As of March 13, 2016, 23 states and Washington DC allow for medical marijuana. In order to qualify for medical marijuana, one needs to see a doctor a get a recommendation. In California, one can get a recommendation for (but not limited to) the following:

• Alzheimer’s disease
• Amyotrophic lateral sclerosis
• Anorexia
• Arthritis
• Cachexia (Wasting Syndrome)
• Cancer
• Crohn’s disease
• Epilepsy
• Glaucoma
• Hepatitis C
• HIV/AIDS
• Lyme disease
• Migraine
• Multiple Sclerosis (MS)
• Muscle Spasms
• Severe and chronic pain
• Severe nausea
• Seizures
• Spasticity

The problems and medical conditions that are approved for medical marijuana vary from state to state, but one can pick up on the vagueness of some these maladies (how do you prove or disprove migraines, pain or nausea?). Besides the subjectivity of a number of these problems, there is an even more pressing concern: clinical research has not be conducted where marijuana was used to treat these illnesses. The doctors are making these recommendations with little to no research about these issues. One doctor I spoke to recently described the practice of prescribing marijuana as perhaps being a bit medieval but definitely pre-enlightenment.

One of the key defenses for doctors is that they are not prescribing marijuana but rather recommending it. That obviously has been set up this way to limit their liability (key word is limit, not eliminate). Is a recommendation a form of medical care or treatment? If it is not, then why is it called medical marijuana? If it is a form of medical care or treatment, then it becomes much clearer that the doctor has some responsibility here. When a medical marijuana user has an accident or experiences some psychological problems from their marijuana use (depression, anxiety, panic attacks, lack of concentration), a strong trial lawyer may make a case against the doctor (and/or the marijuana dispenser) for liability.

It will happen. The question is where and when.

Earth people is a colloquial term that Alcoholics Anonymous (AA) members sometimes use to describe non-alcoholics. It is neither a compliment nor an insult – just a way of separating the kind of person who would drink despite horrific consequences or take ludicrous risks from a person…who wouldn’t.

For the last 10 semesters, I have co-taught a senior level seminar at the Rutgers School of Communication with Lea Stewart, who is both a much loved professor and the Dean of Livingston Campus (she is also a major ally of the Recovery House). The class is Advanced Health Communications (AHC) and we conduct outreach with 1st and 2nd year students to address problem drinking. The outreach campaign is called RU Sure, and we share statistics to let students know what normal drinking looks like. We put theory into practice. Simply put, we let undergraduates know that:

– 2 out of 3 students drink three drinks or less

– and that 1 out of 5 don’t drink at all

Each semester, I teach students about how I diagnose someone with a substance disorder, how alcohol (and drugs) affect the brain, services available on campus, and I bring in a student who is in recovery to tell his or her story. The final part of the class that I am responsible for is that I send all of them to an open 12-step meeting and have them write about it. In their papers, they have to write a paragraph about what they expect the meeting to be like. After they attend the meeting, they have to tell me where they went, the demographics of the meeting, a gist of what was shared (while keeping it completely anonymous) and then their reactions to the entire experience. The 15 students this spring probably did the best job of any class with this assignment, and one student wrote the greatest 12-step reaction paper that I have ever read.

Some highlights from what these Earth people expected:

1) I could just see everyone staring at the “new girl” coming to get help. The uncertainty of what it was going to be like showing my face for the first time at an AA meeting was causing me extreme stress and anxiety. I did not want to go there and have people think I was an alcoholic, or have someone ask me to tell my story and then I would have to awkwardly answer, “I’m here for a class.” As I continued to wonder and worry, I expected everyone to be quiet or sad.

2) I was very nervous. I didn’t want to be in a room with older, scummier male alcoholics. I didn’t want to sit through a venting session and I didn’t want to have to awkwardly have to say to the group, “Hi, I’m XXXX and I’m not an alcoholic.”

3) I thought it would look like people in a small room, sitting in a circle, telling each other about their feelings. I also assumed it was going to be a lot of white people, based upon what I’ve seen in the media.

4) In class, we had spoken about how prior alcoholics sometimes turn to caffeine or cigarettes to ease their cravings. Therefore, I was expecting to see some people smoking outside of the building. I was also expecting coffee to be provided at the meeting.

5) I figured it would be a group of people sitting in a circle half talking about the struggles or temptations they’ve had to stay sober, and the other half not wanting to say anything. I imagined AA to be therapy or catharsis for those involved, but lacking in positivity.

6) For some reason, I picture gray folding chairs in a circle and people open to anything. Everyone is willing to share and not afraid to cry. I expect to see only a handful of people, but amongst those that are at the meeting there is a leader – someone who organizes and was previously certified to host these meetings.

7) I was amazed at the amount of meetings available to me within a five-mile radius.

8) Going into this meeting I feel especially anxious to see a large population of college students because I think it will make me feel sad and upset that such young kids are dealing with addiction; although I really feel sad thinking about any person of any age having addiction.

And their reactions to their actual AA experience:

1) It made me upset when a member mentioned that he would constantly drive drunk. I was shocked to learn that many members attend daily meetings, regardless of being sober more than five years. Lastly, it was interesting to hear how God and prayer are both a large focus in these meetings. Since I come from a religious family, I enjoyed hearing about God’s presence in the members when they spoke.

2) AA continues to exhibit the patriarchal monotheistic society of its origins. AA is not as open as it would have you believe. The literature may profess a higher power of your understanding, but it continues to address that high power as God and Him.

3) …I’m a complete stranger and she seemed so happy to see a new face here and welcomed me.

4) …after the meeting, almost everyone went outside for a smoke, which kind of threw off the whole vibe I was getting where people come here to fix problems and not just to replace them with something else.

5) The family-feel and the work those involved put in just gave off a really positive vibe. It put a new perspective on alcoholism for me and took away the stereotype I had in mind of what meetings are like.

6) One thing that stood out to me about the speakers was that they were really humble. They did not credit their recovery solely to their own strength and abilities, but made sure to recognize the major role that their loved ones, AA community, sponsors and/or higher power had in their journey.

7) I was really impressed with one guy who had been sober for 20 years. I thought that was amazing because I cannot imagine the amount of dedication that this took for him. Some people’s stories made me tear up a bit and I have a new appreciation for people going through this struggle. The people at these meetings are like one big family. It was very welcoming and I felt so comfortable the entire time.

8) I was surprised to find out what a big role God plays in AA, and at first I was a little taken aback by this factor, but I came to better understand the concept of “God as we understand him,” especially when one of the speakers shared that he does not believe in God. He was able to make the program work for him though. Besides that, I think the biggest impact this meeting left on me was seeing that anyone can be an alcoholic.

9) It was disappointing to see the speaker as the only Latino besides myself.

10) It made me realize that I should learn to practice empathy.

11) It was surprisingly difficult to find the meeting.

12) I realized that although they have a problem I do not have, I am more similar to them than I could ever imagine.

13) I could tell these people really cared for each other and wanted the best for each other.

14) One small thing happened on my way to the meeting. I got lost and met a girl who was also trying to find it. Her name was XXXX, she was an alcoholic and this was her first time coming to this meeting. I helped her find the building and we walked in together. This interaction immediately made me think about all the times I have been new somewhere and hadn’t been so graciously received and welcomed. Overall, and maybe most importantly, after leaving the meeting I can truly stand behind the RU Sure message for the first time and feel authentic doing it. When I came into the class,  I was afraid that I would look like a hypocrite campaigning for safe drinking when I went out and drank, but I realized that I do drink safely and when I drink unsafely I really hate it and end up regretting it. These experiences make me feel ready to be an active part of RU Sure, eager to help people and well-equipped to educate students.

I have long considered that attending Rutgers was the second best decision of my life. Besides getting a world class education, I formed a number of very close friendships and met some extraordinary people. I count Eric Arauz as both a close friend and an extraordinary person. Eric is the President of the Trauma Institute of NJ – it is an organization that trains doctors, psychologists, social workers, nurses, academics and community members about trauma and suicide.

I met Eric in the fall of 1997 when we were both undergraduate students. I was a 21 year soldier in the Army National Guard and he was a 26 year old Navy Veteran from Gulf War I. I studied history and English while he majored in American Studies. We discussed the military, history, literature, recovery, spirituality, movies and sports as we walked around New Brunswick fueled by coffee. We both had dreams of advanced scholarship and helping people on a large scale.

Eric graduated with high honors from Rutgers in 2000. A few years later, he completed a Masters in Labor Relations from Rutgers, where he was once again a top graduate. During the 2000s, I worked at Integrity House, Elizabeth High School, Hunterdon Drug Awareness and Rutgers. Eric came to every place I worked (multiple times) and spoke to my clients/students about his life, the importance of education, why substances are dangerous, and how they could do anything with their lives. For all three years I taught high school English at Elizabeth, Eric came in to the school on or around September 22 and talked to my students. He did so in three different classes per day, which is exhausting – both physically and emotionally. That date is significant to me because it was the anniversary of the overdose death of my friend Frazer Curry. Eric knew him also and how important it was for me that young people learned from Frazer’s experiences.

In the mid-2000s, Eric dedicated himself to becoming an expert speaker and trainer. He worked for NCADD-NJ and National Alliance on Mental Illness (NAMI), served on a national project for Substance Abuse and Mental Health Services Administration (SAMHSA), and won a Voice Award in 2009. For the last six years, he has been a faculty member at the Rutgers Medical School in the Psychiatry Division. He was appointed to the NJ Governor’s Council on Alcoholism and Drug Abuse in 2011 and immediately fought for me to be brought on as well. Eric was instrumental in helping create and run the NJ Heroin and Opiate Task Force. Our report was released in 2014. One of the handful of recommendations that has been successfully implemented was the NJ Warmline – Eric suggested it, wrote that part of the report, and then met and fought for it behind closed doors.

Eric’s story, An American’s Resurrection, was published in the fall of 2012. It is his story of surviving childhood abuse at the hand’s of his schizophrenic father, substance abuse, mental illness and institutionalization. I have read many books written by people with mental illnesses, and I think that this is the best one about bi-polar disorder and what it is like to be in an inpatient VA hospital. It has won numerous awards and is highly regarded within the medical and professional communities. I have assigned it to all of my senior social work students at Rutgers over the last four years. Eric has generously come to each class, hit upon aspects of his story, inspired students, and signed their books. He always gives them his email address and pledges to help them in whatever way he can. This is hard to fathom, but he does it. And he follows through. Eric finishes things. It’s so impressive.

Eric has helped me in my work with soldiers, veterans and law enforcement officers. These are professions that have high rates of alcohol abuse, divorce and PTSD. There is a huge stigma in seeking help and talking about problems in those fields. Eric understands cumulative stress and secondary trauma far better than anyone that I have ever come across. Much of the work I’ve done in those areas has been made possible with the training and advice that Eric has provided me.

Eric has keynoted the American Psych Nurses (APNA) National Conference and won their Champion of Psychiatric Nursing Award in 2012 with First Lady Rosalyn Carter.  He was a faculty member with APNA on their five year Recovery to Practice grant with SAMHSA (the largest grant in SAMHSA’s history). He also co-authored APNA’s first set of national suicide competencies for inpatient nurses.

Eric recently signed a deal with the NJ Division of Children and Family (DCF). He was the sole creator and head trainer for their Trauma program called Taming Trauma. He will train all 6000 workers. He will help them deal with the stressful conditions of their jobs – seeing kids malnourished, beaten and even sexually abused. Like soldiers and cops, child welfare workers have high rates of burnout and it shows in their divorce rates, mental health problems and substance abuse. Some of the fields that people work in are potentially very damaging – Eric is helping those that help others. He deserves every recognition and award that has come (and will come) his way. On behalf of both NJ and America, thank you Eric.

On Friday March 4, 2016, I visited NJ’s first and only recovery high school. It is called the Ray Lesniak Recovery High School (they have a Facebook page too). I wrote an article about the history of the recovery high school movement in NJ back in August of 2014, and was thrilled when they had their official opening that November.

I was invited by Morgan Thompson, a MSW student at Rutgers who is also a member of Young People in Recovery (YPR) and a NCADD-NJ trained advocate. She works there as a recovery mentor – she is with the students for much of the day and helps organize the speakers who come in each Friday afternoon.

The school is located on the Kean College campus and they have their own building on the west end. There is a library, computer room, a number of smaller offices and a huge classroom where the students take their online classes. It is decorated nicely and has the feel of a small school where everyone knows and cares about each other.

I spoke with the students for about an hour. They told me where they were from, how they get to school each day, and how some of them didn’t want to be there at first (but now they all love it). They spoke glowingly of Morgan and the other staff members and all plan on going to college (I pushed Rutgers hard). The kids were so sweet, grateful and bursting with energy and hope.

If you are a professional in the field of prevention, treatment or recovery support services, I urge you to visit. Ditto if you are an advocate. Every student assistant counselor (SAC) and guidance counselor in the state needs to be aware of it – if you are a parent or educator, make sure your local school is aware of the Ray Lesniak Recovery High School in Union County. Students in recovery from anywhere in the state of NJ can go to the school, and they will receive a strong education and have a far better chance at staying sober than if they stayed in their current high school (I so wanted to write the word drug-infested, but I thought the better of it).

We need to get the word out. Governor Christie has not only failed in visiting (or even talking about) the recovery high school, but last summer he rejected a bill that would allow the creation of other recovery high schools in NJ. We must succeed where the Governor has not even dared to try – get the word out. Please help. This amazing school should be bursting with students.

I’ve written about the difference between criminalization, decriminalization, medicalization and legalization a number of times over the last few years.Gallup released a poll last year that stated that 58% of Americans now support marijuana legalization. If you favor legalization, here are a few questions to consider:

Do you think that marijuana should be advertised on television?

Do you think that marijuana should be advertised on billboards?

Do you think that marijuana should be advertised in magazines or comics?

Are you ok with a cartoon character selling marijuana?

Should marijuana gummy bears be sold at your local Quick Check, Wawa or 7-11?

Should bus drivers, taxi drivers and uber drivers be allowed to smoke marijuana? If not on the job, how long before they drive should they be allowed to smoke?

Should companies that grow, process, sell or advertise marijuana be exempt from lawsuits from people who use, misuse or abuse marijuana?

These are all outcomes that are not only possibly, but probable in a United States that legalizes marijuana. Before you decide to be pro-legalization, think these questions through. If you want to learn more about legalization and marijuana policy, they should check out Smart Approaches to Marijuana and any article that features Kevin Sabet.

In this final section of my interview with Sam Quinones, we discuss how doctors should receive more addiction training and the importance of continuing medical education units (CMEs). The discussion moves back to the concept of social isolation and how it has increased in lockstep with opiate abuse.

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Frank Greenagel: So, I have a question on doctors. I appreciate your mentioning earlier when we talked about Big Pharma that there’s not one Boogeyman. The medical community has some responsibilities here too. You spent a good amount of time on David Procter and the pill mills. Again, I’m not saying all doctors, or even most, but the medical establishment has a role here which you detail in Dreamland. One of the things I’m pushing for is at least 40 hours of addiction and treatment and recovery education with PAs and doctors and nurses and pharmacists. I’m also pushing for at least one day of continuing medical education for every two-year relicensing period. Right now, 49 of the 50 states have prescription monitoring programs. About 10 of them are mandated. I really want to see a universal PMP around the country that’s mandated that everyone has to access to and harsher penalties for doctors who overprescribe. That’s an omnibus medical package. Any comment on any of those policies, stuff that would work, not work? What your thoughts are about doctors and what we can do?

Sam Quinones: There’s no doubt that doctors across the country, far too many of them, lost their common sense when it comes to this stuff, that these drugs are somehow nonaddictive and that you knew this to be true for everybody is crazy. It just makes me want to go what Kool Aid were you drinking? That’s a crazy idea given the 3,000 year history we have with opiates. One thing that struck me is the story about isolation. The theme of this scourge is isolation. We’re talking about the destruction of communities, we’re talking about drugs that create isolation among people. Addicts find isolation preferable, not just okay, but preferable when they’re using their dope. That kind of thing. This is also true in the medical community. Do you know that there is no place that I’m aware of that brings together the three aspects of medicine that need to come together and talk about this all the time? That is addiction studies, pain management studies, and general practitioner medicine. There ought to be a journal, “Pain, Addiction, and General Practitioners,” or something like that. The Journal of Pain, Addiction, and General Practitioners. These folks don’t know each other. They don’t get together. They don’t meet in conferences. They don’t know each other socially. If those folks begin to come together and hear each other and be at the same conferences and go out for a beer later, I believe we would be able to, through the synergy of those voices and those great minds, come up with a whole bunch of solutions that are not presenting themselves right now because medicine is so siloed, in such isolation.

All of that stuff that you mentioned, I’m amazed that it doesn’t exist already. It’s like we need far more addiction preparation on the part of doctors. We need far more attention to pain and treatment on the part of general practitioner. We need addiction studies understanding that the problem that general practitioners face, which is that, yes, they do have a whole lot of people coming in great pain, so what are you going to do? You can’t just ban drugs. That’s not going to work. A lot of this, though, just seems to me, when I learned that it didn’t exist I was stunned. You’re talking about in medical school like, what, 4 hours of training in your entire medical school career?

Frank Greenagel: I know, that is stunning, especially when you think of that for a lot of general practitioners, the number one source of income as is pain management and the number one source of liability is pain management, and yet they’re getting so little education and little to no requirement for continuing medical education.

Sam Quinones: Exactly. Also, this is something they’re going to see daily. Who doesn’t go to the doctor without pain? That’s why you go to a doctor most of the time. All of that, I think, is extraordinarily important. I really do believe in the synergistic effect of bringing together the specialists and people from these different disciplines with medicine.

Frank Greenagel: I just want to be clear. I’ve got something I’m going to spend some time thinking about and see what I can do here in New Jersey too, at least get some nascent movement for general practitioners, pain specialists, and addiction providers. I think you’re absolutely right and it’s not something I’ve considered before, but obviously it makes perfect sense. I think that’s such a market inefficiency, that just getting them together is going to have some benefit and then maybe even something greater comes out of that. I think that’s a wonderful recommendation.

Sam Quinones: At least it needs to be tried. Who knows what will come of it? My feeling is that once people get together and actually do hear each other and go out for a beer, and then maybe go out and watch a ballgame or something, and get to know one another in ways that they simply do not right now, that that community created by that will also help create new approaches, solutions that hadn’t been thought of, whatever. Again, this is all about isolation versus community. That’s how I got into it, that we have a century of isolating ourselves and applauded ourselves for doing it. The effect or the end result has been widespread heroin abuse. It doesn’t surprise me now. It doesn’t surprise me because we have spent so much effort isolating ourselves, and making sure that we don’t know each other, and making sure that we don’t get together, and making sure that we don’t have the forums, and parks, and the places where we can meet and get to know one another publicly, being out in the public sphere. We have demeaned the public sphere so intensely in so many ways making sure that everyone is terrified of the child molester lurking around every tree that now everybody is so isolated that when it does happen, we can’t do anything about it. I think had we been more connected, or operating more as a community, that this plague would not nearly have spread so badly. It spread largely because people are alone. They’re alone in addiction; the family is alone thinking that no one else in the whole neighborhood has this problem, when actually probably 1 out of every 5 families might even have it. They’re alone and they don’t know who to go to. They make horrible mistakes and the kid ends up dying, easily avoidable mistakes because they don’t know who to talk to, they don’t know who to ask for help, they don’t know where to go. It’s all of this, this theme of this, is about America today and the isolation that we have created for ourselves and heroin is simply the expression of all those values in one substance.

Frank Greenagel: Do you remember the book that came out in 1995 by Robert Putnam called Bowling Alone? He talked about the decline of the American communities. Our talk is hitting upon it a lot … Because he says in the ’50s, and not that I want to make the ’50s this bucolic time because obviously there was horrific segregation and other problems and we were reaping the economic benefits of winning World War II, but the reason he titled it Bowling Alone was because there were these bowling leagues and people were members of communities, and churches, and groups like that. He talked in the ’90s about the increasing self-isolation of Americans, and this is even before the internet and online video games and social media. Again, it’s a theme that you seem to be picking up on very adroitly here.

Sam Quinones: That was ’95. Twenty years later, people aren’t bowling alone; they’re shooting up alone. It’s a direct result, though. The lineage goes back to this idea that making money is top to happiness when really happiness accrues when you do something else that you love. Happiness comes from it. What they’re talking about is we’re seeking pleasure. Pleasure is not happiness. Pleasure does not lead to happiness and we as a country, I believe, sought pleasure over fulfillment way, way, way too much. Heroin is just the final embodiment of that.

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Sam Quinones’s Dreamland was published by Bloomsbury in 2015. It provides a complete history of the opiate epidemic and examines the roles of the medical industry, Big Pharma, drug traffickers, law enforcement, drug users, their families, and the government. In December, Bloomsbury gave me permission to reprint a chapter from his book on the History of Heroin. A central theme of Dreamland is the collapse of American towns and the sense of community. Mr. Quinones was born in Claremont, CA and earned his BA in economics and American history from Berkeley. He wrote for the LA Times from 2004 to 2014. Dreamland is his third book. I interviewed him over the phone on December 14, 2015.

In the first article, we discussed the role of the pharmaceutical industry in the current American opiate epidemic. In volume two, we talked about race and how drug policies in the 1980’s with crack are very different than the 21st century policies surrounding opiates. In the third edition, we discussed how Mexican immigrants became some of the key sellers of black tar heroin, does supply or demand lead to bigger drug problems, and we briefly touched upon the rhetoric of Donald Trump. The fourth volume focused on the Affordable Care Act, politicians and how regular Americans can influence public policy. Part five addresses how the collapse of communities and social isolation has contributed to the surge in prescription drug and heroin use. In the sixth edition, Mr. Quinones talked about how towns that have large recovery populations are rebounding from the heroin plague.

This is the sixth article that came out of my interview with Sam Quinones. In this edition, Mr. Quinones talks about how towns that have large recovery populations are rebounding from the heroin plague.

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Frank Greenagel: There’s a number of themes that you’ve hit upon here that you also obviously talked about in your book that are reminiscent of a book I read earlier this year by George Packer, the writer for  The New Yorker. He wrote a book called The Unwinding and it’s about the decline of the middle class and the loss of factory jobs and the ruination of communities. In your travels, have you seen any strong American community that’s resisted this or any small town or village that seems to be a tight community and as a result they’re doing okay? The reason I ask that is I was just over I Asia and I spent some time in some poor Thai villages where people didn’t have much, but there were a bunch of healthy kids. They didn’t have a drug problem. My translator looked at me and said, “Well, they live in a village. They know everybody else and they’re totally connected.” This was told to me just as I was reading your book. Now, you’ve also been talking to me about the decline of communities. Is there any place in America that’s doing a good job with the sense of a village or a community?

Sam Quinones: In the very town of Portsmouth you’re seeing some very interesting things going on. Now, it doesn’t look it. If you go to Portsmouth, you will see a town with a lot of abandoned building and a lot of fast food places. You would not think it, but if you get to know the town, it definitely seems to be putting in place a certain kind of … I think it’s a town that is rebounding. That it’s a town that for a long time many have given up or could have easily given up and did not. I think it’s a town that shows how important supply is in all this. Once they got those pill mills, remember those Ohio State legislature passed the law that got rid of those pill mills and those pill mills all shut down? All of a sudden now you have a recovery community in that town that’s enormous. Talk about 10% of the population, roughly. Those are estimates, but 10% of the population is in recovery from opiate addiction. The one thing that’s interesting, when you get a large percentage of people who are in recovery, it’s very much like getting a big influx of Mexican laborers. Mexican immigrants bring energy, optimism, a desire to break through any wall to get ahead, to move on with their lives, to reinvent themselves, and a huge dose of gratitude for a second chance. It turns out, in Portsmouth I think what you’re seeing is that recovering addicts provide the same kind of energy and excitement and gratitude. That’s a very, very healthy thing for a town that has been losing people for decades now and where fatalism had kind of overtaken the town and heroin and those damn pills were just part of that fatalism. I think people need to spend a little bit more time understanding what’s going on in Portsmouth because obviously it’s been dealing with this probably longer than most everybody. For me, I find there was a new attitude. Once you get rid of the supply, the attitude changes. People started getting into recovery and the attitude changes. People say yes we can instead of what’s the point, which is what they were saying for so many years. That’s a very, very potent thing. A mental change, a psychological change like that, is a very, very potent thing, particularly in an area where people have always said what’s the point for 35 years.

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Sam Quinones’s Dreamland was published by Bloomsbury in 2015. It provides a complete history of the opiate epidemic and examines the roles of the medical industry, Big Pharma, drug traffickers, law enforcement, drug users, their families, and the government. In December, Bloomsbury gave me permission to reprint a chapter from his book on the History of Heroin. A central theme of Dreamland is the collapse of American towns and the sense of community. Mr. Quinones was born in Claremont, CA and earned his BA in economics and American history from Berkeley. He wrote for the LA Times from 2004 to 2014. Dreamland is his third book. I interviewed him over the phone on December 14, 2015.

In the first article, we discussed the role of the pharmaceutical industry in the current American opiate epidemic. In volume two, we talked about race and how drug policies in the 1980’s with crack are very different than the 21st century policies surrounding opiates. In the third edition, we discussed how Mexican immigrants became some of the key sellers of black tar heroin, does supply or demand lead to bigger drug problems, and we briefly touched upon the rhetoric of Donald Trump. The fourth volume focused on the Affordable Care Act, politicians and how regular Americans can influence public policy. Part five addresses how the collapse of communities and social isolation has contributed to the surge in prescription drug and heroin use.

Sam Quinones’s Dreamland was published by Bloomsbury in 2015. It provides a complete history of the opiate epidemic and examines the roles of the medical industry, Big Pharma, drug traffickers, law enforcement, drug users, their families, and the government. Last month, Bloomsbury gave me permission to reprint a chapter from his book on the History of Heroin. A central theme of Dreamland is the collapse of American towns and the sense of community. Mr. Quinones was born in Claremont, CA and earned his BA in economics and American history from Berkeley. He wrote for the LA Times from 2004 to 2014. Dreamland is his third book. I interviewed him over the phone on December 14, 2015.

This is the fourth of eight articles from that interview. In the first article, we discussed the role of the pharmaceutical industry in the current American opiate epidemic. In volume two, we talked about race and how drug policies in the 1980’s with crack are very different than the 21st century policies surrounding opiates. In the third edition, we discussed how Mexican immigrants became some of the key sellers of black tar heroin, does supply or demand lead to bigger drug problems, and we briefly touched upon the rhetoric of Donald Trump. The fourth volume focused on the Affordable Care Act, politicians and how regular Americans can influence public policy.

Part five addresses how the collapse of communities and social isolation has contributed to the surge in prescription drug and heroin use.

___________________________________________________________________________

Frank Greenagel: Your book takes the title from the town of Portsmouth, Ohio and the Dreamland Pool. You spent some time writing about the decline of working class towns how they’re hit hard with pain management clinics and pill mills. Later, they transition to heroin because it’s very cheap. The town loses job, the landscape is filled with broken dreams, empty pools and they use heroin to drown their sorrows. You also wrote about a bunch of more well-off towns, like Charlotte and Nashville, and how they’ve also been hit. It’s not a wonderful question, but I’m going to ask it anyway. What type of town seems to be more hit by the opiate epidemic? Is it the rich towns or is it the poor towns?

Sam Quinones: Basically, I think it happens first in Appalachia. It happens in Appalachia and it’s allowed to spread from there because we, as a country, are used to not paying attention to Appalachia. It’s a bunch of poor white people whose dysfunctionality has been notorious for generations. No one paid any attention. We might not be having this conversation had there been real different prescribing guidelines put in place in 2001, say, or 2003 maybe. Nobody paid any attention to that place and so then it reached out to the wealthy areas.

Which is more heavily impacted? I would say probably Appalachia because it could least afford it. It’s interesting. This is something I’ve thought about a lot. They say that addiction doesn’t discriminate, cuts across all races, etc, etc. Yeah, that’s not true here. It’s all white people. It’s entirely white people. I defy you to find like 10% of the population of new addicts who is actually non-white. I have not seen it. I’ve never found it. Every drug counselor I’ve ever talked to about this. There are some lingering addicts from the 70s who are black or Latino, but by and large, the new wave is almost … I’ll say it’s 90% white. I think it’s probably more like 98% white honestly. What it doesn’t discriminate along is economic lines. It’s all levels of the economy with just white people. What’s fascinating to me, though, as part of this, is that when you talk about some of the economically better cities, like Charlotte, like Nashville, Minneapolis, Indianapolis, Reno, Salt Lake City, etc., you’re talking about a population of kids whose families have done extraordinarily well in the last 20-25 years. You would think, judging from their neighborhoods, that they really don’t have many problems. Why is it the class that’s done best in the last 25 years and probably lives better than anybody in the history of the world, almost literally the history of the world, why is it that they are turning and getting addicted to drugs used to numb pain?

Frank Greenagel: That leads into the next question. I listened to a podcast of yours with the people from Ohio State, and you talked about social isolation and I want to pinpoint that a little bit more. Then I also want to break it down into maybe a workable policy recommendation even though I know your thing is stories. I’m a policy guy, so I’m always trying to think about what I can do to address this. I have a friend that’s an Australian lawyer. After the Sandy Hook Elementary School shooting, he talked about the American Soul Sickness because we have all these gun deaths that no other industrialized nation has. Very recently, a UN report said that basically the heroin problem is far worse in America than anywhere else and there’s far more overdose deaths here than there are in other countries. So, we have all this gun violence and then we have the world’s leading opiate epidemic. The overdose numbers overtook car crashes in America in 2011, but the latest figures from 2014 state it’s 47,000 people die from overdoses versus 36,000 from car crashes, so it’s running away with the number one cause of accidental death now and just getting worse. I’ve been haunted by my friend’s words for the last three years, the American Soul Sickness. Do you think there’s something to that?

Sam Quinones: I would say this. I believe that we have spent decades now, at least 35 years and maybe some more, shredding communities in our country. I believe the antidote to heroin is not naloxone. It is community. We have done a marvelous job of demeaning despising government and all that can it can do to create community and public infrastructure. We don’t want to pay our taxes because, oh, look it’s so inefficient, and oh it’s a bunch of people who don’t work more than a few hours a day. It’s all I think nonsense, but it feels good to say that and that’s a terrific rationalization for not properly funding all kinds of infrastructure. As I talk to you now, I’m driving on roads that are … They look like Mexican roads honest to God. I’m in California. We have done a magnificent job at destroying community, of demeaning, of despising government as a way of very superficially not paying taxes that we should be paying. At the same time, very conveniently, we have exalted the private sector. We have applauded these kings of finance whose job it is apparently to devise new gimmicks and new rationales for sending all our jobs to Mexico, Malaysia, China, and wherever else. We have sat around, and this is again a perfect example, this opiate epidemic is the perfect example of that. We have seen one family, the Sackler family, become one of the wealthiest in America because they made Oxycontin. The profits from this scourge have all accrued to a few companies and the costs again have gone to the public sector.

We have destroyed certain things, like Dreamland Pool is a stand-in for a lot of things that we have allowed to die or we have actively destroyed that create community. These could be factories. These could be not properly funding parks, a variety of things. We now have a situation in which we have suburbia that is horrible isolated, yet we call these towns prosperous. We have people terrified of the public sphere. Parents won’t let their kids outdoors. They hover over them. The outdoors is this horrible threat to them. We look at people who let their kids go outside without hovering them as somehow deviant. These parents must be awful parents for letting their kids play outside when all the while, this scourge has taken place. If you talk to addicts about, it so often takes place in private bedrooms where the kids are all alone isolated from everybody else. It’s the perfect place to hide your dope. It’s the perfect place to use your dope. It’s a private bedroom. This has been our creation over the last 35 years and we are a country that has suffered mightily from it.

The embodiment, the extreme … What’s the term I want to use here, expression of all these values, is heroin. Heroin is one drug … We’ve spent years exalting the consumer, believing that consumption was the way to happiness, but pleasure seeking was the way to happiness. Heroin embodies all of that. It is a drug that turns every addict into a solitary, narcissistic, self-absorbed, hyper consumer. It is the poster drug for our generation without a doubt. That is what I believe to be the case. Does America have a soul sickness? I’m not sure I’m qualified to say, but I do believe, yes, that we have isolated ourselves so mightily from each other, from ourselves, even within families. People are isolated horribly to the point where parents don’t have a clue what their kids are up to in those private bedrooms. That lack of connection, that lack of contact, that fettering of community that I relate in the destruction of pools called Dreamland, is all across this country. Therefore, why do we wonder that heroin is everywhere? Why should we be surprised that heroin is all over the country? When I started this book, I thought it was a book about drugs and drug trafficking, that kind of a crime book, that kind of thing. I realized midway through it that, no. This is a book about who we are as a people right now and what we’ve created in the pursuit of exalting the private sphere, the private sector, what we have created along the way to that. It’s a scary thing. Heroin is really the poster drug of our time.

When the NJ Heroin and Opiate Task Force held hearings around the state in 2012, we heard testimony from medical professionals, treatment providers, law enforcement, politicians, bureaucrats, representatives of 12-step organizations, people in recovery, the parents of dead kids, policy experts, and advocacy groups. Everyone told a story, some provided data, and most offered up a few suggestions. There was a representative from Partnership for a Drug Free NJ that testified. He told us we were doing a good job and, as far as I remember, did not offer up any specific suggestions (though I’m pretty sure he said he’d like to help us).

Last week, I testified before the NJ State Senate Health Committee about the opiate epidemic (I talked about a number of failed bills I liked, made a bunch of suggestions, and levied criticism at a number of industries, politicians and programs). Partnership for Drug Free NJ sent the same representative again, and he told the Senate they were doing a good job and offered no suggestions. Everyone else that testified that day had something substantive to say, regardless of whether I agreed with it or not. The testimony was empty. It irritated me. After careful thought, I realized that they show up to events just to put in an appearance, but they clearly do not like to stake out positions. This is almost certainly because they do not want to upset their donors.

The Partnership for a Drug Free America was founded in 1985 in New York City. It is a private non-profit that enjoys 501c status. They created well known ads such as This Is Your Brain On Drugs and I Learned It From Watching You. None of their ads addressed alcohol or tobacco use. This was probably because some of the major donors during the first 12 years of their existence were Phillip Morris, Anheuser-Busch and RJ Reynolds. After the donations from the tobacco and alcohol industries became public, PDFA stopped taking their money in 1997.

PDFA never criticized the Just Say No campaign. It never expressed a concern about the draconian sentences and mass incarceration of petty drug users. It would not mention the dangers of prescription drugs until the 2000s, and it was careful to never criticize the pharmaceutical industry. This is clearly because three of the top seven donors in 2013 were Jazz Pharmaceuticals, Mallinckrodt Pharmaceuticals and Purdue Pharma. Mallinckrodt makes Exalgo (hydromorphone) and generic forms of Hydrocodone, Oxycodone and Dextroamphetamine (DXM). Purdue Pharma released Oxycontin in 1996 and is the company that most aggressively oversold the benefits of prescription opioids and understated the negative side effects. Purdue Pharma also produces other drugs made from fentanyl, codeine, and hydrocodone. To see a complete list of the PDFA’s 2013 donors, click here.

In 2014, those three pharmaceuticals were again among the top nine donors. Joining them was the Pharmaceutical Research and Manufactures of America, a trade organization that represents the pharmaceutical industry. To see a complete list of the 2014 donors, click here.

Near the end of 2013, PDFA issued a news release about the increase of Adderall abuse by high school students. The only stance that PDFA took was that this was a concern. It did not address the aggressive marketing of Adderall, the misdiagnosing of ADHD, nor the overprescribing of many of the ADHD medications (like Ritalin, Vyvanse, Concerta). Their position on those topics is that they had no position. To be clear, there was no criticism of the pharmaceutical industry or doctors.

Earlier that fall, Mike Males wrote a stinging critique of PDFA. He discussed how PDFA had started to label prescription drug abuse as “the nation’s worst crisis” but only focused on teens. In 2013, Mr. Males wrote that “the middle aged epidemic” was far worse (in November of 2015, the New York Times reported that middle aged whites were dying at huge and ever-increasing rates due to prescription drug overdoses). In 2014, PDFA changed their name to Partnership for a Drug Free Kids (PDFK) and said they would focus exclusively on people under the age of 18 and their parents.

In September of 2015, the Food and Drug Administration (FDA) announced that it had approved Oxycodone for use by teens between the ages of 11 and 16. I was outraged and wrote an article comparing this to how Paxil was once considered safe for teens, until it was discovered it wasn’t 14 years later. PDFK posted an article on their site about the approval of Oxycodone. It included statements from the FDA about why this was necessary. This appeared to be a perfect opportunity for PFDK to protect its primary group by admonishing the FDA and Purdue Pharma. The only criticism offered was by Senator Joe Manchin (D-WV), who said, “This recent decision by the FDA to prescribe OxyContin to children as young as 11 years old is a horrifying example of the disconnect between the FDA approval process and the realities the deadly epidemic of prescription drug abuse are having on our communities.”

Another top donor to PDFK over the years has been the FDA. That might explain why they have apparently never criticized the FDA.

On their website, PDFK states that they support Prescription Drug Monitoring Programs (PMP or PDMP). Their position is that they should be in all 50 states (only Missouri does not have one) and that they should be interconnected (I completely agree). This is not noteworthy, as almost every politician and policy expert supports  PMPs. The only controversy is whether they should be mandated or not (I am very much in favor of mandating them). PDFK does not have a published stance on whether or not PMPs should be mandated. Their site also states that they support Good Samaritan Laws, the use of Naloxone and Medication Assisted Therapies. If they have actively contributed through messaging or funding to the passage of those laws and programs in any state, I have not been able to find it.

In the 1980s and 1990s, the PFDA released a number of strong anti-marijuana ads. An infamous ad in 1987 said that marijuana “flattens brain waves.” The Schaffer Library of Drug Policy wrote a powerful rebuke of the ad:

In the commercial, a normal human brain wave was compared to what was supposedly the (much flatter) brain wave of a 14-year-old high on marijuana. It was actually the brain wave of a coma patient. PDFA lied about the data, and had to pull the commercial off of the air when researchers complained to the television networks.

A number of experts have argued that the exaggerated claims about the dangers of marijuana created a mistrust of anti-drug messaging (much like the movie Reefer Madness did in 1937). PDFA’s 1987 ad was not only contained manufactured data, but it may have made it harder for prevention messages to be effective. This is the opposite of what their supposed mission is. In 2016, PDFK has a very different message about marijuana. On the FAQ section on their site, they provide their stance on marijuana legalization:

As the country debates new policies on marijuana – medicalization, decriminalization and legalization – none address our sole concern: the health and well-being of young people. We recognize that the status quo is changing. We do not believe that any drug use, including alcohol, should be treated as primarily a law enforcement issue, but rather a health issue. Further, we acknowledge the discriminatory way in which marijuana prohibition has been implemented in the United States. The Partnership for Drug-Free Kids supports what is in the best interest of families and their kids’ health, and the use of marijuana or any substance in adolescence is an unhealthy behavior for kids.

Their only clear opinion is that they don’t want kids smoking marijuana. That is uncontroversial. They make no statements about legalization, decriminalization, or criminalization. They do write that more research should be done to see if there are any benefits to medical marijuana. In short, all their statements are bland and add nothing to our national conversation on drug prevention, treatment or policy. The Partnership for Drug Free Kids spends almost $100 million* a year and they have almost** nothing substantive to show for it. It’s time for them to go away.

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*In 2013, the PDFA reported expenses of $85.7 million. In 2014, the PDFK reported expenses of $96.7 million. To read about their financials, click here. This is their 2013 tax return and 2014 tax return.

** PDFK helped spread messaging about securing medicine cabinets in the 2000s.

4/5/2016: An earlier version of this piece claimed the executive that testified at the 2012 and 2016 hearings was from PFDA rather than Partnership for Drug Free NJ. I have corrected that. It was that testimony that caused me to look closely at PFDA (now PFDK). I also have written up a follow-up piece after speaking with the President of PFDK and a volunteer. It can be read here.

Sam Quinones’s Dreamland was published by Bloomsbury in 2015. It provides a complete history of the opiate epidemic and examines the roles of the medical industry, Big Pharma, drug traffickers, law enforcement, drug users, their families, and the government. Last month, Bloomsbury gave me permission to reprint a chapter from his book on the History of Heroin. A central theme of Dreamland is the collapse of American towns and the sense of community. Mr. Quinones was born in Claremont, CA and earned his BA in economics and American history from Berkeley. He wrote for the LA Times from 2004 to 2014. Dreamland is his third book. I interviewed him over the phone on December 14, 2015.

This is the fourth of eight articles from that interview. In the first article, we discussed the role of the pharmaceutical industry in the current American opiate epidemic. In volume two, we talked about race and how drug policies in the 1980’s with crack are very different than the 21st century policies surrounding opiates. In the third edition, we discussed how Mexican immigrants became some of the key sellers of black tar heroin, does supply or demand lead to bigger drug problems, and we briefly touched upon the rhetoric of Donald Trump.

This fourth volume focuses on the Affordable Care Act, politicians and how regular Americans can influence public policy. With the New Hampshire primary on Tuesday, this is the time to publish that exchange.

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Frank Greenagel: You mentioned that the legislature in Ohio passed laws that got rid of the pill mills. Is there anything else that the state of Ohio did that you think was helpful toward bringing Portsmouth back a little bit?

Sam Quinones: Oh, most definitely. Yeah. John Kasich, now running for president, definitely deserves a huge tip of the hat for going around a Republican legislature and making Medicaid available to all Ohioans. The reason he did that was because he knew that people who were suffering with addiction, that their families most likely were tapped out. They didn’t have the ability to pay for this and the only way they were going to get people into treatment was through Medicaid. He risked a lot politically…

Frank Greenagel: …by taking the Affordable Care Act expansion of Medicaid.

Sam Quinones: Over the objection of the Republican legislature. That is amazing, so a tip of the hat to John Kasich because that guy understood what he needed to do and he didn’t play politics, and he didn’t obey the political dictates of the people in his party, many of whom did block it in other states. It’s huge! That is so big, I mean so big, that so many people now who before could not afford it, either because they were too poor initially or because addiction had tapped out all their funds, can now get treatment. I think it’s a big … Here’s another thing I think that’s coming out of this. I believe that there will be far less support than a lot of Republicans believe for doing away with Obamacare because Obamacare allows states to fund addiction treatment, rehab treatment, and that was something that was denied to a lot of people. There’s a lot of people out there for whom this issue is enormous and a lot of people who are quite conservative for whom this issue is enormous. I’m not sure that, maybe in the next Congress, that the Republicans will find as much support as they think is out there for doing away with that because that’s a huge part now of the approach in many parts of the country.

Frank Greenagel: Yeah, you see that in Kentucky. The Medicaid expansion was hugely popular and so the idea that Mitch McConnell and some of the other Republicans there have talked about doing away with Obamacare but maybe they can keep the Medicaid. But really, the Medicaid expansion was a crucial aspect of the Affordable Care Act.

Sam Quinones: Exactly right. You talk about terminology that … We’ll call it this, we won’t call it Obamacare, but we’ll keep all the major provisions of it. I don’t know, but it’s dawning on me when I get to some of these areas that people are not going to go along with that. I’d be very surprised in some areas. Now, some areas maybe the problem isn’t as bad and so these folks may not have the political voice they might have in other areas, but my feeling is, yes. States like Kentucky. And certainly Ohio, John Kasich is roundly applauded by people in very conservative parts of that state because of what he did.

Frank Greenagel: I’ve been very critical of my own state governor, Governor Christie. He got a lot of press a month ago by giving an impassioned speech about his mother’s tobacco use and his law school buddy’s drug problem. Conservatives liked it and Democrats liked it and he was praised on MSNBC. I’ve heard the speech before, but when push comes to shove, he doesn’t fund anything. He still criminalizes marijuana; I’m for the decriminalization of it. He criminalizes marijuana, he hasn’t funded treatment bills, he resisted naloxone expansion, he resisted the Good Samaritan law. There’s point after point after point, so his rhetoric soars high above his actual policies. What happened after his speech is that politicians on both sides of the aisle have been tripping over themselves in announcing that they have a friend who is an addict. Or my family member is an alcoholic. I’d like you to speak to that. I know you like what Governor Kasich did in Ohio. Is there anyone else or anyone that has any kind of policies that said anything that seems to get it or is it all just a kind of campaign bravado, like I’ve seen from Governor Christie?

Sam Quinones: Regardless of what follow-throughs he did or did not do, the mere fact that people are beginning to talk about it is really important and remarkable. I don’t know his record in New Jersey in funding programs are and passing laws. I did think it was interesting to listen to him to say that because those words spoken 15 years before would have disqualified him from the Republican nomination. His campaign would have halted right then. Now, you can see these Republicans now are, again, as you say, tripping over themselves trying to tell the most gripping story of addiction in their family, which I think is a huge step forward. I really do. I think it’s very important. I don’t know that I see anyone who has understood the issue well enough. Nor do I even think Barack Obama does. I watched him at the Charleston, West Virginia town hall meeting that he held and it seemed to me that it was an issue that was far off for him. He did not feel comfortable with it, didn’t know how to pronounce Naloxone and this kind of thing. That’s understandable. He’s got ISIS. He’s got a million other things that are important, but it seems to me that it’s still in the phase where people are approaching this, or not entirely comfortable with this topic yet.

I’m not sure how you get there exactly, but I would hope that at a certain point people would come to the idea that they need to understand this in a deeper way, but that’s just where we are as a country. We do not understand this. I really didn’t understand it too well. I still have a lot to learn, I would say. I’m not proposing myself an expert on this. I’m not an addict myself, so I don’t have a deep reservoir of experience on all this. I look around the political stage and I don’t see a lot of folks, honestly, who figured this out.

Not long after the book came out, Hillary Clinton’s health policy campaign adviser called me and wanted to ask about what do we do about this. I gave her a bunch of policy prescriptions that I thought might have been helpful. I’m not a policy expert. I’m not the guy to set policy for a major presidential candidate, but I did feel like talking about it, getting it out there, making it part of the national discussion is necessary.

Here’s what needs to happen, though. All the people with a lot of stake in this game, and I mean counselors, public health people, and coroners, and judges, but above all, parents, need to make this, need to push this issue to the forefront. They’re the only ones who are going to do it. Candidates oftentimes follow what they perceive as the interests or the desires of whoever they seem to be talking to or whatever state they happen to be in. If you are not at a town hall meeting, if you are not at the campaign rally with signs saying, “What about addiction?”, “What are we going to do about the heroin problem?”, “What are we going to do about the doctors who prescribe this for wisdom teeth extraction?”, these pills, then it’s never going to be the issue that it ought to be. I think I would say that at the end, that basically this needs to be something really that is pushed by those actors who really feel it, who have to deal with it day-in, day-out, who have dealt with it day-in, day-out maybe for a decade or more now. They need to be the ones pushing that. If they don’t, I would say that I would find it hard to imagine it becoming the issue that it ought to be.

Next week: We discuss the collapse of American towns and communities, social isolation and what a friend of mine called “the American soul sickness.”

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Some final thought before the New Hampshire primaries tomorrow. Governor Christie was deemed by many to have won Saturday night’s debate, particularly in the way he dressed down Senator Rubio and exposed him as someone with canned, robotic statements. Christie hammered Rubio on the fact that he doesn’t answer questions, but rather digresses onto other topics. A few people that are up in New Hampshire wrote me and said that Governor Christie has sounded great all week and that he spoke movingly about addiction. I can not stress enough how he does not follow through with actual policy or significant funding. Here is a link to my appearance on NPR last November, where I gave very specific instances about that.

Both Governor Bush and Carly Fiorina have talked about addiction in their families. Despite their personal experiences, neither have offered up substantive policy recommendations. I wrote about that last month. Even though Dr. Ben Carson’s campaign is all but over, here is a link to his disastrous response about addiction treatment and policy.

I agree with Hillary Clinton wanting to move marijuana from a schedule I (completely illegal, no medical value) to a schedule II drug (controlled, prescribed, some medical value). Moving marijuana would allow for more research. While I disagree with the notion that marijuana can help 200+ medical conditions, I am willing to look at data that suggests it might help with 5 or 6 problems. Secretary Clinton is still woefully behind on Suboxone.

The candidate who probably has both the best understanding and track record about the Heroin Epidemic is Governor Kasich.

President Obama’s latest plan to combat heroin addiction was well received by most people in the treatment field, but I was less than pleased. You can read my reaction here.