Dreamland (15 page)

The UW pain clinic set itself against trends in medical marketing. Those Valium ads that years before insisted that one pill could solve a patient’s problems were wrong, researchers at UW believed, at least where pain was concerned. Pain was complicated.

But “there is a philosophy among many patients—‘I’m entitled to be free of pain,’” said Loeser. “People are entitled to health care. Health care should be a human right. Pain management must be a part of health care. But they are not entitled to pain relief. The physician may not be capable of providing them with pain relief. Some problems are not readily solvable. A patient is entitled to reasonable attempts to relieve the pain by reasonable means. You’re not entitled to pain relief any more than you’re entitled to happiness.

“But usually the patient says, ‘I come to you, the doctor. Fix me.’ They treat themselves like an automobile. People become believers in the philosophy that all I need is to go to my doctor and my doctor will tell me what the problem is. That attitude has been fostered by the medical community and Big Pharma. The population wants to be fixed overnight. This is the issue we addressed with chronic pain patients. They have to learn it’s their body, their pain, their health. The work is done by them.”

Bonica’s protégés at the University of Washington were suggesting a comprehensive approach to treating pain, in which opiates played only a small role. By the early 1990s, hundreds of clinics in America followed the UW model. Yet, almost from the beginning, insurance companies balked. In time, they stopped funding crucial parts of multidisciplinary treatment that weren’t strictly medical: physical, occupational, and psychological therapy, in particular. Loeser and his staff battled them incessantly. He would show the companies that the patients became healthier, and this saved the companies money in the long run. “But the people making the funding decisions have nothing whatsoever to do with health,” Loeser said. “They were more and more restrictive in what they would pay for.”

Thus doctors were increasingly deprived of some crucial tools to treat that pain just as patients were taught to believe that they had a right to pain relief.

The Man Comes

Los Angeles, California

The Man had come out of the west dusty and wizened.

His grandfather, whose name he bore but whom he never knew, had two women, two families—one in Phoenix, the other in New Mexico. His father’s half brother, whom he never knew, was murdered by Pablo Acosta, a weed smuggler and the first Mexican drug lord.

In 1939, the Man’s father moved the family from New Mexico to California. The agricultural town of Brawley in California’s Imperial Valley was a pit stop for Depression migrants taking the southern route into the Golden State. His parents worked on the Brawley farm of a relative, and during this time the Man was born. They then moved to Fresno, where his father became a farm labor contractor.

His parents separated when he was thirteen. He went with his mother to Van Nuys in the San Fernando Valley of Los Angeles. They found a house in the Van Nuys barrio, a place without sidewalks or much police presence. This being the 1950s, Mexican Americans, in the Valley’s sea of white people, rarely ventured out of their barrios unless it was to go to work. Families in Barrio Van Nuys owned their homes. The men were employed in the lower rungs of the movie industry or as city and county workers, paving roads, landscaping public buildings. They hung out after work at the neighborhood store and drank beer under pepper trees.

The Man dropped out of Van Nuys High, got his diploma at a continuation school. By then he was also trafficking—cutting up pounds of weed and selling joints in the neighborhood. When pills—whites, reds, bennies—became the fashion, he drove to Tijuana, stayed all weekend, bought jars of them, and tripled his money back in Van Nuys. He liked to think that he was something of a shot caller among his generation. He was nineteen. About then he started using heroin. Many of the young men in Barrio Van Nuys used it and most of them died young.

He became a steamfitter later, and had other jobs, two marriages, and children, but mostly he was, as he put it years later, a “drug merchant.” He liked to see himself as sticking it to the Establishment, living outside the law. He served several prison terms; it usually took less than forty-eight hours of freedom before he was shooting up again. Not much mattered to him but the drug. He bought houses for his family, his kids. Mostly, though, money was to be used to get more dope. About the only other thing that held his interest for so many years was gambling on NFL games.

What bedeviled him was a reliable source of heroin supply. His sources had always been difficult to maintain. People were always going to jail, or he was. Or they died. Either way, it was always a battle to find consistently good-quality heroin in large amounts.

In the 1970s, he met a guy, a relative of a lieutenant of Ernesto “Don Neto” Fonseca. Fonseca was a grizzled Mexican drug kingpin who later gained infamy, and a life prison term, for his part in organizing the Sinaloa drug cartel. Fonseca’s nephew, Rafael Caro Quintero, joined him behind bars for arranging the torture killing of DEA agent Enrique “Kiki” Camarena in 1985.

The Man and his contact took the train down to Mexico to buy a kilo from Fonseca. They met the legendary capo in the hotel he built in downtown Culiacán, the sweltering capital of Sinaloa, the birthplace of Mexican trafficking.

“I’m gonna give you this kilo and see what you guys can do with it up there,” Fonseca told them. “I’d like to open a market up there. You guys do right and I’ll keep supplying you.”

For four months, they did Don Neto right and he kept sending them kilos. Then they were arrested and the Fonseca connection disappeared. The Man found other sources in Mexicali, which didn’t last long either.

But all that was years ago.

When I met him, the Man was slowed by a liver problem. His eyelids often hung at half-mast. Years of trafficking, gambling, and spiking his veins had sapped him, in his seventies, of any real mirth. He never read novels, only nonfiction. His laugh issued from him as a dry chuckle, thin as cardboard.

But when he was in his late fifties, he had happened on a scheme that would, in his eyes, make his life worthwhile. It involved bringing black tar heroin to new people and places east of the Mississippi River. He had blown into these cities across America like a wind, a different name in every town, in old used cars that were gray or beige. He left behind a drug that would change these places, and bring misery to thousands of families.

Through the 1990s, that drug, in turn, transformed the small Mexican town of Xalisco, Nayarit, a place he would come to view as his own, where he would buy property and keep a woman. He was a contemporary of David Tejeda, whom he knew, though not well. Tejeda was among the pioneers to ignite the first stage of the Xalisco heroin expansion in the early 1990s. The Man began the second, in 1998. So, after I tracked him down, I visited him often and listened to him talk about the past. He held the answer, I came to realize, to how black tar heroin crossed the Mississippi River to stay.

He liked to think himself a hero to the young men from the small town of Xalisco, Nayarit, whom he recruited and taught to retail the drug. “I’d have fathers and mothers come ask me for work for their sons, knowing exactly what they were going to do, exactly what I did,” he said one day in the living room of his Central Valley home. “These are people who are dirt poor. They see all these other young kids with new trucks, building houses, mothers and fathers driving around in a half-nice pickup. Then the kid’s bugging them, ‘I want to go up north.’”

Initially, the market they sold to was older addicts like him—the heroin underworld that had survived since the 1970s, when the drug was last popular. But as it happened, illicit use of another drug—a pharmaceutical called OxyContin—was creating a vast new market for heroin among middle- and upper-class white people. Folks with money. When he heard about OxyContin, he began to follow it, knowing that if he did, he would soon have a market.

The relentless Xalisco retail delivery system evolved as it fed on this ever-growing base of customers addicted to OxyContin in America and on the deep frustration of young, landless working-class men in Mexico. These men did not form a cartel. They could not. The envidia—small-town jealousy—and the wild-bronco attitudes that rule Mexican ranchos prevented grand organizations from forming. “Families cannot work together,” the Man told me. “We’re real envious of each other.”

But precisely because they could not, their heroin system became pernicious and successful. It aroused the entrepreneurial spirit of rancheros, young and driven, as it harnessed a cheap and addictive product to the power of small-scale free-market capitalism. The system marked a radical departure in the way Mexican traffickers sold and profited from dope, and it challenged U.S. law enforcement.

“We didn’t start the heroin-dealing business. We just used a different method,” the Man said. “We weren’t a cartel. We were all different cells. Everybody’s their own group. There’s the boss of each little group. They all work individually. There’s some heavy dudes; some who are mediocre and some who are trying to make it. Some go bust. Some got a lot.”

The Revolution

In 1986, Russell Portenoy, then thirty-one, and his mentor, Kathy Foley, published what became a declaration of independence for the vanguard of pain specialists interested in using opiates for chronic pain, though Portenoy hardly intended it as such.

Other researchers had been issuing papers saying that many chronic-pain patients using opiates invariably ended up addicted. Portenoy and Foley hadn’t seen that. They reviewed the cases of thirty-eight of their cancer patients with chronic pain who used opiate painkillers. Only two grew addicted, and they had histories of drug abuse. The rest functioned well and most of them without pain, to boot.

Portenoy and Foley wrote a paper reporting those observations and submitted it to a medical journal called
Pain
. Opiates themselves were not inherently addictive, the authors suggested; a lot depended on the people taking them.

Cited among the footnotes supporting the paper was a letter to the editor, by Jane Porter and Dr. Hershel Jick out of Boston, in a 1980 edition of the
New England Journal of Medicine
. It was headlined “Addiction Rare in Patients Treated with Narcotics.”

The idea in the
Pain
paper, Portenoy said later, was that “these drugs have certain characteristics, which, when interacting with a certain kind of brain, can lead to bad outcomes; but it’s not inherent in the pill such that everybody given that pill becomes an addict.”

From that gradually grew the idea that opiates might be prescribed not only to people dying from cancer but to others, perhaps those with chronic pain, a far more controversial idea. The paper warned against prescribing them for patients with a history of drug abuse. In later interviews and research, Portenoy made clear he believed a doctor needed to spend a good deal of time with each patient, delving into his or her medical and family history. He described a questionnaire a doctor should give to patients to determine the risk of addiction in each individual. He proposed two famous extremes: a teetotaling seventy-plus-year-old woman with bleeding ulcers and osteoarthritis, and a twenty-something kid who’s smoked weed for several years, has tattoos on his back, and suffers chronic pain in his knees from surgery a year before. The former was at far less risk of opiate addiction than the latter. Yet most of the decisions a family doctor had to make—for family docs were on the front lines in prescribing pain relievers—were far more complicated. What about the forty-year-old construction worker, with a brother in jail, who in his early twenties drank a lot, but who is successfully raising a family and suffers from chronic back pain?

That
Pain
paper, which Portenoy believed would be forgotten, was instead feverishly debated. With Foley and Sloan Kettering’s name on the paper, it convulsed the consensus against the limited use of opiates. Portenoy was attacked personally. Treating chronic pain with opiates went against so many long-held medical beliefs. The drugs were dangerous and addictive, many felt, when used that way. One researcher wrote to
Pain
claiming Portenoy and Foley did not understand the nature of pain.

“The anger that that paper generated, and people buttonholing me at conferences and telling me that I was a bad guy and stuff that makes that even sound good,” Portenoy later told an interviewer. “It was really an interesting time to live through.”

Against this vehement reaction, Foley and Portenoy viewed themselves as warriors on patients’ behalf, cracking a tired prohibitionist dogma that had outlived its usefulness, particularly as technology and drugs advanced.

Nodes of support for their position emerged around the country.

One was Salt Lake City. Lynn Webster’s acute-pain service at Holy Cross Hospital was only part of it. Pain researchers and clinics congregated in Utah seeking other ways of treating pain patients. The state’s Mormon population stayed put, so clinicians could do a study on a group of people, followed by another five years later, and five years after that with the same people. Moreover, while many Utahans, as Mormons, didn’t consume caffeine, nicotine, and other drugs, the clandestine use of prescription pills, primarily painkillers, had taken hold, giving clinicians ample opportunity to study addiction.