Dreamland

Hershel Jick was in a better position than most to gather findings on the topic. At Boston University, he had built a database of records of hospitalized patients. The database charted the effects of drugs of all kinds on these patients while they were in the hospital. The database grew from the thalidomide scandal of 1960, when babies were born with defects after their mothers were prescribed the drug. Only anecdotally did doctors discover the risk of thalidomide. In the early 1960s, Dr. Jick was asked to begin building a database of drugs used in hospitals and their effects.

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Mexicans in your community meant your area was growing. Huntington and West Virginia had no jobs, no Mexicans either. So, I wondered, how is it black tar heroin from Mexico could have killed so many people here over so many months? And what’s more, since when did West

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So what was black tar heroin now doing east of the Mississippi River?

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heroin mafia Ohio and the eastern United States was used to. “Crazy thing,” he said. “They’re all from the same town.” I sat up in my chair. “Yeah, which one’s that?” He called over a colleague. They talked in muffled

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One Man and Medicine. He became a world-class collector of Chinese art, and at parties at his house, guests hobnobbed with Luciano Pavarotti and Isaac Stern. As doctors raced to keep up with rapidly changing medicine, Sackler saw another marketing opportunity. He pushed his drug-company clients to fund CME—continuing medical education—seminars that were increasingly required for doctors to keep their licenses. By funding CME seminars, he saw, drug companies could grab the ears of physicians.

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Like no other particle on earth, the morphine molecule seemed to possess heaven and hell. It allowed for modern surgery, saving and improving too many lives to count. It stunted and ended too many lives to count with addiction and overdose. Discussing it, you could invoke some of humankind’s greatest cultural creations and deepest questions: Faust, Dr. Jekyll and Mr. Hyde, discussions on the fundamental nature of man and human behavior, of free will and slavery, of God and evolution. Studying the molecule you naturally wandered into questions like, Can mankind achieve happiness without pain? Would that happiness even be worth it? Can we have it all?

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Excess contaminated the best of America. Caltech churned out brilliant students, yet too many of them now went not to science but to Wall Street to create financial gimmicks that paid off handsomely and produced nothing. Exorbitant salaries, meanwhile, were paid to Wall Street and corporate executives, no matter how poorly they did. Banks packaged rolls of bad mortgages and we believed Standard & Poor’s when they called them AAA. Well-off parents no longer asked their

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What gave the morphine molecule its immense power, he said, was that it evolved somehow to fit, key in lock, into the receptors that all mammals, especially humans, have in their brains and spines. The so-called mu-opioid receptors—designed to create pleasure sensations when they receive endorphins the body naturally produces—were especially welcoming to the morphine molecule. The receptor combines with endorphins to give us those

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glowing feelings at, say, the sight of an infant or the feel of a furry puppy. The morphine molecule overwhelms the receptor, creating a far more intense euphoria than anything we come by internally. It also produces drowsiness, constipation, and an end to physical pain. Aspirin had a limit to the amount of pain it could calm. But the more morphine you took, Coop said, the more pain was dulled.

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For this reason, no plant has been more studied for its medicinal properties than the opium poppy. As the mature poppy’s petals fall away, a golf-ball-sized bulb emerges atop the stem. The bulb houses a goo that contains opium. From opium, humans have derived laudanum, codeine, thebaine, hydrocodone, oxymorphone, and heroin, as well as almost two hundred other drugs—all containing the morphine molecule, or…

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Tobacco, coca leaves, and other plants had evolved to be pleasurable and addictive to humans, Coop said. But the morphine molecule…

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Then it exacted a mighty vengeance when a human dared to stop using it. In withdrawal from the drug, an addict left narcotized numbness and returned to life and to feeling. Numbed addicts were notoriously impotent; in withdrawal they had frequent orgasms as they began to feel again. Humans with the temerity to attempt to withdraw from the morphine molecule were tormented first with excruciating pain that lasted for days. If an addict…

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The morphine molecule resembled a spoiled lover, throwing a tantrum as it left. Junkies I talked to, in fact, said they had an almost constipated tingling when trying to urinate during the end of withdrawal, as if the last of the molecule, now holed up in the kidney, was fighting like hell to keep from being expelled. Like a lover, no other molecule in nature provided such merciful pain relief,…

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Certain parasites in nature exert the kind of control that makes a host act contrary to its own interests. One protozoan, Toxoplasma gondii, reproduces inside the belly of a cat, and is then excreted by the feline. One way it begins the cycle again is to infect a rat passing near the excrement. Toxoplasma gondii reprograms the infected rat to love cat urine, which to healthy rats is a predator warning. An infected rat wallows in cat urine, offering itself up as an easy meal to a nearby cat. This…

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became the poster molecule for an age of excess. No amount of it was ever enough. The molecule created ever-higher tolerance. Plus, it had a way of railing on when the body gathered the courage to throw it out. This wasn’t only during withdrawals. Most drugs are easily reduced to water-soluble glucose in the human body, which then expels them. Alone in nature, the…

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“We still can’t explain why this happens. It just doesn’t follow the rules. Every other drug in the world—thousands of…

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some towns, the saying was “Baile el viernes; cuerpo el sabado” (“Dance Friday night, body Saturday morning”). A shooting at a dance could embitter a family against another for years. Keeping track of the bewildering history of conflicts became an essential ranchero survival skill.

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They had been in the San Fernando Valley for almost a decade. Yet they still ran their business for a few months, made some money, and shut it down, less afraid of the police than of what people back home would say.

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hul and gil for the poppy, translating it as the ‘joy plant,’” wrote Martin Booth, in his classic Opium: A History.

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The drug provided huge revenues essential to the British Empire and was one of their few products for which the self-sufficient Chinese showed an appetite. That it lost two of these Opium Wars to the British explains China’s

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In London in 1874, Dr. Alder Wright was attempting to find a nonaddictive form of morphine when he synthesized a drug that he called diacetylmorphine—a terrific painkiller. In 1898, a Bayer Laboratory chemist in Germany, Heinrich Dreser, reproduced Wright’s diacetylmorphine and called it heroin—for heroisch, German for “heroic,” the word that Bayer workers used to describe how it made them feel when Dreser tested it on them. Heroin was first believed to be nonaddictive. Heroin

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As junkies ever since have discovered, heroin is an effective constipator and was thus marketed as an antidiarrheal. Women used it, on doctor’s orders, for menstrual cramps and respiratory problems. Doctors didn’t have much else to prescribe for pain or disease. Thus addiction exploded—to a drug that people believed was safe because doctors said so.

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Addiction was not yet considered a disease, so an addict technically wasn’t a medical patient.

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Physicians soon stopped prescribing the drugs. People with real pain were left to endure. Addicts, meanwhile, turned to crime. “[Because the addict] is denied the medical care he urgently needs,” one medical journal

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They reminded me, in fact, of another group I’d heard of—the Herreras. The Herreras were Mexico’s first vast drug-trafficking ranchero family in the United States.

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connections. With faith in the addictive power of their dope, the Xalisco Boys harnessed these junkies who led them to rich new markets where almost no Nayarits lived, but where thousands of middle-class white kids were beginning to dope up on prescription opiate painkillers. Junkies could track the telltale signs through the streets of a new city to the hidden customers that the Xalisco Boys might never find otherwise. Junkies knew the slang and could read looks of desperation. Most important of all—and crucial to the expansion of the Xalisco Boys—was that junkies

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The painkiller known as methadone was synthesized by German scientists in the effort to make Nazi Germany medicinally self-reliant as it prepared for war. The Allies took the patent after the war, and Eli Lilly Company introduced the drug in the United States in 1947. U.S. doctors identified it as a potential

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In time, though, methadone became a battlefield between those who thought it should be used to wean addicts off opiates, and those, like Vincent Dole, who saw it as a lifelong drug, like insulin for diabetics.

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One strategy or the other might well have worked. But the worst of both emerged at many clinics. Methadone was often dispensed as if the goal was kicking the habit, with small doses. But as methadone clinics became for-profit affairs, many cut the counseling and therapy that might help patients kick opiates altogether. Critics could be forgiven

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for seeing some clinic owners as drug dealers, stringing patients out for years, and charging twenty and thirty times what the drug actually cost, which was about fifty cents a dose. In 1990, the U.S. General Accounting Office reported that half the clinics were poorly managed, unaccountable, and provided little counseling or aftercare.

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At clinics that combined low doses and insufficient rehab therapy, addicts took to using methadone and heroin interchangeably.

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though, no one could conceive of such a thing: a system of retailing street heroin that was cheaper than, as safe as, and more convenient than a methadone clinic. But in the mid-1990s, that’s exactly what the Xalisco Boys brought to towns across America. They discovered that methadone clinics were, in effect, game preserves.

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Methadone clinics gave Xalisco Boys the footholds in the first western U.S. cities as they expanded beyond the San Fernando Valley in the early 1990s. Every new cell learned to find the

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One Xalisco Boy in Portland told authorities of a training that his cell put new drivers through. They were taught, he said, to lurk near methadone clinics, spot an addict, and follow him. Then they’d tap him on the shoulder and ask directions to someplace. Then they’d then spit out a few balloons. Along with the balloons, they’d give the addict a piece of paper with a phone number on it. “Call us if we can help you out.” The value of each Xalisco heroin tiendita was in its list of customers. “This is how they would build and maintain it,” said Steve

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This girl was, in her own words, “a known quantity” down in Xalisco, a town she had never visited. Xalisco Boys who were just getting started in Cincinnati asked for her, looked her up, and pushed dope in her face wanting her help in establishing heroin routes throughout the Cincinnati metro area. It made kicking the habit almost impossible. “They can’t even say my name. But they tell them down there, ‘Ask somebody for White Girl. Lower Price Hill.’ One guy even came with a note with my name on it. Somebody had written my name and misspelled it,” she said.

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off on his own. His big break was meeting Jefferson. Over the next two years, she helped Padilla-Peña and his family carve out heroin markets in Salem, Denver, Seattle, Colorado Springs, Oklahoma City, and Omaha—usually by enrolling herself in methadone clinics and giving away free black tar to the clinics’ clients she met.

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Another such guide was a kid from Mexico who grew up in Reseda. He didn’t use drugs, but he had something else the Xalisco Boys needed. He was bilingual. He was from Mexico but was raised in the San Fernando Valley. In Reseda he met many Xalisco immigrants. In 1995, he was seventeen when a new cell leader hired him to work in Maui, Hawaii.

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heroin at age twenty in New York and that first shot made him feel the way he wanted to feel the rest of his life—like the King of the World and the President of Everything.

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courteous, and looking quite out of their element, were driving the town in old cars, delivering heroin. “All of a sudden you got a dispatch center taking orders and calling these delivery guys,” he said. “It made it very hard to get a good case. You were looking at hours of surveillance for five or six small bags of dope.”

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The delivery drivers did tours of six months and then left. If they were arrested they were deported, not prosecuted, because they never carried large amounts of dope. The cases were always light. Baldessare first

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Later he realized that, quite to the contrary, they had learned how drug investigations worked: prosecutors prized cases with large quantities of drugs. Crack and methamphetamine were the priorities then, each measured in kilos. As camouflage, these Mexican heroin guys used just-in-time supplying, like any global corporation, to ensure they had only tiny quantities in their cars or apartments. This, too, was sophistication Baldessare didn’t see

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As the drivers tooled around Portland all day making deliveries, Baldassare spent ten, twelve hours a day in the plane, watching from twenty-five hundred feet in the air, stopping only to refuel. This was before GPS; nor were there cell phones to track.

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“It was line of sight,” he said. “If you looked away, you could lose them. So you picked your times to look away. If your neck

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Their business card was yellow. It had a phone number and an eagle with a snake in its talons, the emblem on the flag of Mexico. That was all. No names. No slogan. Call anytime, Alan Levine was told. One night, he did. Give us twenty minutes, said the guy on the end of the line. To Levine’s immense surprise, within fifteen minutes, a Mexican kid was knocking at his motel door. He was young and nervous and clean-cut. He looked like a farm boy. He spoke no English. But

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The Mexicans were the only dealers Levine had encountered who never ran out of dope. In time, prices dropped to as little as five dollars a hit as these crews brought huge supplies of high-quality tar heroin to Portland and competed against each other. Yet he noticed that they never feuded. They gave him credit. They often gave him a little extra, avid to keep him as a customer.

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Levine got in his car and followed the driver across Portland. They came to a house. Out came a man Levine years later determined to be Enrique Tejeda-Cienfuegos, but whom he came to know then as El Gato.

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Levine down through his ex-wife because by then I realized the history of heroin was best told by addicts, the older the better. I sat in a chair while he, legless, sat in his bed, smoking constantly. Cigarettes gave his voice a growl as grizzled as his face and

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“When he spoke, they acted,” he said. “He had some status. He took a liking to me because I paid on time. After that, they’d come and say, ‘Gato said to give you this; Gato said to give you that.’ They called me Liver because I told them I had hepatitis C and I didn’t want to share needles.”

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Levine had never known any dealer to give away free drugs to get people hooked, or to keep addicts from getting clean—the kind of mythical pushers the government and the media had invented amid the “dope fiend” scare. Until he met the Xalisco Boys.

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“This marketing technique was about that. They knew what they were doing. They were marketers.”

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The job of heroin driver resembled sweatshop work. The cell owners changed the drivers in and out, moving them into apartments and out again six months later, switching cars even more frequently, and ordering drivers to hand out beeper numbers to junkies on the street along with free samples. By the early 1990s, the San Fernando Valley was like a convention, a reunion of people

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One dealer, known as El Gato, from the village of Aquiles Serdán, was especially aggressive. El Gato didn’t care what people said about him back home. Enrique admired that. El Gato wanted people to know that in his house, hunger was a thing of the past. El Gato came home with clothes, cars, ice chests full of American beer, and guns of various calibers. “El Gato is everywhere and it won’t be easy to run him out,” his uncle said.

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patrolled the streets of the San Fernando Valley like the state trooper he once wanted to be—now looking for addicts. He’d give them a free sample and a phone number. Within a few weeks, Enrique raised the daily take to five thousand dollars.

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David Tejeda had that store going in Hawaii. These kinds of moves rocked the Xalisco heroin world in the San Fernando Valley. Above all, they showed the Xalisco Boys that they could find new markets, that the system could succeed far from the Valley’s Nayarit enclave.

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side business. They beat him for his temerity, gave him eighteen hundred dollars as payment for his months of work, and packed him off to Nayarit.

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feet high, were one way a family showed neighbors that it had arrived. Didn’t matter if some days it got no reception, the towering pole and broad dish made a statement. His family had no decent bathroom, Enrique wryly observed, but it had a satellite dish. Still, his father was happy, so the family was relieved. One day the land would be his, his father reminded him. Enrique should get used

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morphine molecule. This seemed a shame to scientists and physicians. Was mankind really doomed to not have it all? Couldn’t it have heaven without hell? Couldn’t the best scientists find a way of extracting the painkilling attributes from the molecule while discarding its miserable addictiveness?

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In 1935, the U.S. Narcotic Farm opened. The Farm contained a section known as the Addiction Research Center (ARC). For decades, the ARC tested on inmates every major opiate that Committee-sponsored chemists produced: Dilaudid, Demerol, darvon, codeine, as well as Thorazine and many tranquilizers and sedatives. Experiments at the Farm showed that methadone lasted longer and spared junkies the severe highs and lows of heroin that spurred their frenzied attempts to score. Thus, they concluded, methadone could act as a replacement for heroin.

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For four decades, heroin and morphine addicts with long sentences would volunteer for studies because they were given dope. After the studies ended, the subjects were given a six-month rehabilitation to ensure they were no longer physically dependent. As American

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destroying the lives of thousands,” wrote Nancy Campbell, J. P. Olsen, and Luke Walden in The Narcotic Farm, a fascinating book on the institution.

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Addiction study emerged there as a scientific field, and ARC staff were the first to conceive of addiction as not a character failing, or a crime, but rather a chronic brain disorder. The ARC was shut down in the 1970s, when the U.S. Senate’s Church Committee, investigating

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spiritual impact of advanced illness. He was forced to learn, for example, how to tell a family of a loved one’s life-threatening illness. Palliative care, he came to believe, was guided by moral issues of patient autonomy and respect for cultural and individual differences. Decisions were made with the input of the patient and family. This was very different from how medicine had treated serious illness and pain. Watching people struggle with pain, and talking to families who faced the loss of a loved one, gave Portenoy a touch of idealism,

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medicine. Through the catheter Webster gave her small, continuous doses of opiate anesthetics. Epidurals had been used in labor and delivery, but new research showed epidurals could be used for other things. They could, Webster reasoned, allow him to gain more localized pain control with less medication than the typical intravenous

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Watching his wife go through searing pain in childbirth in 1943 set Bonica on his career as an anesthesiologist. He trained hundreds of anesthesiologists in the U.S. Army Medical Corps. After the war, he became chief anesthesiologist at Tacoma General Hospital and wrote a classic textbook, The Management of Pain. Bonica opened America’s first pain clinic when he was appointed chief of anesthesia at the University of Washington School of Medicine in 1960. Pain could only be salved, Bonica believed, when many disciplines within

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term Loeser coined. “We were trying to teach [patients] that they were the ones who controlled whether they were well or not well,” Loeser said. “The patient has to do the work. Chronic pain is more than something going wrong inside the person’s body. It always has social and psychological factors playing a role. Physicians have traditionally ignored such things.”

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could solve a patient’s problems were wrong, researchers at UW believed, at least where pain was concerned. Pain was complicated.

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“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

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means. You’re not entitled to pain relief any more than you’re entitled to happiness.

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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.”

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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

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“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.

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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.”

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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.”

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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

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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

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doctors should attend to pain as routinely as to the other vital signs. In 1998, the Veterans Health Administration made pain a “fifth vital sign”—another gauge of a patient’s baseline health, along with pulse, blood pressure, body temperature, and respiration. The Joint Commission for Accreditation of Healthcare Organizations (JCAHO)—which accredits sixteen thousand health care organizations in the United States—did the same. Hospitals

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From all this, the idea took hold that America was undertreating pain. Tens of millions of people, surveys reported, were in pain that wasn’t being treated. Pain’s undertreatment was viewed as an unnecessary epidemic, for medicine now had tools to treat it. A 2001 survey of a thousand

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They demanded legal clarity. So, beginning with California, states passed laws exempting doctors from prosecution if they prescribed opiates for pain within the practice of responsible

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mission, a duty, to use them. In some hospitals, doctors were told they could be sued if they did not treat pain aggressively, which meant with opiates. Russell Portenoy, meanwhile, was made director of the

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from several drug companies, he pressed a campaign to destigmatize opiates. The drug company Baxter and others produced intravenous patient-controlled analgesia (PCA) pumps, allowing patients to administer their own painkiller with the push of a button. In Tulsa,

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operations without the aid of analgesics. She became a nurse. In the 1980s, with the smiley face fad in recent memory, the women devised a series of six faces a child could point to. The chart begins with a smiling face and ends with a tearful, grimacing face. The Wong-Baker FACES scale is now a standard in gauging pain in children. There are other versions for adults. Patients are asked to quantify their pain according

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“The fifth vital sign” was a “concept, not a guide for pain assessment,” one report read. Along with the pain number scale, a doctor ought to ask numerous questions about a patient’s pain history, the pain’s location, severity, impact on daily life, as well as the patient’s family history, substance abuse, psychological issues, and so on. In fact, pain was really not a vital sign, after all, for unlike the four real vital signs it cannot be measured objectively and with exactitude. The National Pharmaceutical Council advised that “the manner in which information is elicited from the patient is important. Ideally, the clinician should afford ample time, let the patient tell the story in his or her own words, and ask open-ended questions.”

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Time was the key. Chronic-pain patients took more time than most to diagnose. Problem was doctors had less time. Just as patient rights were emphasized and surveys were circulating asking them to judge their doctors’ performance, patients were in fact losing their most precious medical commodity: time with their doctors. With the managed care movement of the 1980s and 1990s, insurance companies cut costs and reduced what services they’d pay for. They required that patients give up their longtime physicians for those on a list of approved providers. They negotiated lower fees with doctors. To make up the difference, primary care docs had to fit more patients into a day. (A Newsweek story claimed that to do a good job a primary care doctor ought to have a roster of eighteen hundred patients. The average load today is twenty-three hundred, with some seeing

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treat somebody’s pain, you’d be out of business,” one longtime family doc told me. “By the model you’re stuck in, you can’t do it. The hospital will get rid of you. If you’re by yourself, you can’t pay for your secretary.” So as the movement to destigmatize opiates and use them for chronic pain gained energy, the seeds of discontent were already being sown. These drugs were advertised mostly to primary care physicians, who had little pain-management training and were making their money by churning patients through their offices at a thirteen-minute clip. Not much time for nuance. Not much time for listening, or for open-ended questions that might elicit long and complicated answers. On the contrary, just as Valium helped doctors deal with anxious patients in the 1960s, opiates helped a harried doctor with what was now the largest drain on his time: chronic-pain patients. As the movement gained strength from new drugs and devices, the crucial ingredient in…

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The Press Ganey patient surveys, it turned out, had an unintended effect in this context. It was to subtly pressure doctors to write unnecessary scripts for opiates. A doctor reluctant to write them was more likely to get a poor patient…

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get raises, and keep my job, based on whether I’m keeping my patients happy,” said a nursing supervisor I spoke with. “When the Joint Commission surveyed us they looked through charts looking at…

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And there was another problem. No one had done serious, long-term studies of whether opiates actually were nonaddictive when used by such patients. Years later, in fact, there still is no evidence of how many chronic-pain patients can be successfully treated with opiates without growing dependent, then addicted. Determining…

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Purdue was unknown to the public, but well-known to pain specialists. It was leading the way with new tools in pain treatment, MS Contin above all, but with other drugs on the way. The company also had attempted to control theft by developing a database to aid law enforcement investigations into pharmacy robberies.

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what was increasingly called a “report” in the New England Journal of Medicine coauthored by a Boston doctor named Hershel Jick, more and more people—especially Dr. Russell Portenoy and salespeople from the little-known pharmaceutical company, Purdue Pharma, which was about to release a new painkiller—answered yes.

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Through the 1990s, the Xalisco system had refined through trial and error. The Boys compared notes at barbecues back in Xalisco and slowly a set of rules evolved that was passed along like folklore. One rule: no violence. At the time, the best-known

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police attention wherever they went. Watching all this, the Xalisco Boys quietly began to expand nationwide by doing exactly the opposite. Polla was part of that 1990s expansion and one place he showed up was Boise.

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withdrawing in jail. As Dennis Chavez had seen in Denver, and as drug agents elsewhere would later discover, Ruplinger noticed that these Mexican drivers often had only a small amount of heroin and no weapons. So they never did much jail time. But it struck Ruplinger’s best police nerve that whenever he could determine where they were from, it turned out they were from a state in Mexico called Nayarit.

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watched a driver swing by an apartment building and pass a trim fellow some money. Here, clearly, was the boss, Ruplinger thought. Yet the first time Ruplinger and his colleagues followed Polla, the suspected ringleader walked into a Mexican restaurant and took his place as a cook behind the grill. The man Ruplinger took for a heroin kingpin appeared instead to be a simple cook and not worth the unit’s time. But Ruplinger’s hunch proved correct. A month later Garcia-Langarica quit the job. From then on, when Polla was in town, he spent all his time supervising his heroin

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Then she said something strange. After building their houses, and providing for their families, what the guys she knew from Xalisco, Nayarit, seemed to want most of all were Levi’s 501s.

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Levi’s 501s were the pantswear gold standard for men in Mexico’s ranchos in the 1990s. They were very expensive in Mexico. One thing that made the Xalisco Boys’ retail system so popular, and young men eager to work in it, was that the system provided a way to accumulate quantities, large stacks, of 501s very cheaply.

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That was because U.S. junkies soon learned these dealers’ tastes and offered endless supplies of shoplifted 501s in exchange for their daily dope. Before long the junkies took orders according to size and color and traded them two for one: two pairs of 501s for one twenty-dollar balloon of black tar.

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caught up in this. Around town, the gossip would start weeks in advance: So-and-so’s coming home with gifts and then we’re going to kill a cow and he’s going to pay for the banda. Every trafficker’s return was like Christmas Day as relatives lined up for gifts, especially those jeans. Some traffickers came pulling trailers full of clothes. “The family wants

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Just as an addict couldn’t choose not to use dope, these men couldn’t not return to sell it. Up north, they slept on the floors of apartments, unwilling to invest even in a mattress, awaiting the day when they could go home bearing gifts. Once back in Xalisco, she said, they walked the town the object of other men’s envy, paying for the banda and the beer, and surrounded by women. And no driver ever wanted to miss the Feria del Elote

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August. “That’s when you get to show off the most,” she said. “It’s like a kid going to Disneyland for the first time. They walk around with their chest out. Everybody looks at them.”

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imagined their mu receptors jolted in endorphins. “They live for it. They save their fricking pennies for it,” she said. “It’s a euphoria. They get high on it. They’re in fantasyland, in a dream where they think they’re the kings. Until the money runs out.”

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Thus with an addict’s energy and single-mindedness, she said, the Xalisco Boys sought new markets with higher profit margins, awaiting the chance to go

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back home, the kings of their dreamland for a week or two. Only the self-centeredness of addiction, she said, explained how farm boys from a traditional and conservative small town could sell a product, anathema to their parents, to sad-eyed, vulnerable junkies and not be tormented.

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“I used to work in a laboratory where they did research on animals, and have to kill them,” the ex-wife said. “The way you deal with that is you disassociate yourself from that animal. You don’t let it get to you. You put up that barrier. That’s what they do. They do that with people.”

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Ruplinger marveled at how massive and connected the Xalisco network was. Polla’s heroin store practiced just-in-time supply, with women as mules every couple weeks bringing up a pound of heroin at a time. Keen to keep competitors at bay, Polla insisted that his drivers provide excellent customer service. Once when a driver reported a customer complaint of a bad batch of dope, Polla promised to make it right; the driver delivered better-quality

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When Ruplinger heard that, he felt he was watching the expansion of some new scary thing, as if he were all alone in a lab where a virus had escaped its test tube.

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With faith in their addictive product, they didn’t need to shoot it out for territory. These drivers knew each other, and would stop to chat or meet for lunch. Even as they competed and drove down each other’s prices, they did so in peace. They went out of their way to avoid attention.

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was no incentive for them to cut their dope. They didn’t make any more money if they cut it than if they sold it as it came. They were employees, guys on a salary, with their costs covered and a stipend of several hundred dollars a week. The last thing they wanted was violence.

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heroin cells were like ants in a garden: You didn’t see them unless you got close enough and knew what to look for. Then, even when you stamped them out, more came to take their place. It was 1997. Well before most other cops in the country, Ed Ruplinger was figuring out how to see the ants.

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One researcher, writing in 1990 in Scientific American, called Porter and Jick “an extensive study.” A paper for the Institute for Clinical Systems Improvement called Porter and Jick “a landmark report.” Then, the final anointing: Time magazine in a 2001 story titled “Less Pain, More Gain,” called Porter and Jick a “landmark study” showing that the “exaggerated fear that patients would become

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Purdue Pharma as vice president for health policy. The other, David Weissman, later described what doctors ought to do in cases of pseudoaddiction. Build trust and “aggressively” increase the dose of opiates until pain was relieved, Weissman wrote.

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who were making money helping me with my demise. They were just people. When it was time to get clean I missed that relationship. It became really hard to hate them.” This was part of why the Xalisco Boys succeeded. To their customers, many Xalisco Boys were not like typical heroin dealers, who were addicts as well, cold and conniving. Some of the boys became friendly with their addict customers. Even through the language barrier, they were personable, sometimes charming.

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Intrigued, Oxman and a team of researchers pored over these death reports in the basement of the medical examiner’s office for the next three months. And there he saw the problem. Each autopsy physician had different ways of describing a heroin overdose. One used “acute intravenous narcotism.” Another used “narcotics overdose.” There was “polydrug overdose,” though not officially listing heroin. Another used, simply, “heroin overdose.” The numbers had been growing steadily, hidden in the tall weeds of inconsistent language. Eventually, he tallied more than a hundred heroin overdoses a year since 1996. He dug further into the files, reading all the overdose reports back to the early 1990s. What he and his team found astonished Oxman. There was no sudden spike in heroin deaths, as RAP believed. It was scarier than that. Deaths had been marching straight up for almost a decade and no one had noticed. Multnomah County had 10 heroin overdose deaths in 1991, about the time the Xalisco Boys arrived, and ended 1999 with 111—a 1,000 percent increase in eight years. “By the time we discovered it,” Oxman said years later, “it wasn’t a new wave at all.” Unbeknownst to anyone, heroin overdoses had become

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Multnomah County’s second cause of accidental death among men twenty to fifty-four years old—after car crashes. “This level of heroin overdose deaths is considered epidemic,” Oxman and his team wrote in a report to the county commission in December 1999.

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Oxman put together a team of public health workers and sociologists to interview street addicts over the next year. Heroin in Portland had never been cheaper, more available, or more potent. For twenty dollars, a beginning heroin user could stay high all day.

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Xalisco Boys’ system and reach, they realized that the small quantities of dope seized were even more ominous than large seizures. It meant that a vast network of traffickers had figured out what defined a successful drug bust for U.S. narcotics agents, their bosses, the media, and the public: large amounts of dope, money, and guns. It meant they

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had rules and practices in place so they’d never be caught with any of that. And they did this relentlessly, over and over, across the country.

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Nayarit, Mexico. Something else: The numbers they called in these cities were turning up in cases the FBI had under way across the country. “A street-level guy selling a tenth of a gram should not hit a half-dozen FBI multiagency cases in other cities and other states. It just does not make sense in our world,” Stone said. He formed a task force with the DEA and the Portland police. They tapped the dealers’ phones and pagers. Stone marveled at their system’s sophistication. Dispatchers sent pages to drivers that baffled investigators. Something like 181230 would show up, for example. Later, informants taught the investigators that the first number was a north–south street, many of which are numbered in Portland; the second number was a code drivers memorized for a major east–west street: 1 was Burnside, 2 was Halsey, and so on; the third number was code for the number of blocks away; the last number was either 0 or 5: north or south, respectively. So 181230 told the runner to meet the addict three blocks north of the intersection of 181st Street and Halsey.

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Sources revealed why dealers didn’t step on the heroin. “It’s because they’re salaried,” Stone said. “The runners are up here, nephews of the regional sales

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manager, and just coming to do a job, paid five hundred dollars a week. They didn’t care what the potency was; they made the salary no matter how much they sold.” Salaried employees were unheard-of in the drug business. “We realized this is corporate,” Stone said. “These are company cars, company apartments, company phones. And it all gets handed to the next guy when they move on.”

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With enormous flexibility on price, they could sell heroin cheaply and with unprecedented potency. Because they competed among each other, their prices dropped. Beginning in about 1991, the loose network of Xalisco heroin cells had arrived, cornered, and then saturated Portland. The result was the decadelong rise in overdoses that Gary Oxman had found—a relatively small group of people creating a major drug plague.

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Overdoses, and not burglaries and robberies, became the new barometers of the city’s heroin problem. Oxman hired an advertising firm to organize focus groups of addicts and design

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OxyContin is a simple pill. It contains only one drug: oxycodone, a painkiller that Germans synthesized in 1916 from thebaine, an opium derivative. Molecularly, oxycodone is similar to heroin.

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“We were selling a lot,” he told me. “But the thing I didn’t like in Dayton was we were dealing with a lot of blacks. I don’t deal with blacks if I don’t have to. In the long run they’ll rip you off. They’ll hurt your kids. They’ll pistol-whip you.”

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“Something big was going on,” he said. “How did they know that article showed up in the Portsmouth Daily Times unless they were tracking that kind of information?” The Counseling Center that Hughes ran had begun in a small house seventeen years earlier. Hughes, a recovering alcoholic, felt rehabilitation really involved rebuilding an enslaved person. He believed recovery was possible only with a multidisciplinary approach to treating the addict—“a continuum of care,” Hughes said. An addict in treatment needed a 12-step program, but he also needed help finding housing, with writing

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by the enormous power of the federal government’s conspiracy laws. These statutes allowed the government to charge a person for involvement in a criminal enterprise even if there was no immediately incriminating evidence—no drugs in an apartment when the cops searched, for example. Wiretap cases were about what was happening at that moment. The conspiracy cases Kuykendall grew to prefer

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Defense attorneys criticize conspiracy cases at times as too broad, sweeping up, for example, everyone a defendant contacts. But Kuykendall found that conspiracy cases appealed to his inner journalist. Conspiracy cases required telling a story. Using conspiracy statutes, an agent learned part of the story of a criminal enterprise as he made a case, then flipped the defendants and came back with more arrests and learned the whole story, or at least most of it.

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had a lot to do with justice Kuykendall came to believe, for little of what these enterprises really were was apparent on the day of a bust.

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If heroin was the perfect drug for drug traffickers, OxyContin was ideal for these pill mill doctors. The drug had several things going for it, as far as they were concerned: First, it was a pharmaceutically produced pill with a legal medical use; second, it created addicts, and not just among those who looked to abuse it, but among many who came in search of pain relief. Every patient who was prescribed the drug stood a chance of soon needing it every day. These people were willing to pay cash. They never missed an appointment. If diagnosis wasn’t your concern, a clinic was a low-overhead

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They also required a physician with a DEA registration number that permitted him to prescribe federally designated Schedule II narcotics like OxyContin. Prescriptions for Schedule II drugs had to be written each month by a doctor for a patient, who had to come to the office in person. That meant a monthly-visit fee from every patient—$250 usually. And that kept waiting rooms full and cash rolling in.

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give her an office job or help with her husband’s workers’ compensation claim if she did not allow him to lick her vagina, though her toddler son was in the room when he did

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While working for Procter, Snyder was addicted to Lorcet and was injecting OxyContin while writing narcotics prescriptions ten and twelve hours a day. He told a DEA investigator that he often split prescriptions with patients, supplying his habit and that of his wife.

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On some days, he saw patients for ninety seconds at a time, and issued forty-six thousand controlled-substance prescriptions—for a total of 2.3 million pills—in nine months.

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Dr. Rodolfo Santos worked in Procter’s clinic for a while, during which time at least one of his patients died. An investigator wrote that Santos displayed “gross ignorance, gross negligence, gross incompetence” and “a level of care that I would not find acceptable in a first year medical student.” Santos said he knew he was dealing with addicted patients who lied, and scammed

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I asked a detective, seasoned by investigations into many of these clinics, to describe the difference between a pill mill and a legitimate pain clinic. Look at the parking lot, he said. If you see lines of people standing around outside, smoking, people getting pizza delivered, fistfights, and traffic jams—if you see people in pajamas who don’t care what they look like in public—that’s a pill mill. And that’s what popped up all over Portsmouth, growing from David Procter’s first clinic.

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No place, apparently, represents the country more faithfully and for that reason Columbus, Ohio, has been known as “the test-market capital of the United States” for several years now.

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He tutored his new Xalisco Boys. Never leave the house with anything in your pockets. Take only what you can swallow if you get pulled over. And never carry a gun. An illegal who is arrested gets deported; an illegal with a gun gets ten years.

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Some of them still dressed as they had back home, with cowboy boots and belt buckles. “Go to the stores downtown,” he told two of them one day. “Look at how they dress the mannequins at JCPenney’s. Buy clothes like that so you blend in with the people here.”

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money is, he told them. Steer clear of blacks. He didn’t have to insist too strongly on this point, either. His runners came with their own ideas forged by the negative view of black people common in Mexican culture that was, in turn, reinforced by the stories of returning immigrants who lived in Compton, Watts,

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So the Xalisco Boys stayed away from black neighborhoods, and this was one reason why, as their system expanded, Nayarit black tar was primarily sold to, and used by, whites.

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Then, every time you found them somebody new, it was a free balloon. Usually it was seven balloons for a hundred dollars. But if you brought them enough people and were spending with them, you could get as many as thirteen balloons for a hundred dollars.”

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A tailor in Los Angeles made them corsets with pockets that held a hundred thousand dollars in cash. He sent the women on airplanes to El Paso where they crossed his money to Ciudad Juárez and from there back to Xalisquillo. For more than a year, he sent two girls a month back to Mexico with a hundred thousand dollars in pure Columbus, Ohio, profit tucked in their corsets.

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The Man used Federal Express to bring the product from Mosca’s apartment in California. He would go to California, and buy a small electric oven from Target or Kmart, open the back of the oven, stuff it with tar heroin, then take it to FedEx for packaging. Police didn’t often search a package that FedEx prepared. He sent the ovens to a pliant Columbus addict who lived in the

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His black tar, once it came to an area where OxyContin had already tenderized the terrain, sold not to tapped-out old junkies but to younger kids, many from the suburbs, most of whom had money and all of whom were white. Their transition from Oxy to heroin, he saw, was a natural and easy one. Oxy addicts began by sucking on and dissolving the pills’ timed-release coating. They were left with 40 or 80 mg of pure oxycodone. At first, addicts crushed the pills and snorted the powder. As their tolerance built, they used more. To get a bigger bang from the pill, they liquefied it and injected it. But their tolerance never stopped climbing.

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attracted kids to whom needles were at first anathema. The way he saw it, every Oxy addict was a tar junkie in waiting, and there were thousands of new Oxy addicts. All he had to do was work

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English (“no credit” or “fifteen minutes”), exchanged with desperate addicts who spoke no Spanish. Discovering emerging markets required an English speaker who understood the street.

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One woman I met lived twenty-five miles outside Columbus and at one point she hadn’t called to buy for three days. A Xalisco Boy called her. “Señorita, why haven’t you been buying recently?” “I don’t have any money,” she said. He drove out to deliver fifty dollars’ worth of heroin to her, for which he required no payment. No, it’s free, he said. “He wanted to keep me using, and buying from him,” she said. She did both.

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“It was eerie how uniform [the stories] were from town to town,” said Rock Stone. “What we were seeing in Portland is what L.A. is seeing is what Denver is seeing. These [Xalisco Boys] are following exactly the same playbook. You couldn’t help but feel how corporate these guys are, how standardized they are. It’s like McDonald’s, where you get the same burger in Louisiana as you get in California.”

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just like any other business. The evolution of Nextel push-to-talk phones by the late 1990s was one example. It allowed bosses to monitor their drivers and make sure they were working through the day. In the room that day in Los Angeles, Jim Kuykendall listened and thought back to that first meeting in Chimayo a year before, amazed at what it had led to. The whole thing was like a web, and thus more flexible and resilient than the rigid hierarchies of so many Mexican drug-trafficking organizations. And it all led back to that little town in one of Mexico’s smallest states.

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Across the country that day, 182 people were arrested in a dozen cities in Operation Tar Pit. Agents seized relatively small quantities of drugs and cash: sixty pounds of heroin and two hundred thousand dollars. Yet Tar Pit remains the largest case—geographically and in terms of manpower used—the DEA and FBI have ever mounted jointly.

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They were a new kind of drug trafficking in America. The Xalisco Boys weren’t the General Motors of drugs. They succeeded because they were the Internet of dope: a network of cells with no one in charge of them all, with drivers rotating in and out, complementing each other as they competed for every junkie’s last twenty bucks, yet doing this without guns, shutting down their phones fast as a website at any hint of law enforcement’s approach.

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funneled crew money home to Nayarit, and sold the Xalisco networks their indispensable cell phones and pagers. He found an apartment that had 155 cars registered to it and shut that down, too.

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“My fellowship director even told me, ‘If you have pain, you can’t get addicted to opiates because the pain soaks up the euphoria.’ Now you look back and it sounds so preposterous. That’s actually what people thought. You can think what you want in the face of ten thousand years of reality.”

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“The real problems were things I couldn’t see. What was that patient doing with the medication when they left?”

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At the time, pain specialists and addiction specialists rarely crossed paths. Even today, despite a national movement to treat pain with addictive drugs, the two specialties, remarkably, still don’t have much contact; there are no joint conferences where the two specialties might meet.

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was faced with the dilemma that prescribers have,” Katz said. “What is the nature of the problem? If it’s an abuse problem, the patient’s not going to tell you.” Before Katz had a chance to find out, Peter died from an overdose of the medication the young doctor was prescribing. His death was a turning point for Nathaniel Katz. “He was dead and I liked him and I wanted to help him.”

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they effective in treating that pain? Katz searched the medical literature and found nothing. “There’s not a shred of research on the issue. All these so-called experts in pain are dedicated and have been training me that opioids aren’t as addictive as we thought. But what

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Overdose deaths involving opiates rose from ten a day in 1999 to one every half hour by 2012. Abuse of prescription painkillers was behind 488,000 emergency room visits in 2011, almost triple the number of seven years before.

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But, as with crack cocaine, the numbers of new opiate addicts by the 2000s were enough to throw hospitals, emergency rooms, jails, courts, rehab centers, and families into turmoil, especially in areas where abuse was new.

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One key to the pill mill explosion was the discovery of locum tenens lists, a clearinghouse for doctors around the country seeking temporary employment. Many of these doctors were desperate. They had license problems, or couldn’t get malpractice insurance, or were alcoholics. These were the docs Procter had hired. Now other clinic owners did the same and quacks flocked to Portsmouth. Tracy Bias, a convicted felon, opened three pain clinics and hired doctors from New Mexico, Michigan, and Iowa, as well as two from other parts of Ohio. Clinic staffers or locum tenens doctors found work at a pain clinic, learned the business,

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The mother and daughter hired temp-agency doctors and threatened those who refused to prescribe pain medication. Several physicians left immediately. In April 2003, the Huffmans solved their labor issues when they hired a Chicago chronic-pain specialist named Paul Volkman. Volkman was so prolific that the Huffmans had to open their own pill dispensary in the back of Tri-State after local pharmacies refused to honor his prescriptions. This pharmacy was somehow legal under Ohio law.

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Huffmans took in some three million dollars from patients paying two hundred dollars a visit, and who lined up well before the clinic opened. The Huffmans paid staffers in pills, but staff also accepted bribes (in pills usually) to move patients up in line. Volkman rarely performed anything resembling a diagnosis. Instead, he met with patients briefly, asked them a few questions—one of which was whether they were undercover law enforcement officers. He often ordered urine tests, but ignored them when they showed high levels of opiates. He had one patient sign a “death waiver,” in which the patient acknowledged he might die from

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painkillers became accepted treatment for chronic pain, workers with on-the-job injuries were mightily affected. Almost alone in the country, L&I, in a three-story glass building off in Tumwater, Washington, far from Portsmouth and the Lucasville Bottoms, sat atop a mountain of data affording a broad vista of what was forming.

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meant there’s no ceiling on dose, that the way to treat tolerance is to increase the dose,” Franklin said. Now, two years into these state

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Mai and Franklin also found that prescriptions for the strongest opiates more than doubled. Prescriptions for much milder pain relievers dropped or remained the same. This was also strange. Normally, doctors would be expected to start out with the milder drugs. But faced with patient pain, doctors were going right to the heavy artillery, and that meant, beginning in about 1997, OxyContin.

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West Virginia, and eastern Kentucky. Portsmouth for a while had a pill mill for every eighteen hundred residents. “My daughter was addicted,” said Lisa Roberts, the city’s public health nurse. “A judge’s kid became addicted. A mayor’s kid became addicted. A police chief’s kid got addicted. The kids who came from excellent families got addicted.” It seemed like an evil lottery, a massive brainwashing. One by one people succumbed. After a while, Roberts could recognize the look, say, in an old friend she hadn’t seen for a while. “They’re coming over to your house [with] these big elaborate stories to get money off you,” she said. “It’s like watching people being picked off one by one by one.” Slaves to the morphine molecule, the generation born into the town’s decline set about tearing Portsmouth apart. You could see them trudging like zombies along Highway 52, which ran through Portsmouth, on missions to placate the molecule. They ripped air conditioners out of houses for the copper wire inside. They stole manhole covers. They took large spools of copper wire from behind the school district office. They stole their children’s Christmas presents. Until finally, alone down on the Ohio River, Portsmouth became a kind of junkie kingdom and pills became currency, more valuable than cash. To a degree unlike any other town in America, a raging, full-blown OxyContin economy developed. DVDs, refrigerators, dentist visits, cable TV installation, Tide detergent, tools, clothes, and children’s school supplies—pills bought them all in Portsmouth, Ohio.

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abuse was a minor subculture back then. Abusing Vicodin or Lortab was hard work. They contained only small doses of opiates, and included acetaminophen or Tylenol to discourage their abuse. People who used them usually developed serious liver problems from the acetaminophen. But they didn’t often overdose on the weaker pills. Once OxyContin arrived, however “it went from people strung out on dope to people strung out and dying on dope,” said one Portsmouth addict who by then was taking so many Lortabs that he permanently damaged his liver. In Portsmouth, OxyContin did something else: It turned pill scamming into big business for the town’s generation of decline. Mary Ann bought the MRI results of a person with a sprained lumbar. She scanned the pages into a computer, and used the MRI repeatedly, changing the name on it over and over. Next, she recruited street addicts. She paid them to go to the doctor, each armed with that MRI in their names. The docs of Portsmouth charged $250 cash per visit. In time, Mary Ann was driving several addicts at a time to one clinic one day, and another group of addicts to another clinic the next, waiting while they got their prescriptions. Usually, each addict left the clinic with scripts for ninety 80 mg OxyContins—three a day, for a month. The doctor also prescribed 120 generic oxycodone 30 mg pills and 90 Xanax bars. Mary Ann took half of the haul in exchange for driving the addict to the clinic and paying the $250 doctor’s fee.

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time, they vowed, they weren’t going to use them. Rather, they were going to sell them and accumulate some cash. Then they would be the ones to drive junkies to clinics and pay their visits. Those dreams evaporated on the long ride home as they snorted or injected their pills and were left again with nothing.

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whatever pills a doctor deems that the insured patient needs. Among those who receive Medicaid cards are people on state welfare or on a federal disability program known as SSI (Supplemental Security Income). In Scioto County, annual SSI applicants almost doubled in the decade ending 2008—from 870 to 1,600. An untrained observer of Portsmouth’s bleak economic landscape might have understood; jobs, after all, were scarce. People needed money and that check helped. That was true, but by then pills and pain clinics had altered the classic welfare calculus: It wasn’t the monthly SSI check people cared so much about; rather, they wanted the Medicaid card that came with it.

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weren’t so easily injured. They didn’t qualify for workers’ compensation. As jobs disappeared, so did the disability income people could receive. Eventually, entire families grew up on SSI, which paid only a few hundred dollars a month. SSI, however, did come with a Medicaid card, and that made all the difference when OxyContin appeared. “Twenty years

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“The checks were higher because they’d go work in the mines and pay into their [SSDI] disability. Now we’ve got people who aren’t working, who are drawing SSI, maybe five hundred dollars a month. We’ve got people who have kids and wives and the whole family trying to survive on five hundred dollars. I’m not making excuses for them. Many haven’t had a job. But it is what it is. When you don’t work, and never have had a job, or paid into the system, you don’t qualify for much. We have boatloads of people who qualify only for SSI. You wouldn’t believe the number of people we see, twenty or thirty years old, have never had a job and are drawing checks since they were teenagers.

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Many of them were in areas, not coincidentally, where the numbers of welfare and federal disability recipients were comparatively high—like southern Ohio and eastern Kentucky.

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Every pill Mary Ann Henson harvested from the addicts whom she took to a pain clinic she could sell for a dollar a milligram—eighty dollars for one Oxy 80 mg pill, in other words.

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Those lines were the addict Internet. News spread along the line about what doctor prescribed which drugs, who had a car stereo for sale. It may have been in those clinic

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Addicts of the morphine molecule valued dope above everything, including children and cash. Pills could not be altered or diluted. Pills held their value, and that value was printed on each pill. It helped that OxyContin came in 40 and 80 mg pills, and generic oxycodone came in 10, 15, 20, and 30 mg doses—different denominations for ease of use as currency. The pill mills acted as the central banks, controlling the “money supply,” which they kept constant and plentiful, and thus resisted inflationary or deflationary spikes.

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the late 1990s a critical mass was achieved and for about a decade the value of most goods in Portsmouth, and many services, was measured in pills.

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Armed robbers in Portsmouth hit dealers’ houses, took the pills, and ignored the cash. Mary Ann once bought a car with OxyContin. She paid an off-duty cable TV worker in pills to install service. She paid a dentist visit with pills. She ransomed Keith from drug-addicted kidnappers with pills. She bought steak and diapers and laundry detergent with pills. Shoes for pills. Purses for pills. Perfume for pills.

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Crucially, pills also bought children’s love. Junkies, whose main relationship was with dope, could briefly emerge from the fog to buy their children the toy, video game, or bracelet they coveted with pills—usually buying it off a shoplifter.

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scrutinized Scioto County doctors, some clinics began requiring occasional urine tests. Probation officers always wanted them. So a black market in clean urine emerged, in which the fluid was exchanged like water in the desert. Addicts bought false bladders they strapped to their stomachs with tubes leading down into their pants. Neighbors of one pain clinic near downtown got used to people knocking on their doors asking if they wanted to sell their urine. Outside the pill mills stood people who charged in pills to pee in a cup, promising clean urine as they chugged water. Veteran clients would crumble oxycodone into the purchased urine, because doctors wanted to see that patients had no drug in their system other than what they prescribed. Kids’ urine was coveted for its

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An addict who said he worked for Lockhart told me Lockhart built virtually his entire house with material purchased with Lowe’s gift cards. All these cards came via merchandise addicts stole from the store: They returned the shoplifted stuff for gift cards; then they brought the cards to Lockhart for pills.

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Shoplifters’ importance to the OxyContin economy grew, in turn, from a new and indispensable rural institution.

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Then Oxy came around, with its large dose of dope, high cost, and much stronger withdrawals. Suddenly dope-sick junkies needed a place where they could quickly come up with two hundred

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“The more money you need to get the pill, the more product’s got to be had,” said Keith Henson, Mary Ann’s husband. “You could go to Walmart and spend a half hour in there and get enough for a pill or two.”

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Of course, users could also con loved ones; they sold dope themselves; they broke into gun shops or robbed drug dealers. Lashed on by the morphine molecule, they did that and a lot more. But for many, the enormous blue retailer drew them like a magnet. Barred from your local Walmart? Another was twenty-five miles away in almost any direction. Some large though immeasurable amount of the merchandise supporting addiction, as the opiates settled on heartland America, was mined from the aisles of Walmart, where Main Streets had gone to die.

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“Walmart has such a big variety,” said Angie Thuma, a former nurse who stole from Walmart for years as a street addict. “I had people I would sell [shoplifted items] to on a daily basis. Everything was in one spot. If you need men’s clothes, it was at Walmart. If you needed shoes, I stole hundreds of pairs of shoes from Walmart. It was everything a person would want in one store.”

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no price listed on say, a Black and Decker circular saw an addict was offering, Keith Henson said, “You’d call Walmart and do a price check. ‘I’m looking for this [Black and Decker] circular saw. How much do them run?’ They’d tell you. ‘It’s sixty-nine ninety-nine.’” Keith would pay roughly half that in pills—usually an oxycodone 30—for that circular saw the addict was offering.

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Of course, prices were subject to a junkie’s desperation. This was pitiless commerce. Mary Ann once offered a junkie an oxycodone 15 for a pair of stolen Nike Jordan basketball shoes because the guy was too dope sick to go find another buyer. She bought a refrigerator from a family with children for three 30s. But generally, if a shoplifter stole a bag of diapers, Tide detergent, DVDs,

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guy’s going to try. But when I’m in withdrawal, I’m tougher.”

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received.) “For a couple months before each Christmas, I couldn’t steal enough,” Thuma said. “Even if I went several times a day, I didn’t have enough arms to get everything they wanted.”

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by and large, it was dealers who fueled the shoplifting trade and prodded the boosters to new ingenuity. As dealers prepared their kids to return to school in August, shoplifters fanned out armed with long

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TVs through a Walmart tire shop, which rarely had much supervision, and had a door with no alarm. Line a purse with aluminum foil and the sensors of any merchandise you put in it wouldn’t activate the alarms as you exited Walmart.

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Another veteran Wal-Mart booster told me he would wear very baggy clothing, with long-john underwear underneath, taped at the ankles. He’d walk through the store stuffing merchandise in his long johns, which would balloon out, though nothing would show under his baggy pants and shirt. “I walked out of there, it looked like I was

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People in Portsmouth opened stores in their apartments, specializing in certain products, most of which they stole from Walmart: garden supplies, tools, automotive equipment. One recovering addict told me he visited the apartment of a woman who stocked everything a baby needed.

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Walmart, for a long time, did not require a receipt for returned goods. Anything stolen could be returned for a gift card for the full value of the merchandise. Dealers bought those cards for half their value in pills. A five-hundred-dollar Walmart card was worth three OxyContin 80s—for which the dealer had paid a few dollars with the Medicaid card scam. A vast trade in Walmart cards kept Portsmouth’s army of pill dealers in household necessities.

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Some remodeled dilapidated houses. Others bought cars or trucks. “When six months ago there were kids going to school with shoes falling off their feet, and now they have new shoes, we feel that’s an accomplishment,” Mary Ann said. “Our parents had all this opportunity. Portsmouth was a booming place then, [with] a bus system and trolley and jobs that lasted. We were raised with a sense of pride for our town. But when we get out into the real world there’s nothing to be proud of. We can’t help our town. So when we found a way to help our town, we did—which in turn backfired on everyone, of course.”

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When some of these kids died, mortified parents told neighbors that their son had a heart attack, or their daughter had died from injuries sustained in a car accident.

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took a full decade before a Portsmouth mother was able to reject pretense and be the first in the state to say publicly that dope killed her son.

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in a restaurant one day. “Otherwise you won’t sleep. “And,” he added, “don’t let the clients die. Care for them. They’re giving you money.” Mario had worked

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truckloads, as he imagined it would, like on those television shows. Rather, it came with couriers carrying a kilo or two at a time. Ant-like, he thought.

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One Albuquerque addict told me this story: He called his Xalisco dealer, whom he considered his friend, to say he was going into rehab. Good idea, the dealer said. This stuff’s killing you. An hour later the dealer was at the addict’s door with free heroin. Now that you’re quitting, the dealer said, here’s a going-away present as a way of saying thanks for your business. The addict kept using.

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woman in Columbus told me her dealer welcomed her home from jail with a care package of several balloons of tar heroin to get her using again.

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