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.