughly 1980, when a lot of our heroin came from the Far East, and had for decades.

Interestingly, Brownfield said, a lot of Afghan heroin does make it to Canada, but not to the United States, where Mexican trafficking organizations, too close by, enjoy a more advanced and efficient distribution network, and offer therefore cheaper prices.

 

Brownfield was talking about the just-issued International Narcotics Control Strategy Report (INCSR), which talks a lot about the heroin/opioid problem in America. Brownfield’s message was a positive one about cooperation between Mexico and the United states on issues of drug enforcement.

A wall of law enforcement cooperation is in place, without constructing an actual wall, he said. Serious problems existed, he said, “but we have a far better architecture to address them today than we did in years past.”

Nevertheless, his answer on heroin’s origin stunned even me. I would not have guessed the estimate would be that high.

I’ve written elsewhere about my belief that it’s unlikely that more border walls between the two countries will do much to staunch the flow of heroin into the United States. What’s really necessary is even deeper cooperation, frank discussion with Mexico that a wall and the emotion it provokes would do much to corrode.

Yet Brownfield’s response highlights two things worth mentioning.

One is that Mexico must truly step up to this challenge. Its unconscionable that such a high percentage of illegal highly addictive dope come from one country to another. China had a similar issue in the 1800s, when the British forced opium into that country, resulting in the massive addiction of Chinese people for decades after.

If border walls are insulting to Mexico, it must understand that they are proposed because of Mexico’s own failings – both with regard to law enforcement and criminal justice, and in channeling the desires of its most hardworking citizens, who then feel the need to migrate illegally to the United States.

Second is that U.S. demand for heroin grows organically out of doctors’ massive prescribing over the last 20 years of pharmaceutical narcotic painkillers – the subject of my book DREAMLAND — something that no border wall will stop, of course. Also, if we get into discussions with Mexico about this topic, soon that discussion will also turn to our very accessible market for guns, many of which then go south through a variety of channels and end up being weapons in that country’s bloody drugs wars. So if we ask a neighbor to behave with maturity, we better be willing to do the same.

We have almost 700 miles of walls along the border that separate the two countries. Drugs aren’t much trafficked through those areas that have no walls, most of which are in forbidding terrain. Our drugs, instead, are trafficked through ports of entry where walls already exist. They are trafficked in cars, trucks, and by pedestrians. With heroin, the problem is exacerbated, as I’ve written elsewhere, by the fact that is the most condensable drug, thus the most easily and profitably trafficked,and one that we now have a huge demand for.

All in all, the issue begs a binational, cooperative solution, seems to me.

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January 30, 2017 · 9:26 am

Keith Dannemiller: A Podcast

Keith Dannemiller, a native of Ohio, has been one of the premier photographers out of Latin America for two decades now. His black and white street shots from Mexico City are strange and dazzling.

Keith and I worked together in Mexico for many years, both of us freelancers. We recorded this conversation a while back when Keith’s first book of photography — Callegrafia – was coming out. It’s sold out, but the chat is interesting – about finding what to shoot, and why, and what got him started on street photography, and how a man devoted to his craft does his job.

Keith’s new exposition of his photography is called Luz Translation, opening in the town of San Miguel De Allende, Guanajuato, on February 2. Check it out if you’re down there. It’s at Centro Cultural El Nigromante Bellas Artes, #75 Hernandez Macias and running until April 23.

Find out more about him at his website, www.keithdannemiller.com, including the photo tours he leads of Mexico City.

 

 

 

Photos by Keith Dannemiller

 

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Video

The Last Velvet Painter in Tijuana

For many years, Alfredo Rodriguez Ortiz – Argo – was among the throngs of velvet painters making a living in Tijuana painting Elvis, Marilyn, John Lennon and John Wayne.

Those were velvet’s glory days of the 1970s. Now interest in the art has fallen off considerably. He keeps at it. Painting Bob Marley and Tupak more than any others.

He’s now among the last velvet painters, and the only one, from what I can determine, who still knows how to paint Elvis Presley on velvet.

I hope you like the video.

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January 14, 2017 · 3:34 pm
January 9, 2017 · 8:33 pm

Juan’s Story – The high cost of cheap prices

We came upon this taxi driver who started telling us of how, in order to build his family a house, he went to Texas to cut rock for housing facades, using a legal visa provided by his employer. Did this for three years, six days a week, 12 hours a day minimum.

Hope you like this video, which I did last week in Mexico.

Let me know what you think, either here on in the Youtube comment box. Please share it if you like it.

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December 20, 2016 · 10:02 pm

A Doctor’s View of Pain Pills

Here’s a letter from doctor with a long exposure to the problem of addiction and pain pills. I get lots of email letters about Dreamland. I’ve put a few up on this blog – always with names and identifying details removed.

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 I have recognized for many years, at least since the late 1980s, that the chronic use of opioid medications was typically a barrier to recovery. I am a physiatrist, a physician procter-1specializing in physical medicine and rehabilitation, since 1986.  We manage patients who have catastrophic injuries: spinal cord injury, traumatic brain injury, amputations and those with multiple and severe trauma. I also treated many patients who had less severe injuries including strains, sprains and other soft tissue trauma. We often manage patients over many years. When the use of opioids became more frequent, in the late 1980s, I was perplexed. I did my best to manage pain, if at all possible, without the use of chronic opioid therapy. I was perplexed even more so in the mid to late 1990s when Oxycontin came on the scene. Physicians no longer were afraid to prescribe opioids for non-cancer pain and did so seemingly without caution. They were duped. Drug companies and their physician spokesmen duped them.

I grew up and later practiced medicine for many years in New Mexico. New Mexico, as you may know, has always had one of the highest drug overdose rates in the nation.  Heroin had been the drug of choice, at least until opioid medications came on the scene. I worked as a house painter’s apprentice in the late 1960s while in college. I worked on one crew that every journeyman painter was an ex-con related to heroin use.  I had plenty of opportunity to use heroin but it scared me. My co-workers told me how great it was. One guy, much older than me, made it sound so appealing. “Come over and we will shoot up and listen to jazz.”  I never tried it though I had lots of opportunity.

I knew quite well how dangerous heroin was and never believed that opioid medications were any less dangerous. When I started practicing in the late 1980s many of the patients I saw were on opioid medications when I assumed their care. Most of the more seriously injured patients I saw were successfully weaned off opioids. Many of the less seriously injured, especially those with work related injuries, were much more difficult to wean. Some patients of both categories ended up on long term opioids but were closely monitored to determine if they were benefitting from opioids and whether they were abusing them. Escalating doses were typically not allowed.

The work related injury group of patients who generally had much less severe injuries, were routinely on opioid medications when I took over their care. My job as a rehabilitation physician was to get them back to their usual activities including return to work. I found that opioid medications were a barrier to their recovery. Some of my referring physicians believed the standard of care was to treat pain with opioids as long as patients complained of pain. Some patients were never going to stop complaining of pain and the reasons were frequently psychosocial in nature. I never believed the hype from drug companies regarding the safety of opioids. I saw from up close as a young man and as a doctor that they were dangerous and in general not appropriate for long term use in non-cancer pain.

I knew little about Dr. Russell Portenoy at the time of the opioid prescription explosion but I knew plenty about what drug companies were saying about the safety of opioid medications and the unlikelihood for addiction. I now understand Dr. Portenoy’s role in this public health catastrophe.  I don’t believe Dr. Portenoy and other drug company marketer’s claims that they are now surprised about the addiction potential and danger of opioids. Intuitively it did not make sense. Oxycodone and hydrocodone are so similar to morphine and heroin both chemically and by their mechanism of action. Why would you believe they are so much safer? Those guys were either just plain dumb and so drunk with drug company money and self promotion that they refused to pay attention to what was happening to patients. I am sure they are not dumb. Dr. Portenoy is a brilliant and charming guy. Just view his video presentations and interviews. He is also a successful academic physician. That is what made him so dangerous.  I am just an average doc who has never had a higher academic position than a clinical assistant professor.  I have never authored a paper that made it to a medical journal. How could I know more than them and have been so right about the proper role of opioid medications?  Why didn’t they? Certainly not because I am smarter.Grand Canyon Trip 2015

I think your book was very even handed, maybe a little too much, with Portenoy and the other opioid selling/promoting physicians. I’m telling you they knew better. Their response of “If I knew then what I know now….” just doesn’t cut it. They are responsible for the hundreds of thousands of deaths and ruined lives. They should not get off the hook. I suspect their narcissism will prevent even one sleepless night for the damage they have done. But they and their benefactors, the drug companies, have created a horrible health crisis that was largely preventable in the United States. It is almost strictly a U.S. problem caused by U.S. physician “thought leaders”, drug companies and misguided bureaucrats.

I applaud your book. Bringing the black tar heroin story into your narrative was great. You connected the dots. I wasn’t aware of that part of the story. Thanks again for your book. It may just impact our legislators and government officials even more so, to focus on rehabilitation not punishment for those young kids who got caught up in a drug problem often caused by misguided or crooked doctors.

The punishment of “pill mill” docs and drug company marketers including their corrupt physician lackeys could never be equal to the suffering they have created. Glad you spotlighted the problem and did it in such a well-researched, entertaining and cogent way. Thank you.

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December 14, 2016 · 12:11 pm

An Ohio Farmer: Trump, Dope, Jobs & PC

A DREAMLAND PODCAST – John Russell is 26 and an organic farmer, raising melons in rural Ohio, not far from Columbus. This year he ran for the Ohio state legislature as a Democrat – and lost badly.headshot-1

I had the chance to talk with Russell today.

We had a wide-ranging  conversation, about his decision to go into farming, about his campaign, about Donald Trump, as well as job loss and opiate addiction in America’s Heartland, PC culture, the challenges Democrats face in rural areas.

He’s one of the few, it seems, to go away to college then return to a rural community. So many towns have lost young people to the cities where the jobs are.

We talked about that as well, and about what happened to guys on his high school football team.

This is the first interview I did like this, via Skype, so I’m still working out the kinks, and there are a few buzzes and etc. So please bear with me.

Meanwhile, contact him at www.johnrussell.info, and follow him on Twitter: @JCruss

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