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

by Sam Quinones

(Interestingly, the natural substances that make humans high actually evolved in their plants as pesticides, to keep predator insects from feasting on their leaves. Nicotine is a pesticide that tobacco naturally produces. So is caffeine in coffee, cocaine in the coca leaf, morphine in the opium poppy, and perhaps THC in marijuana as well.)

Our revolution in neuroscience research has shown that around 30 percent of people have a genetic disposition for addiction. But no matter what a person’s genetic disposition, no one gets addicted to drugs she hasn’t tried.

Part of the brain creates a neurotransmitter called serotonin. Serotonin binds with the opioid receptor, too. Its job, when it does that, is to promote satiation, contentment, happiness, patience—telling you you’ve had enough, you’re fine. Our brains have evolved to naturally keep serotonin and dopamine in competitive balance. Dopamine tells us that something better awaits us; serotonin says we have enough.

The prefrontal cortex is just behind the forehead. It is in charge of executive decisions: planning for the future, reining in impulses, delaying gratification, considering others, and learning from mistakes. It connects to the brain’s system of emotion and pleasure, acting as a brake on impulsivity. (Its connection to our system of processing emotion is why, neuroscientists believe, we take pleasure from solving problems.)

When the reward pathway demands actions that feel pleasurable, the prefrontal cortex assesses their consequences. It develops many years after the reward pathway, which is there from birth. Before the prefrontal cortex is fully formed—in a teenager, for example—the reward pathway dominates the brain and governs behavior. Hence the me-first immaturity associated with teens.

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.

When addicts grew tolerant to fentanyl’s towering potency, simple heroin was too weak to prevent withdrawal. By the time I was finishing this book, heroin had all but disappeared from many areas of the United States—replaced by fentanyl from Seattle to New England. This devastated opium-poppy growing in Mexico, according to some remarkable fieldwork by three journalists—Romain Le Cour Grandmaison, Nathaniel Morris, and Benjamin Smith—in their 2019 study “No More Opium for the Masses” for Noria, a French research collective. Mexican poppy farmers had been enjoying a bounty supplying the US opiate addiction epidemic. As fentanyl arrived in America, raw opium prices, the authors found, fell by as much as 75 percent in the mountainous poppy-growing areas of western Mexico. Depression settled on regions where many farmers grew almost nothing else. “The gringos now have this new stuff,” a farmer told the authors. “They don’t like heroin anymore, that’s why we don’t sell.”

By mid-2019, Chinese chemical companies stopped selling fentanyl under orders from their government. Instead, they switched to selling Mexican traffickers the chemical ingredients with which they could make the painkiller. Mexico emerged as the center of illicit fentanyl manufacturing.

Among the first couriers to bring them into San Diego was a woman named April Kelly. April was a heroin addict whose addiction began in 2004 with Vicodin prescribed to her after a C-section during the birth of her son. By 2017, she was experienced in going to Tijuana to bring back small amounts of heroin for her and her boyfriend. At the proposition of a trafficker, she moved to Tijuana and began crossing the bright blue pills, pressed in Mexico and containing only fentanyl.

An online Chinese vendor sold him a quarter kilogram—250 grams—of fentanyl for $5,000. The first order came hidden in the box of a puzzle that a family might put together on its living-room table. He had it sent from China by the slowest rate, so it got lost among the millions of packages cascading into the United States every day. On the internet, he bought a high-quality pill press that churned out five thousand pills an hour. He added a scale, and powders to bind with the drug. He bought a high-quality powder mixer, avoiding the Magic Bullet blenders as he considered them too risky. He mixed a quarter milligram of fentanyl in each pill. They cost a nickel each to make, and he could sell them on the darknet to wholesalers for $2 apiece. Four thousand pills per gram—$8,000 gross from each gram that cost him $20. On a grander scale, $2 million in revenue from that $5,000-quarter-kilo of fentanyl.

Cash became something he wore almost like a cologne. On his Instagram account, @yung10X, he posted photos of himself bathing in a tub of cash, counting cash leaning against some rare sports car, bills spilling over the hood, then videos of more cash, jewel-encrusted watches, and women with hundred-dollar bills stuffed in their cleavage.

It took a year and a half. Deputies watched it happen, day by day, this strange fog lifting only slowly inside a man’s mind. Along the way Rob Burd became the first addict many cops in the department got to know without handcuffs; they watched his struggle, saw that he didn’t quit, and came to feel for his befuddlement. “It softened us up a bit,” said Holbrook. “Once you see somebody, knowing them personally, you start looking at other people and you see them a little bit differently, too.”

I was reminded of the pill-mill doctors who discovered that prescribing a combination of opioids and benzodiazepines (Xanax) got patients quickly dependent, making them reliable customers. Together, the two drugs were more powerful than each alone.

“Each of our ancestors was, in effect, on a camping trip that lasted an entire lifetime,” the couple wrote. “This way of life endured for most of the last 10 million years.… [That experience] sculpted the human brain, favoring circuitry that was good at solving the day-to-day problems of our hunter-gatherer ancestors—problems like finding mates, hunting animals, gathering plant foods, negotiating with friends, defending ourselves against aggression, raising children, choosing a good habitat, and so on. Those whose circuits were better designed for solving these problems left more children, and we are descended from them.” Eating, exercise, sex, connecting with others—all that helped us stay alive. Our brains evolved to reward us with feelings of pleasure when we engaged in them. We evolved prodigious memory to remember where food and threat resided; slow learners died fast. Our brain evolved to be easily distracted because those who weren’t got eaten. Our brain also required that we be physically touched by others—hugged, squeezed, kissed, patted on the back—as a way of reinforcing the group that kept us alive.

Casinos hire the brightest psychologists to design rooms that are more difficult to leave. Chicken nuggets were invented in a lab at Cornell University by combining the bird’s byproducts into a “chicken clay” that is 60 percent salt and fat, two elements that over hardscrabble millennia our brains learned to treasure.

The social media giant’s algorithms are programmed to keep us engaged, which is best achieved through provoking strong emotion—especially outrage. Outrage is intoxicating. Our brains evolved to feel outrage at the transgressions of someone in our group. It was essential to survival. Enforcing social norms, correcting the misbehavior of others also made us feel noble. “When people decide to punish somebody who has behaved unfairly, we see activation in brain areas associated with reward,” Molly Crockett, a Yale University psychologist, told the podcast Hidden Brain. “There’s a visceral satisfaction in doling out punishment.”

Social media, moreover, ignites feelings of social activism, as if with every Like and Retweet we’re changing minds and the world. Instead, tweeting and Facebook likes are to social activism what heroin, meth, and other drugs are to happiness. Both are easily achieved with little lasting effect.

In 2018, when the Los Angeles Times reported that “L.A.’s Homelessness Surged 75% in Six Years,” this made a lot of sense to Eric Barrera. Those were exactly the years when supplies of Mexican “weirdo” meth really got out of hand. “It all began to change in 2009 and got worse after that,” he told me as we walked through a homeless encampment in Echo Park, west of downtown Los Angeles. “The way I saw myself deteriorating, tripping out and ending up homeless, that’s what I see out here. They’re hallucinating, talking to themselves. Now, it’s people on the street screaming. Terrified by paranoia. These are people who had normal lives.”

But cartels collude to raise the price of what they produce. The Organization of the Petroleum Exporting Countries (OPEC) is a cartel and proved it in the 1970s, when its members cut back on oil production and the price of gas skyrocketed across America.

Amid all this, I read Good Habits, Bad Habits: The Science of Making Positive Changes That Stick, a fascinating book by Wendy Wood, a psychology professor at the University of Southern California, who argues that habits change when they’re harder to practice. Addiction isn’t about rational decisions, she wrote. If it were, Americans would have quit smoking soon after 1964, when the US Surgeon General issued his first report on its risks. American nicotine addicts kept smoking, knowing they were killing themselves, because nicotine had changed their brain chemistry, and cigarettes were everywhere. We stopped smoking, Wood argues, by making it harder to do—adding “friction” to the activity. In other words, we limited access to supply. We removed cigarette vending machines, banned smoking in airports, planes, parks, beaches, bars, restaurants, and offices. By adding friction to smoking, we also removed the brain cues that prompted us to smoke: bars where booze, friends, and cigarettes went together, for example.

“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.

Will Pfefferman makes his bed every day. He yanks the sheet drum-tight across his king-size mattress. He fluffs the pillows just right, throws the bedspread over them, and pulls it tight, too, leaving it wrinkle-free. Then he’s ready for the day. The importance of this exercise was made clear to him not long before I met him, after he’d seen his buddy Mike on the street. Mike was a recovering addict Will met when Will was rehabbing from heroin in a treatment center in the Northern Kentucky town of Covington, near where Pfefferman grew up. Mike had visited the center to talk about his own recovery from dope. Now, though, Mike was shooting up again. What happened? Pfefferman asked him. “I quit making my bed,” Mike told him. With that, Mike said, his discipline frayed, and he began to slouch in other parts of his life as well, until he was back on the streets. “He quit answering his door and his phone and quit making his bed,” Will told me.

All that now bequeathed Will Pfefferman what in addiction recovery is called the “gift of desperation.” He landed, worn out and beat down, in Covington’s Grateful Life treatment center.

He moved to Appalachia and to Hazard, Kentucky, the buckle on America’s OxyContin belt,

a parolee two years off heroin, with a felonious past and notorious reputation,

Problem was that each inmate did nothing productive while in jail, waiting three to nine months for his case to resolve—at a cost to taxpayers of $42.45 a day.

Everyone thought Kirsten was schizophrenic. Instead, it was the P2P meth at work. As I was working on this book, I began to realize that the drug was creating Kirsten’s symptoms in people across America. I came late to this understanding. I had started this book focused on how Mexico produced quantities of methamphetamine so vast that they could cover the country and still lower the price nationwide.

Southwest Virginia hadn’t seen meth for almost a decade when suddenly, in about 2017, “we started to see people go into the state mental hospital system who were just grossly psychotic,” said Eric Greene, a drug counselor. “We wondered where all these people were coming from. Since then, it’s caused a crisis in our state mental health hospitals. It’s difficult for the truly mentally ill to get care because the facilities are full of people who are on meth.”

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.

Henry Molaison, neuroscience’s most famous patient, who had lost all his short-term memory when that part of his brain was removed.

The growing homeless encampments in many cities and rural towns are meth’s deadening creation, I’m convinced. Though other drugs and alcohol are part of the mix, many encampments are simply meth colonies. They provide a community for users, creating the kinds of environmental cues that USC psychologist Wendy Wood found crucial in forming habits. Encampments are places where addicts flee from treatment, where they can find the warm embrace of approval for their meth use. “It took me twelve years of using before I was homeless,” said Talie Wenick, a counselor in Bend, Oregon. “Now, within a year they’re homeless. So many homeless camps have popped up around Central Oregon—huge camps on Bureau of Land Management land, with tents and campers and roads they’ve cleared themselves. And everyone’s using. You’re trying to help someone get clean, and they live in a camp where everyone is using.”

Suboxone is the brand name for a combination of buprenorphine and naloxone. Buprenorphine is an addictive opioid, but it also blocks the worst cravings, dims the withdrawals, and lessens the chance of overdose. It is an essential tool in managing an opioid addict’s recovery, giving her time to move away from the drug world, restore family relationships, find work and housing, recover driver’s licenses, get health and dental care, pay traffic fines.

For many, buprenorphine in the form of Suboxone was a lifesaver. They used it daily the way a heart patient (like me) uses daily blood thinners and anticholesterol drugs to stay alive. But part of a heart patient’s recovery is life repair: weight loss, better diet and exercise, no smoking. Such continuum of care was often absent when it came to addiction.

When you snitch on someone, Will said, it’s for your benefit. That’s not what’s happening here. When someone holds you accountable, it’s not for his benefit; it’s for yours. So that you can change, feel the effect of your actions on others. You gotta understand the difference. “When you do,” Will said, “you start to learn what integrity is.”

These families began to emerge from the shadows in 2015. Drug overdose fatalities each year surpassed the total of American deaths during the Vietnam War.

Blocking fentanyl usually required several doses of naloxone, he told them. “Remember, with that amount of naloxone you put them in instant withdrawal. They could come up swinging.” This was a remarkable insight into opioids: their control of the brain’s reward pathways can be so complete that even when an overdose victim is revived from death, his response is often to fight the person who revived him.

Both marketing and dope invite us to confuse pleasure with happiness or fulfillment. I came upon a YouTube video of a speech in which Dr. Robert Lustig contrasts pleasure and happiness. Pleasure, Lustig said, is fleeting; happiness is long-lived. Pleasure comes from taking or getting; happiness comes from giving. Pleasure is achieved alone; happiness with others. Pleasure comes from substances or things; happiness does not. Pleasure releases dopamine in our brains, the constant search for more; happiness releases serotonin, producing feelings of contentment, an end to consumption. All of which means, Lustig said, that pleasure can prod our reward pathways into addiction; happiness cannot.

The United States is the world’s leading per capita consumer of both opioids and sugar.

Tents. They protect many homeless people from the elements. But they have another, far less benevolent role. Tents and the new meth seem made for each other. With a tent, the user could retreat not just mentally from the world but physically. Tents often became pods of exploitation where people used dope, sold dope, or performed acts that allowed them to procure it. In Los Angeles, the city’s unwillingness, or inability under judicial rulings, to remove the tents has allowed them to stay for weeks, sometimes months. Encampments resembled Third World shantytowns. The tents went from gifts of compassion to hives of crime, addiction, disease—and now pimping.

Nothing indicated meth-induced homelessness like a bicycle fixation. Stolen bikes went hand in hand with the drug. Bikes allowed for mobility for people without cars. P2P meth seems to provoke the hoarding of junk, which is why tent encampments are so often full of bizarre collections of seemingly useless stuff. Bikes allowed a user to travel greater distances looking for junk. In the homeless P2P meth world, bikes became currency, easily exchanged for dope.

With the money packed away, he quickly felt broke again, which is what he wanted. He prized his ability to postpone gratification, like an entrepreneur.

By now his phone was often clogged with calls from people on Napoleon asking for help. He bought diapers for pregnant women, paid rent for mothers. Meth made him the street’s benefactor. “Knowing that I can help the ones I love around me,” he told me, “that’s what made me feel cool.”

Nobility despite criminality

That was the gung-ho motto of the Opioid Era in America and many companies jumped in. But Purdue embodied the era. The company’s main product—virtually its only product—was an addictive narcotic, sold with outlandish claims about its risk-free nature, targeting overworked doctors and nurse practitioners with little training in pain management, by highly incentivized salespeople in a company run by a family-dominated board who saw its annual payouts connected to that product’s sales and sought always to increase “cash flow” from the enterprise.

OxyContin tended to take patients up to towering daily levels of use. This was particularly true of the high-dose versions—40 mg, 80 mg—in the high quantities that Purdue reps prodded doctors to prescribe. Some doctors then cut off their patients; other patients lost their insurance. Either way, many of those patients migrated to the street market for prescription painkillers, where prices were a dollar per milligram. People habituated to 200 or 300 mg a day could not afford that. So they migrated again—to potent, cheaper heroin from Mexican traffickers, who had awakened to this new market. The first people I met who switched to heroin did so in the late 1990s, early in the life of OxyContin.

Stockholders might have seen the damage. They might have pushed the company to action, to diversify the company, rely on more than just revenue from an opioid, or related products. But the Sacklers did not. Perhaps OxyContin revenues had been too intoxicating for too long. Money will do that.

In 2014, as the flows of the new meth were just beginning, Californians passed Proposition 47. Rather than expanding the ways felony drug-possession arrests could be used as leverage by judges to push people into treatment and recovery, Prop. 47 made those charges misdemeanors. Cops stopped making those arrests. Those who were arrested tended to refuse treatment and judges had no leverage to force them into it. So they remained on the street and fewer addicts went to treatment, just as the street drugs they used became more prevalent, addictive, and brain-damaging than ever.

When asked how many of the people he met in those encampments had lost housing due to high rents or health insurance, Eric could not remember one. Meth was the reason they were there and couldn’t leave.

Having lived in Mexico for ten years, I believe solutions will come only when Mexico and the United States work together. This is crucial because walls don’t stop dope. Not in an era of free trade. The price of meth hit historic lows by arriving via millions of trucks, cars, and people through our many official border crossings, some of the most heavily guarded places on earth. Same with heroin and fentanyl.

Drug demand is important in all this. But it must be said: these stories begin with supply. Our opioid addiction epidemic began with a mighty supply of pain pills prescribed every year, which created widespread addiction that continues to this day. Right about that time, traffickers were discovering that synthetic drugs were not just immensely profitable but could create or shift demand simply because they could be made in unprecedented quantities all year long. So they flocked to them.