Dreamland: The True Tale of America’s Opiate Epidemic (Bloomsburg Press, 2015) is a nonfiction book by American journalist and writer Sam Quinones. It won the NBCC Award for General Nonfiction and was on Amazon’s list of best books of the year in 2015 as well as Slate’s list of the 50 best books of the past 25 years. In the book Quinones charts the parallel rise of prescription opiates and black tar heroin, and describes how they came together to constitute the most fatal drug crisis in US history. Told in a series of short sections profiling families, drug addicts, doctors, and dealers, Quinones explores how well-intentioned attempts to treat pain and changing demographics in America combined with greed to create the opiate crisis.

The book opens with a description of ground zero for the opiate crisis: Portsmouth, Ohio, which was once a prosperous, middle-class community with thriving community institutions like the pool that gives the book its title, but the town collapsed after factories closed and jobs moved overseas. In the wake of these departures, many people turned to federal disability support as a source of income, and with the diagnoses that allowed for them to claim this support—some legitimate, some not—came prescriptions for opiates. As opiate addiction became more widespread, pain clinics opened in great numbers in Portsmouth, dispensing large amounts of drugs that flowed through the community. This was facilitated by the changing conception of pain in the medical community.

In Part 1 Quinones describes the long history of the use of the morphine molecule to numb pain, which dates to ancient civilizations. But the demonization of opium, then morphine—the sleep-inducing element in opium—and finally heroin throughout the 19th and early 20th centuries made doctors stop prescribing the drugs, driving heroin into the streets and prompting researchers to look for nonaddictive alternatives. Into this situation stepped Arthur Sackler, the physician turned advertising executive who pioneered a new approach to selling drugs: appealing directly to doctors. One of these was a tranquilizer called Valium, the industry’s first billion-dollar drug, and as it turned out, an addictive substance. Later, the company he created, Purdue Pharma, sold an opiate painkiller called OxyContin in much the same way. The drug was positively received in a medical field that saw freedom from pain as a human right and opiates as a way of achieving that goal.

Meanwhile, in Xalisco, a town in the Mexican state of Nayarit, young men were starting to see the trafficking on black tar heroin as a route to a better life. In the 1990s young men from Xalisco streamed north to start cells selling black tar heroin or to work in others’ cells. They went to the places where there were no existing cartels, to avoid violence. In seeking these new markets, they also targeted a new demographic: middle-class white people. Some dealers, like the one Quinones calls the Man, followed the trail already cut by OxyContin, “knowing that if he did, he would soon have a market” (91). The entrepreneurial, independent attitude of the men who formed these cells prevented them from forming a cartel, as they were divided by long-held rivalries in Xalisco. But this shared context also allowed them to coexist, saturating the market with a cheap and potent product. This decentralized structure also made black tar heroin trafficking hard to stamp out; as Quinones describes at the end of Part 1, those arrested in a massive DEA-FBI operation were quickly replaced by more young men from Xalisco.

In Part 2 Quinones describes the consequences of the opiate crisis at it became entrenched in medicine and in towns across the United States, and among the traffickers of black tar heroin in Mexico and America. By the 2000s, tens of millions of pain patients were taking opiates for their pain, but as the crisis developed, more prescriptions were issued for people who weren’t in pain at all but had obtained prescriptions through pill mills, pain clinics that dispensed high volumes of opiate prescriptions. In places like Portsmouth, these clinics were commonplace; at one of them, a single doctor wrote prescriptions for a million pills in just two years, generating roughly $3 million for the clinic. This fueled an opiate-based economy in the county, with pills as a kind of currency that could purchase everything from chain saws to flat-screen TVs, often shoplifted from Walmart. Given the location, much of this happened unnoticed, but Quinones describes the few doctors and researchers who began to track overdose deaths from opioids and who realized that those deaths surpassed fatalities from car crashes—an unprecedented milestone in America. Lawyers in private practice and the government pushed back against pharmaceutical companies, filing suits against Purdue Pharma and others for misbranding their products as nonaddictive. Finally, in addition to rising demand for heroin due to prescription opiate addiction, the FBI-DEA operation described in Part 1 fueled more young men from Xalisco to get into trafficking; far from ending heroin sales, the operation pushed cells into new markets, often following the trial of OxyContin. Lured by the promise of quick cash, more young men left their jobs in Nayarit to participate.

In Parts 3, 4, and 5 Quinones describes the individuals and systems that were established to address the opiate crisis. The first of these was an increase in drug courts, which aim to divert users from prison and into treatment. Though these courts predate the crisis, Quinones describes how they gained greater support as prisons reached capacity due to the crisis and the supporters of legislators began to be affected. Meanwhile, jurisdictions like Portland, Oregon, adjusted their approach; rather than deporting smalltime dealers, they used a Len Bias approach, a strategy that carries stiff penalties for supplying drugs involved in a fatal overdose. This approach was used to encourage dealers to flip until they yielded someone with more authority; it also acted as a greater deterrent to men who’d come to see deportation as part of the experience of going north.

Parents also began to change the course of the epidemic, by speaking out about what had happened to their children, breaking the culture of silence around opiate abuse. By the 2010s, pharmaceutical companies were subject to huge fines and settlements for misbranding, and forced to change their sales tactics; doctors also became much more leery of prescribing opiates. But this came too late to stop the opiate crisis, because as Quinones notes, many addicts turned to the black tar heroin that was now available across America, an element of the crisis “ushered in on the prescription pads of physicians, the vast majority of whom were sincere in intent” (305). Despite this grim dynamic, Quinones ends the book on a hopeful note in Portsmouth, which began to claw its way back from the crisis by preserving one of its remaining industries, forcing the pain clinics to close, and rebuilding the sense of community that was shattered by “the most selfish drug” (330).