Dreamland (49 page)

“We overtest, perform surgery, stick needles; these people are worse off,” he said. “If we work on their nutrition, diet, sleep habits, smoke habits, helping [them] find work—then they improve. You have to be accountable. If you give a treatment that kills people or makes people worse, you gotta stop. You can’t continue making money on stuff that doesn’t work.”

Cahana saw “stuff” as the problem. Our reverence for technology blinded us to more holistic solutions. “We got to the moon, invented the Internet. We can do anything. It’s inconceivable to think there are problems that don’t have a technological solution. To go from ‘I can do anything’ to ‘I deserve everything’ is very quick.

“All of a sudden, we can’t go to college without Adderall; you can’t do athletics without testosterone; you can’t have intimacy without Viagra. We’re all the time focused on the stuff and not on the people. I tell pain patients, ‘Forget all that; the treatment is you. Take charge of your life and be healthy and do what you love and love what you do.’”

And he ignored that very advice. Cahana came to Seattle at 260 pounds, and gained forty-five more over the next five years as, stressed and overworked, he battled to rebuild the historic clinic. The clinic won numerous awards, was highlighted as a model. He was on CNN and in
People
magazine, gave a TED talk, and testified before the U.S. Senate on overprescribing in medicine. He grew fatter all the while. He was taking medications for hypertension, cholesterol, and then more for the side effects from the medication—nine pills a day, fifteen hundred dollars a month in co-pays.

“I couldn’t walk two flights of stairs without huffing and puffing,” he said.

His own doctor was about to prescribe something for elevated blood sugar when Cahana had enough. He seemed to be living like an addict. He had spent years trying to change public policy, influence academia, and shape legislation on the overprescribing of pills for pain. Now he decided to become the change.

He resigned from the clinic. He is now a consultant to low-income communities on health issues. He went on a regimen of healthy eating and daily training of running, strength conditioning, and yoga. His pills became gradually unnecessary. He lost 110 pounds and runs marathons.

The U.S. medical system is good at fighting disease, Cahana believes, and awful at leading people to wellness.

“They don’t know how to do it and the path they offer actually makes people worse.”

In 2013, the committee that John Rockefeller Jr. formed to search for the Holy Grail of a nonaddictive painkiller turned seventy-five.

Its annual conference was at San Diego’s Bayfront Hilton under impossibly azure June skies. The seminars took place in darkened conference rooms. Speakers presented data in voices muted by thick carpets.

I attended because I wanted to understand what had become of the search for the Holy Grail. The search for a nonaddictive alternative to opiates had a fairly spotty historical record. It had produced drugs, many of which were once believed, incorrectly, to be nonaddictive: Demerol, nalbuphine, Talwin. But this was the oft-repeated story, as humankind sought heaven without hell. The companies that first manufactured heroin thought it was nonaddictive and marketed it that way. A hundred years later, so did the company that made OxyContin. Maybe this was just nature’s way of saying that we can’t have it all.

The committee was now known as the College on Problems of Drug Dependence. It had expanded and more CPDD researchers studied addiction treatment. At the conference, I had a beer with Andy Coop, the University of Maryland chemist, who was nice enough to take the time to explain his fascination with the morphine molecule and how it worked.

Drugs that contained variations on the molecule were “damned good at being painkillers,” he said. “We are working to find other drugs that are as good, without the undesired effects. My call is it’s not going to happen. We have been using morphine clinically for a hundred years and we’ll be using it a hundred years from now. I’m not going to say it’s never going to happen, but I don’t see how it’s going to happen.”

Then, as if thinking out loud, he added, “If we could only stop the euphoria but not the analgesia, I think we would actually have what I would call the Holy Grail.”

Among the conference throngs was Martin Adler, a professor of pharmacology at Temple University. Adler had been a member of the CPDD since the 1960s.

“Virtually all of us, and certainly me, believe the chances of finding the Holy Grail drug are slim to none,” Adler told me. “People keep looking and industry keeps looking.”

I asked Adler if he thought such a drug was even desirable. Can humans handle having it all? After all, Americans had it all for a brief time and many of the kids who benefited most from the country’s embarrassment of riches had turned to drugs used to numb pain.

Perhaps not, Adler allowed. Morphine was, he said, a great metaphor for life. “The bad effects of morphine act to minimize the use of the drug, which is a good thing. There are people born without pain receptors. [Living without pain] is a horrible thing. They die young because pain is the greatest signaling mechanism we have.”

Adler believed the lesson of the last fifteen years was that the conception of pain needed to change.

“I don’t think you’re going to find one treatment for pain,” he said. “You don’t use one drug to treat all cancers; if you do it’s because you don’t know how to treat [each cancer] specifically. I think where we’re headed is to find the most effective treatments for different kinds of pain. Chronic back pain, neuropathic pain—we just don’t know enough about them. That may be because pain isn’t a single disease.

“The body is incredible,” he went on. “The most amazing thing we can imagine. What you do learn is that there is nothing that’s so isolated from everything else that you can just attack that. Everything is tied to everything else. When you’re dealing with the brain, they all intersect.”

I called Nathaniel Katz, the pain specialist in Boston. In the years since his patient Peter’s death and his encounter with Peter’s sister, Katz had come to see the foibles of human nature at work in all this.

“My instructors told me that when you take opioids for pain you can’t become addicted because pain absorbs the euphoria. That was at Harvard Medical School. It was all rubbish, we all know now. Why do we listen to those messages? Because we wanted them to be true.”

I told him I had spoken with people who pointed to Foley and Portenoy’s 1986 paper in the journal
Pain
, and then to Portenoy’s funding from pharmaceutical companies, including Purdue Pharma, as he traveled the country urging doctors to adopt a new view and use of opiate painkillers. These critics saw the potential for a conflict of interest.

One of them was Andrew Kolodny, a physician who watched the epidemic unfold from his addiction specialty in Brooklyn. Kolodny later cofounded Physicians for Responsible Opioid Prescribing, an organization of doctors critical of the new opiate prescribing.

Portenoy “starts lecturing around the country as a religious-like figure,” Kolodny said. “The megaphone for Portenoy is Purdue, which flies in people to resorts to hear him speak. It was a compelling message: ‘Docs have been letting patients suffer; nobody really gets addicted; it’s been studied.’

“[Purdue] created organizations that were meant to look grassroots. They gave loads of money to front organizations, which approached state medical boards about liberalizing regulations for prescribing. Every effort to control the problem, if it ended in less prescribing, you had all these groups saying what you’re going to do is bad for pain patients.

“You now have an industry of pain specialists and this is their business model: They have a practice of patients who’ll never miss an appointment and who pay in cash. The whole thing is really outrageous.”

Katz, however, saw another story at work. Katz admired Portenoy, who, he said, had spent a career searching for better ways to relieve his patients’ real and considerable pain. Portenoy had helped make pain a topic of research. Moreover, Portenoy was always clear that pain treatment needed balance and time; doctors needed to be selective in the patients who received this treatment.

But “people want simple solutions,” Katz said. “People didn’t want to hear that and the commercial interests didn’t want to emphasize that.”

Meanwhile, Katz said, physicians everywhere faced insistent patients who felt entitled to relief. “You’re standing there with keys to the opioid cabinet. Suffering is certainly real,” he said. “For years, the doctor has had to say, ‘I wish I could give them to you, but they’re addictive; you can overdose. I want to but I can’t.’ The keys to the kingdom were there but the doctor as gatekeeper could not in good conscience open them.”

In this context, Portenoy and Foley’s 1986 paper became influential because, Katz said. “[It] was telling doctors what they already wanted to hear: ‘Your patients are suffering. Aren’t we so much smarter than scientists of many years ago? Now we know that if you take [opioids] for chronic pain, you can’t get addicted.’

“You had a new priesthood that emerged, a priesthood of prescribing opioids for chronic pain and a small number of pharmaceutical companies collaborating with these doctors. These companies had these tools—these new drugs. Doctors were being told by the mechanics—the pain specialists—that the tools worked. I think it’s more useful to look at people as fundamentally reasonable—looking at why they did the things they did. You had a whole bunch of reasonable people doing what they thought reasonable and it didn’t work well.”

As Katz spoke, I thought back on all I’d heard and seen and thought it remarkable that all this could be part of the story behind why a town in Nayarit, Mexico, was now selling gobs of heroin in some of the wealthiest and safest places in America. I told him that I thought it just as bizarre that all that reasoning he referred to could, in some measure, hinge on the misinterpretation of a one-paragraph letter to the editor of the
New England Journal of Medicine
in January 1980 written by Dr. Hershel Jick, who intended nothing of the sort.

“Porter and Jick is amazing for the absence of information in it,” Katz said. “[But] that paragraph gives you relief from your inner conflict. It’s like drinking from the breast. All of a sudden the comfort washes over you.”

The Internet of Dope

Central Valley of California

“I might be down in Mexico next time you come through,” the Man said to me one morning as I sat again in his living room in California’s Central Valley.

He slouched in his easy chair, skullcap over gray hair, smiling hazily through the anemia, a once-handsome face now pale and without the bronze gleam it once possessed. He stared out the screen door of the home his family bought for twenty-two thousand dollars years ago, and onto the street of cracked asphalt, prim lawns, and working-class stucco houses.

We’d spoken for hours on my visits over many months since his release from the years in prison that he served for his part in Operation Tar Pit. He had a gripping story of how heroin dealers from one small Mexican town spread black tar to new markets across the United States. I spent hours in his presence, listening to his faint voice speak slowly of the past.

Much of what he said I knew to be true or found ways of confirming. His knowledge of Xalisco was detailed; so, too, his knowledge of methadone clinics in cities of America. The rest sounded entirely plausible. But in the underworld, as many people want to exaggerate what they’ve done as want to hide it. So I didn’t know what to believe until I tracked down a DEA agent who’d worked Operation Tar Pit from the beginning. He confirmed the Man’s role, which he knew from listening to endless hours of wiretaps.

“He expanded the organization’s network into other cities, especially into cities where there wasn’t any competition,” the agent said. “He would target methadone clinics where they’d find a client base and build upon it.”

Now, fifteen years later, the crews the Man had set up were still dealing misery. Countless young men from Xalisco, Nayarit, were doing long federal prison terms.

Xalisco avoided the notice of Mexico’s drug cartels for a long time. After all, what did cartel traffickers care about crews that sold a kilo of heroin at a time? In 2010, however, the Zetas and the Sinaloa Cartel went to war in southern Sinaloa. The violence spread south and engulfed tiny Xalisco, Nayarit. The results were predictable. Dead bodies appeared here and there. In one shootout, eleven people were killed, including Jose Luis Estrada, known as El Pepino, the Cucumber, a reputed local drug boss. Xalisco officials spoke of canceling the Feria del Elote and the State Department warned Americans against traveling to Tepic. Cell leaders, who’d already been moving to Guadalajara, moved there even faster; they kept a low profile and couldn’t live in the houses they’d spent so much heroin money building.

This went on for more than a year until it appears the Zetas triumphed. Cell leaders began paying protection to the cartel and things calmed down.

The flow of Xalisco black tar into the cities of America never slowed, however. East of the Mississippi, Xalisco drivers tormented Nashville, Memphis, Indianapolis, several cities in South Carolina, Cincinnati, Charlotte, and, of course, Columbus, and the suburbs for miles around each city.

In Florence, Kentucky, narcotics officers arrested a cell of Sánchez family operators, including one local woman who’d been a go-between for the family in Nashville during Operation Black Gold Rush in 2006. The cell had been using only local white drivers to deliver heroin, providing them with cars and cell phones—presumably because it could no longer find laborers back home to do the job.