After hearing Sam Quinones on EconTalk, I finally stopped procrastinating and read Dreamland. It only took a few days over which every other activity was a distraction from finishing the book. Dreamland provides a unified story of the opiate epidemic starting in the late 1990s with both the overall social trend and close-ups on the lives of dealers, addicts, doctors, cops, epidemiologists, and mourners. I’ve watched every episode of Justified and read Case and Deaton PNAS 2015, so I was not surprised by the broad argument of the book that a shift in medicine towards prescribing opiates created ubiquitous chemical dependence that was eventually met by black tar heroin, all of which disproportionately affected rust belt white people. What made the book amazing to me even knowing the broad contours of the social facts it describes was how every detail of the book illustrated and illuminated another aspect of sociology. As I remarked on Twitter, my discipline of sociology could very well treat Dreamland the same way political scientists treat History of the Peloponnesian War.
In no particular order, here are a few of the themes I noticed.
The dealers who come up from Xalisco, Nayarit to live for a few months in spartan conditions working long hours driving around with balloons of dope in their mouths are motivated by relative deprivation. As more and more dealer-migrants return to Xalisco flush with cash this creates a new standard of living in the village and transforms being an impoverished sugar cane farmer from just how life goes to a status that can be rejected. But relative deprivation is too weak to explain Xalisco life, which is better characterized as competitive feasting straight out of Mauss’s The Gift. Xalisco-style potlatch can occur whenever a migrant returns with suitcases full of Levis 501s to disburse to a receiving line of supplicants, but is especially centered on the corn festival, where migrants would compete by sponsoring banda performances (104). Interestingly, while dealers often planned to save enough wages to capitalize a small business, they tended to dissipate their wealth in gifts to family and “the rest on beer, strip clubs, and cocaine, and walked the streets of Xalisco for a week or two the object of other men’s envy” (261). This envy is something Quinones emphasizes repeatedly and the way it is formed by public feasting and is sublimated into a need to reciprocate so as to restore honor, which in turn creates the labor supply for black tar heroin retailing as men seek another bundle of cash through which to engage in such honorable public profligacy.
Social capital also plays a strong role in explaining how Xalisco drug crews operated, which was distinct from most drug dealers. Notwithstanding a handful of murders in the book, Xalisco dealers generally eschewed violence and never carry guns. Competing heroin crews had an approach of friendly competition rather than violent turf wars over territory. Quinones attributes this partly to their “pizza delivery” business model as compared to traditional corner slinging, but mostly to the thick interconnected ties based in a small rancho back home where everybody knows everybody. Another distinctive aspect of the Xalisco boys business model is that dealers earn a salary, whereas typically drugs are sold on commission. This would normally present a principle-agent problem, but it was not an issue for Xalisco dealers. Crew bosses did engage in monitoring through calling junkies to confirm that their dealers were prompt, polite, and the heroin was of high quality, but these monitoring costs were feasible because of the high level of trust. Crew bosses basically trusted their dealers because they weren’t junkies (Xalisco boys consider heroin disgusting) and they had thick communal ties from the rancho. This is the positive aspect of social capital, but there is also a negative sense of social capital in that men were pushed into drug dealing and returning to drug dealing by the insatiable demands to support relatives. That’s all supply side, but social capital also characterizes Quinones’s understanding of the demand side, though in a sense closer to Putnam than Portes, in blaming the rise of opiates on the collapse of community. In this aspect of the story Quinones is a staunch communitarian moralist, which didn’t bother me as I’m a communitarian moralist too, but YMMV and blaming opiates on the collapse of community was the only argument in the book that was more tell than show.
On the prescription opiates side, Quinones tells the story of how medicine lost its traditional reluctance to prescribe opiates in the pain revolution and particularly the key role played by Porter and Jick NEJM. The article itself is a one paragraph letter noting that in-patients treated with opiates rarely became addicted. The role of this brief letter in the pain revolution is instructive for scientific epistemology. In terms of scientific epistemology it provides a valuable cautionary tale for the problem of generalizing beyond the scope of the data. The finding showed that in-patients receiving very conservative doses of opiates rarely became addicted but this was interpreted as it being completely safe to provide out-patients with liberal supplies of opiates. In Quinones’s telling, the article is something of a Sleeping Beauty citation, taking off after it was cited in a 1986 Pain article by Foley and Portenoy. However a Google Scholar search= shows that the article began getting cited almost immediately (the earliest citation is from 1982 in a nursing journal). Nonetheless the story of how a brief publication summarizing a single database query was interpreted well beyond its original scope conditions to justify risky changes to medical practice can provide grist for the mill of historians and sociologists of science. A key part of the story as to why people cited this tiny publication is because they wanted to believe it as it created a permission structure for prescribing effective but dangerous drugs and pharmaceutical detailing exploited this by promoting Porter and Jick, or even just the black-boxed factoid of “1% addiction rate” to physicians.
A few other themes I noticed:
. pharmaceutical detailing in opiates, as in all drugs, follows my model of obfuscated transactionalism and Quinones has a lot of material on the history of detailing
. the submerged state gives Medicaid rather than cash transfers and a lot of diverted opiates came from pill mills paid for through Medicaid fraud
. Xalisco boys engage in statistical discrimination by only selling to white customers who they see as less likely to rob them than black customers
. chain migration characterizes some aspects of Xalisco boy migration, but they also are entrepreneurial in relying on junkies as scouts to explore new markets, including ones with no history of Nayarit migrants
. doctors prescribed opiates in part to get patients out of their offices quickly and prescribed 30 day packs of pills rather than 3 day packs of pills to avoid return visits. Proper pain management is extremely labor intensive, but hard to get insurance reimbursement. This follows logically from Baumol’s disease in that as high-skilled medical labor grows more expensive, insurance companies will substitute capital (drugs).
. reactivity is everywhere. Pain is part of doctor and hospital ratings, but iatrogenic addiction is not so doctors prescribe dope. Sentencing is based on large quantities of dope and carrying a gun so Xalisco boys carry only small quantities of dope and go unarmed.
And oh yeah, there’s also some stuff in the book about how this is an enormous social and public health epidemic, killing tens of thousands of Americans a year and stealing the souls of many more — debasing them into the kind of people who steal their children’s Christmas presents to trade for pills. But I’d rather focus on how it provides material for developing theory because I prefer to be fascinated than livid and that attitude is how I made it all the way through the book only breaking down in tears once.
Cross-posted at Code & Culture