It’s the kind of line that causes readers to do a double take. A July 25, 2015 Washington Post article reports that Falmouth is “a place now ravaged by heroin — four overdoses, two of them fatal, in the last 10 months, in a town more accustomed to nothing of the kind.”

Once the scourge of cities, heroin has entered the mainstream weaving a path of death and tragedy from upscale suburbs to small towns to quiet rural areas. In Maine, heroin related deaths have increased over 700 percent, from seven in 2010 to 57 in 2014. Fourteen heroin overdoses were reported in Portland on one day in July alone.

Across the country, heroin is readily available, cheap and, as always, relentlessly addictive. Communities that never faced heroin addiction problems are now seeing a surge in addicts, overdoses and related crime and disease.

Sam Quinones’s book “Dreamland: The True Tale of America’s Opiate Epidemic,” provides an important frame of reference for understanding America’s opiate epidemic. His theory is that two seemingly unrelated factors conspired to trigger the crisis: the proliferation of prescription opiate use and an influx of inexpensive heroin from Mexico.

Quinones claims that America’s prescription opiate epidemic was ignited by a misinterpretation of a simple, one-paragraph letter to the editor of the influential New England Journal of Medicine in January of 1980. The letter, by Jane Porter and Hershel Jick, stated that, of over 11,000 patients treated with opiates while under inpatient care in a hospital setting, only four who had no previous history of addiction had become addicted.

It wasn’t a study, and the letter didn’t make any claims or predictions. It wasn’t remotely what could be called evidence-based science. It was just a letter containing some anecdotal information.

But in a pre-internet age, when access to the full text of publications was difficult for those without subscriptions or a nearby medical school library, the letter took on a life of its own. In 1986, two authors writing in the journal Pain noted that an opiate addiction rate of 4 per 11,000 is “less than one percent.” The “one percent” tag stuck, along with its variant: “Addiction is rare among patients treated with opiates.”

Quinones describes how, as the letter was cited in other articles and seminars, its legend grew. One textbook called it a “landmark report.” In a National Institutes of Health Publication, researchers from Harvard and Johns Hopkins referred to the letter as a “study,” and an article in Scientific American upgraded Porter and Jick’s brief letter to the status of “an extensive study.” Time magazine said that the article proved “the exaggerated fear that patients would become addicted” when prescribed opiates was “basically unwarranted.”

Thus, one of the two major forces behind the current opium epidemic was unleashed, starting on the East Coast and heading westward. The pain relieving qualities of opiates were abundantly clear. Once “study” after “study” seemingly established that opiates were not addicting, the floodgates were opened.

Patients demanded relief from their suffering and expressed their satisfaction or dissatisfaction with their doctors’ responses on increasingly prevalent patient satisfaction surveys. Moreover, physicians had legitimate concerns about liability for causing their patients to “suffer” by not prescribing opiates. Quinones believes that most physicians felt they had no choice but to prescribe these drugs vigorously and, after all, a decision to do so was ostensibly based on good science.

Quinones writes, “I felt for doctors. Prescribe and they risk a patient growing addicted. Don’t prescribe and a patient may have to live with crushing pain.” Patient demand for prescription opiates was stimulated by the world class marketing infrastructure of big pharma. On the supply side, there was a proliferation of unscrupulous prescription drug mills. “A pill mill was a pain-management clinic, staffed by a doctor with little more than a prescription pad,” according to Quinones. These pill mills “became a virtual ATM for dope as the doctor issued prescriptions to hundreds of people a day.”

At around the same time, a second force – inexpensive heroin – emerged in the West Coast and headed east. Young men, mostly farmers and bakers, from Xalisco in the western coastal Mexican state of Nayarit began selling low-cost black tar heroin in the United States. Unlike other cartels that sold heroin in urban areas and relied heavily on violence, the Xalisco dealers had a much more refined business model. First, they minimized their risk of drawing the attention of law enforcement by eschewing violence, possessing only small amounts of heroin and blending in.

They sold heroin in middle and upper-middle class neighborhoods, ensuring a well-off customer base while at the same time avoiding the need to compete with well-established and violent heroin cartels in urban areas.

Moreover, they were models of customer service, offering frequent buyer bonuses and approaches that could have been taken from a business school textbook for customer service. Buying heroin was as easy as ordering a pizza. Friendly service and follow-up customer satisfaction inquiries were the norm. The Xalisco dealers had a remarkable ability to retain customers. Quinones illustrates with the following example:

One addict “called his Xalisco dealer, whom he considered a 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.”

The medical community began to reject the notion that opiates were not addicting and authorities began to crack down on opiate mills. Unfortunately, with prescription opiates less available, there was a ready alternative. Quinones writes, “Heroin had spread to most corners of the country because the rising sea level of opiates flowed there first.” He concludes that it was easy for the Xalisco dealers to sell heroin “in a region where OxyContin had already tenderized a generation of folks to opiate use.”

Quinones ends “Dreamland” on a cautious and semi-optimistic tone. Cities like Portsmouth, Ohio, that were among the first to feel the effects of prescription drug and opiate addiction are trying to rebuild their “shredded” communities. Increasing numbers of people are in recovery, but the mood is more somber than triumphant.

There are three lessons in all this for Maine. First, education and prevention should be a top public health priority. People who experiment with heroin try it again, because it is by all accounts a breathtakingly appealing drug. Heroin’s transformational sense of well-being overwhelms better judgment about the risks of becoming an addict. Prevention is the most powerful lever at our disposal in combating heroin addiction. Once someone is addicted, they likely have to manage their disease for the rest of their lives, and that’s assuming they stop using in the first place.

Second, we must make treatment widely available for addicts. Moreover, we need to “market” treatment with the same vigor and creativity of heroin dealers. Treatment should replace criminal penalties for addicts, because incarcerating addicts is counterproductive and a misuse of law enforcement resources.

Finally, additional law enforcement resources are needed to protect Mainers from the sophisticated organized criminals who bring heroin to Maine as part of highly functioning distribution systems. Reducing the supply of heroin will likely result in fewer new addicts, which is an important pathway to resolving the crisis.

The opiate addiction crisis facing Maine is a complex problem. As Quinones makes so clear, solving it will require a sustained multi-pronged approach with efforts from the medical community, state and local government, and law enforcement.

Dave Canarie is a Portland attorney and adjunct faculty member at the University of Southern Maine and St. Joseph’s College.

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