The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth

by Sam Quinones

Fentanyl was the era’s poster drug. A wonderful medical tool, the hyperpotent synthetic emerged as the underworld’s hyperprofitable heroin substitute. Supplies of it came from China, then from Mexico, as well. Fentanyl upended the dope world the way tech disrupted business. No farmland needed—no pesticides, no harvesting, no seasons, no irrigation. It shrank the heroin supply chain—from dozens of people down to two or three, none of whom were likely to be scary cartel types. Illicit fentanyl spread first through the midwestern and eastern states. By 2018 it was all over the West as well. Overdose deaths shot farther north; more Americans died yearly than in the entire Vietnam War. Cuyahoga County, where Cleveland is located, saw overdoses double from 2014 to 2017—from 353 to 727, with almost 500 deaths involving fentanyl. San Francisco saw a similar increase between 2018 and 2020, when three times as many people died of overdoses as of COVID-19. Philadelphia had long been a heroin town, but by 2019 90 percent of 1,150 fatal overdoses were due to fentanyl. Traffickers, meanwhile, had discovered a way to make methamphetamine in harrowing new amounts. While I was on the road, their meth reached all corners of the country and became the fourth stage of the drug-addiction crisis. Opiate addicts began to switch to meth, or use both together. This made no sense in the traditional drug world. One was a depressant, the other a stimulant. But it was as if their brains were primed fo...

Fentanyl and this new meth were in the interest of traffickers, not their customers. Traffickers had unlimited access to world chemical markets, and the population of American drug users had expanded coast to coast. These drugs could be made year-round, in greater quantities, cheaper and more addictive than anything grown from the ground, and thus could create or shift demand. Their meth and fentanyl ended the notion of recreational drug use. Now anything could kill or mentally maim. What started as an epidemic of opiate addiction became, as I traveled, simply an epidemic of addiction, broadened by staggering supplies of corrosive synthetic dope.

In 1974 Janssen scientists synthesized a molecule with an entirely new level of efficiency in reaching the brain. They called it carfentanil. Carfentanil was ten thousand times more potent than morphine. It had no valid use on humans, they believed, but they saw that it sedated elephants, rhinoceroses, and other large mammals. In the United States, later, carfentanil was made legal only for zoo veterinarians to possess. (UK scientists concluded that in 2002 the Russian government used carfentanil to attack Chechen rebels who had taken over a Moscow theater, dispersing it through the building’s air duct. At least 170 people died, including 121 hostages. The UK scientists based their conclusions on tests of items of clothing and blood belonging to British citizens who were near an exit and thus among the hostages revived by a Russian assault team that day. The Russian government has never commented on what it pumped through the theater beyond to say that it was a “mixture based on derivatives of fentanyl.”) Paul Janssen proved that once fentanyl was invented, it wasn’t difficult to replicate. Making fentanyl got easier as years passed. An anonymous chemist, known today only as Siegfried, published a simpler method, in English, for making fentanyl—with five chemical steps compared to Janssen’s seven. The method fits on a single sheet of paper and appears on a rudimentary website of the kind common to the internet’s early days. No one seems to know who Siegfried is or was, or ...

In the late 1960s, to the alarm of their countrymen and elected officials, US soldiers fighting in Vietnam began returning home addicted to heroin. Yet the great majority of those soldiers kicked dope when they got home. They were no longer at war. They were distant from the drugs. They were back home in places where heroin, if there was any at all, was expensive and feeble. The Far East heroin of the 1970s crossed two continents and an ocean and went through New York before reaching the addict’s arm, weak and expensive. Nothing like what they’d encountered in Southeast Asia. By the late 1990s, that changed. The supply of prescription pain pills was massive and everywhere, because doctors prescribed them. Heroin followed; supplies skyrocketed, and prices fell. If the pills were potent, the heroin was more so, for it came now from relatively close by, in Colombia and Mexico. Unlike those soldiers returning from Vietnam, these new addicts could not escape it. The dope was at their high schools, in their locker rooms. Even small rural towns had pill and heroin dealers. The sellers popped up in states with no history of opioid abuse: Utah, Tennessee, West Virginia, Oklahoma, Maine, Indiana, North Carolina, and they were all over the state of Ohio.

The opioid epidemic was very different. It came with no street violence to speak of. On the contrary, it spread because it was quiet, insidious. Crime rates fell across America as addiction and overdoses rose. Instead of violence, the dead were the barometers now. Later, some people would claim that the opioid addiction epidemic was only getting attention because the great majority of its victims were middle-class White people. That was true. The other truth was that the plague hid for years because so many of its victims were middle-class Whites. Families seared by the loss also had to navigate the shame. They covered up, mortified at how their loved ones had died, afraid to stain their memories. Newspaper obituaries reported that a twenty-seven-year-old died of a “heart attack”; a middle-aged brother “died suddenly” at home. Amid this nationwide silence the plague festered, metastasized, and, like a virus, took on a life of its own.

In Carter County, community was created in church; there, children were raised, business connections were forged, romances begun. But an addict or unwed mother entered these churches with difficulty. Clothes drives, casseroles for families with a terminally ill child—churches knew how to do that. But addiction was different. It was something on the national news that allowed folks in Carter County to take comfort that they didn’t live in a big city. Churches had no custom of coming together in support of an affliction that many in the congregation believed would give them a bad name, or seemed to reflect the member’s weak faith, or was the choice and fault of the person affected. Some churches hid from uncomfortable facts. Others didn’t know what to do. Many felt their responsibilities extended only to their congregations and no further. Whatever the case, their silence hid how widely addiction had spread. “I was tired of being quiet,” Angie told me. “Silence is what’s killing people. We put on the pretty face that’s the look of church: everybody’s dressed, looking great—‘How you doing?’ ‘Wonderful!’ But if we can get people to start opening up, can you imagine what we would learn?”

In human brains, behind each ear and just above the brain stem, lies a blue spot that has helped guarantee our survival. It’s known as the locus coeruleus (Latin for “blue spot”), though those who study it just call it the LC. In humans, the LC evolved early, as it had to. The main job of the LC is to send a chemical—called noradrenaline—to other parts of the brain that ignite warnings of life-threatening menace. Noradrenaline helps sound the alarm, pushes the panic button, in a sense. Without it, we would have died off long ago. Opiates change a lot in our brains. One thing they do is stifle the LC. They shut it down. Under their influence, the LC can no longer send the chemical igniting panic. Smothered so completely, the LC, product of millennia of evolution, is muted, even as the drug sends the body into overdose. In fact, like some menacing extraterrestrial, opiates convince the LC that doing without them would be the life-threatening event. With opiates removed, the now-unbound LC leaps into action. Studies of the brain of an addict entering withdrawals show that the LC gets agitated, releasing outsize amounts of noradrenaline that produce alarm, panic, anxiety, and insomnia. The result amounts to, in effect, a chemical shriek that the addict must have the drug immediately or all is lost. I submit the bizarre case of the tiny locus coeruleus because, in the smallest of ways, it illustrates how drugs of abuse, and opiates in particular, change the chemistry of our bra...

Drugs of abuse, it seems, take advantage of our brain’s remarkable power to learn. Their euphoria produces strong memory associations in the hippocampus: a drug-using buddy, a needle, a phone call to the dope dealer. Heroin dealers seem to understand that forcing addicts to wait for them enhances their customers’ anticipation, spurring their continued patronage. The Velvet Underground sang about this in “I’m Waiting for the Man,” on its first album: “He’s never early, he’s always late. First thing you learn is that you always gotta wait.” (The Velvet Underground’s entire first album, from 1967, amounts to a love letter to heroin and a cue for shooting up. Apart from “I’m Waiting for the Man,” “Heroin” is the best-known rock song in praise of the drug. Some writers find “Femme Fatale” to be plausibly about heroin. More than that, though, the drone and thrum of the album harmonizes with heroin’s euphoria, according to many addicts.) Cues provoke a massive release of dopamine, reminding us that pleasure is just around the corner. Over time, though, they torment the addict: they trigger the dopamine that produces the urge for the activity that it associates with pleasure, but the nucleus accumbens has protected itself against overstimulation by providing fewer receptors for the dopamine to lock onto. So though the brain intensely desires an activity, it can produce less of the pleasure associated with it. The result is wanting, craving, desperation. An addict enjoys a drug les...

Fentanyl in enormous supplies was opening the drug trade to almost anyone, which is one reason why it created such damage nationwide. Years before, during America’s real-estate bubble in the mid-2000s, people with paltry income and shaky employment, with no steady way of paying for one house, now owned several. Into the industry rushed shyster closing attorneys, corrupt appraisers, banks, and other lenders with no connection to any community. They offered adjustable-rate mortgages to janitors and restaurant workers. For a brief, intoxicated time, lenders got rich and buyers saw a chance to have more than just a home. They bought themselves cars they didn’t need and took dream vacations. It marked the liberation of the nucleus accumbens in its battle with the prefrontal cortex. In the words of one lawyer I spoke with, “There was so much available money and so few impediments to accessing it.” Fentanyl was something like that in the drug world. By 2015, supplies of fentanyl were flooding in from Chinese chemical companies selling on the internet and Mexican traffickers. Like the home-loan industry a decade before, fentanyl took barriers that had kept the unprepared out of the market and replaced them with incentives that enticed them in. It was about as easy for a nobody in the drug business to come by large amounts of the stuff as it had been to own multiple houses during the real-estate bubble. Like the real-estate bubble, illicit fentanyl fit snugly into a part of America...

All this was part of how fentanyl disrupted the traditional drug world, just as Amazon and Uber upended retail and taxis. Kingpin quantities of drugs were being made or available to be sold by people with no control of geography, no labor force. Procuring large quantities of illegal drugs once required underworld connections, and dealing with scary people. Fentanyl allowed a dealer to go around all that. Thus, fentanyl reached every corner of America and pushed the overdose-death toll far beyond anything we’ve seen as a country. This wasn’t because users demanded it. Instead, fentanyl was a boon to traffickers and street dealers. It aligned perfectly with their interests: an immensely profitable drug easy to smuggle, cheap, and highly addictive. That was why its damage was so great. Anybody could be a fentanyl kingpin.

The other question arose: Why would dealers want to sell a substance so powerful that it killed their customers? Individually, they probably didn’t. But the power of free-market competition took hold. Anybody could procure fentanyl as easily as one of those home loans a decade earlier. It was more potent than any street drug before it. Anybody selling drugs that didn’t include the powerful boost of fentanyl wasn’t going to have customers for long. Dealers didn’t dare not mix it in. About the only way to introduce caution regarding fentanyl into the street drug world is for district attorneys to charge with murder those who sell anything containing fentanyl that ends up killing a user. Fearing they will “catch a body,” dealers back off. Soon, fentanyl became a market-expansion tool. Even a casual user of cocaine or meth, once those drugs were laced with fentanyl, would soon be a fentanyl addict—and thus a daily customer. “They don’t want fentanyl,” said Richard Mason, chief operations officer at House of Hope in Columbus, Ohio. “But they get their meth or cocaine cut with fentanyl without knowing it, and they love the high and they go back for more. I don’t think our clients at first were seeking fentanyl. Now they’re just straight-up fentanyl addicts.” In the 1980s, Latin American heroin came in stronger and cheaper and outcompeted the heroin that for decades had been coming from the Far East. By the early 1990s, no Far Eastern heroin was for sale in America. That’s what f...

But Sundell told me that the dealers she knew quickly saw that with fentanyl they could create opioid addicts who would buy daily, instead of occasionally, as many cocaine users do. Once one dealer did it, they all did it. “They do it because fentanyl is so addictive,” she said. “They do it just enough for you to be become addicted. You’re not addicted to coke, you’re addicted to the fentanyl—but you think it’s coke. I don’t think [the customers] knew that it was mixed.” In the summer of 2016, Akron’s street drugs changed again. Over the Fourth of July weekend, a cluster of deaths broke out due to carfentanil—the rhinoceros anesthetic, many times more potent than fentanyl. It’s hard to know its origin, as well. But in Akron, a long-time drug dealer named Donte Gibson began ordering fentanyl and carfentanil mailed to him from China. By May 2016, according to court records, Gibson was selling the synthetic drugs across Akron and other nearby towns. Over the next two years, Gibson made enough from dealing this new product that his wife tallied almost $700,000 in bills at Saks Fifth Avenue. The couple added an in-ground swimming pool to their south Akron home. Carfentanil killed 130 Summit County residents that year.

In 2009 Purdue hired McKinsey, the worldwide management consultant, to study how OxyContin sales might be rejuvenated. Purdue’s relationship with McKinsey dated to 2004 and would last until 2019. Through the years, McKinsey seemed to originate the idea that pushing doctors to prescribe more OxyContin and at higher doses was essential to Purdue’s profit. On Purdue’s board, Richard Sackler seemed the driving force behind this idea. He kept the pressure on, insisting that sales staff come up with tactics for “exceeding 2007 Rx numbers.” He wanted to know how sales staff would get patients to take higher doses and stay on opioids longer. How many patients had insurance reimbursement for unlimited quantities of Purdue opioids? How many were limited to sixty tablets per month? The records showed that limits on OxyContin’s use seemed to rankle him. When staff offered a plan to get pharmacies to increase their stocks of OxyContin from two bottles to three, Richard Sackler wanted to know why they couldn’t get four bottles or more. When Purdue staff noted reports of deaths due to OxyContin and a 2001 public meeting in which OxyContin was compared to heroin, Richard Sackler said that addicts and drug dealers were creating a problem, while “no one is speaking for the patients in pain.” Then in a confidential email, “We have to hammer on the abusers in every way possible. They are the culprits and the problem. They are reckless criminals.” “What else more can we do to energize the sale...

With labs popping up everywhere, a pound of meth fell below $1,000 for the first time on US streets—a 90 percent drop from a decade earlier in many areas. Yet traffickers’ response to tumbling prices was to increase production. Producers were independent, so each started more labs, hoping to earn with, say, five labs what he had been making with two when prices were higher. The chemicals they needed were flowing abundantly through Mexico’s Pacific Coast ports. Authorities raiding meth labs found tons of crystal meth stashed away by owners who, like brokers of any commodity, were presumably waiting for the price to rise. Meanwhile, the competition among producers drove meth purity to record highs. Pot was also part of this story. Marijuana was the gateway drug for Mexican traffickers. They learned the drug business smuggling weed beginning in the 1960s and it lifted many of them from poverty. They could depend on it to sell, year in and year out, no matter what harder drug was in fashion. Yet as American states legalized marijuana, Mexican pot revenue faltered. Many switched to making meth and found it liberating. Marijuana took months to grow, and was bulky and could rot. These traffickers were rancheros who bridled at working for others, but had few connections to move their product to the border. Thus, traffickers higher up the chain dictated the prices they paid to farmers. Exploiting pot growers “is how [certain traffickers] got big and stayed big,” said the Sinaloan d...

“Meth reminds me of what alcoholics go through,” said the director of a Los Angeles treatment center I spoke with. “There’s alcohol everywhere. Meth is now so readily available. There’s an availability to it that is not the case with heroin or crack. It’s everywhere.” Yet something else was different about this new meth coming in. Ephedrine meth was a euphoric, social drug, a party drug—the kind Eric Barrera remembered from his first years of using. P2P meth, made with toxic chemicals, was more sinister. As unprecedented amounts of it found their way to every part of the United States, so, too, did the mental derangement Dillon had seen in his customers and the violent delusions Eric Barrera had felt. This meth quickly drove users to symptoms of schizophrenia—violent paranoia, agonizing hallucinations, and fantastical conspiracy theories—as well as horrible dental infections. “I don’t know that I would even call it meth anymore,” one director of a drug-rehab center told me. “Meth was meant to keep you up,” said one Kentucky truck driver, who saw the change as he used it for many years. “You was able to concentrate on one thing. This meth now, though, you’re hallucinating. It got so bad with the new meth, I screwed my windows shut, my doors shut, because I didn’t want nobody around me. I locked my family in the house with me.” All this was noticed only by users, paramedics, cops, and drug counselors. The rest of the country was focused on the opioid epidemic. The funding an...

Mahoney had studied the effects of ephedrine meth on the brain in the early 2000s at UCLA. The psychosis he saw then was bad, but it was usually the result of extended sleep deprivation. In 2016 Mahoney took a WVU job as a meth researcher and specialist in the university’s addiction clinic. Less than a year into the job, the P2P crystal meth from Mexico started showing up. Mahoney was inundated with meth patients who came in ranting, conversing with phantoms. “I can’t even compare it to what I was seeing at UCLA,” he told me. “Now we’re seeing it instantaneously, within hours, in people who just used: psychotic symptoms, hallucinations, delusions.” Sarah Skoterro, in Albuquerque, a veteran of thirty years as a drug counselor, remembered the meth years ago was a party drug. Then, she said, “around 2009, 2010, there was a real shift—a new kind of product. I would do assessments with people struggling for five years with meth who would say ‘This kind of meth is a very different thing.’ ” Skoterro watched people with families, houses, and good-paying jobs quickly lose everything. “They’re out of their house, lost their relationship, their job, they’re walking around at three in the morning, at a bus stop, blisters on their feet. They are a completely different person.” As I talked with people across the country, it occurred to me that P2P meth that created delusional, paranoid, erratic people living on the street must have some effect on police shootings. Police shootings were...

For its first few years, Jobe’s court handled a lot of meth addicts when “shake-and-bake” manufacturing was still used. They were gaunt, she remembers, and picked at their skin. But they were animated, lucid, with memories and personalities intact when they arrived at her facility, detoxed of the drug after months in jail. By 2017, as the P2P meth from Mexico arrived, the men were coming to her stripped of human energy, even after several months in custody. “Their dopamine receptors don’t work anymore; nothing is pleasurable for months,” she said. “Normal recreational activities where guys talk trash and have fun, there’s none of that. It’s like their brain cannot fire. All the functions of the prefrontal cortex, the decision making and immediate response we have to stimuli, are extremely slow. They’ve been so overstimulated that normal brain chemistry doesn’t stimulate them. We don’t see a lot of anger at first. Not a lot of fury at all. It’s zombie-esque. “The tooth devastation is amazing—nothing but blackened stubs in the front of the mouth. We are seeing twentysomethings in need of full sets of dentures. The teeth simply cannot be saved.” Treating them was daunting. Unlike opioids, methamphetamine has no medical treatment. Despite years of research, science has found no meth equivalent of methadone or Suboxone to help subdue cravings and allow an addict a chance to break from the drug and begin life repair. So that was one problem. Also, the new meth, Jobe found, damag...

In Unit 104, inmates governed themselves. One way they did this was by calling out each other for not putting forth their best effort, for getting up late, sleeping during the day, for lying or not making their bed. This went against everything that drug addiction and custody taught them. Dissolving the criminal code, learning to postpone immediate gratification and combat addiction—it all required using criticism to fuel personal change. In neuroscience terms, it was part of strengthening the prefrontal cortex in its battle with the nucleus accumbens’s me-first impulse. In 104, they called it “holding someone accountable.” But to Fariello, with almost half a life behind bars, it sure looked like snitching.

Like many American towns, though, Columbus has invested little in mental-health housing. So if jails won’t do, police often take people in this man’s condition to Riverside’s emergency room. The next morning, as mood stabilizers calmed the patient, the ER staff learned more about him: he suffered from anxiety, and maybe he was bipolar, though it was too soon to tell; his mother was bipolar. Perhaps at the root of it all, staffers were not surprised to learn, he had been molested as a child. Overlaid on that traumatic past now was the new crystal methamphetamine. “When I first came [in 2015] we never saw meth,” said Dr. Megan Schabbing, a psychiatrist and director of the ER’s psychiatric ward. The city then was grappling with opioid addiction. Riverside opened its ER psychiatric ward to deal with those patients as police stopped taking them to jail. But nothing quite prepared the hospital for P2P meth. This began, if Megan Schabbing is any gauge, in May 2018, about the time she and the staff were getting used to treating patients on fentanyl. “Within a week, it was multiple people coming in on meth,” she remembered. “Elaborate delusional sentiments, violent. I watched a guy run through a set of very hard doors. We call it supermeth. They’re brought in by police, bashing in car windows, walking into a stranger’s house. They appear to be psychotic, look like they’re schizophrenic. But when they’re off the drug, they’re not. Riverside spent millions of dollars to retrofit its ...