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.