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.

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.

every human brain has capacity for addiction. Isolation is part of why some people get addicted and some do not. So was trauma. Abuse, rape, neglect, PTSD, a parent’s drug use were as unspoken in America as addiction and as prevalent. The epidemic was revealing this. I also connected the epidemic to consumer marketing of legal addictive stuffs: sugar, video games, social media, gambling.

The twelve months ending September 2020 tallied the highest number of overdose deaths in the country’s history—87,000, according to a preliminary estimate by the Centers for Disease Control and Prevention. Much of that was due to illicit street fentanyl. By the time this book is published, we will likely have learned that close to 100,000 Americans died of drug overdoses in 2020—dwarfing any annual tally the country previously produced.

Perhaps the path to national reassessment begins when things fall apart. The addiction epidemic was already doing that. Nationwide death from abuse of the most isolating of all drugs was pushing Americans to come together in county after county. People I met were breaking down silos, acting on the idea that it was through reliance on each other, through community—which we had done so much to destroy—that we would most likely find some way out of this.

addicts, gripped by drug-induced self-centeredness and isolation, are just extreme examples of each of us and our time. Once freed, they discover what we all need. They discover grace, patience with others. A feeling of being part of something bigger than themselves. Optimism and gratitude. A recognition of themselves in others. If

San Diego emerged as the meth capital of America, with supplies heading out across the country. With ephedrine, many more people could now cook meth in many more places—a motel room, a storage shed, a bathroom. And, beginning in the mid-1980s, they did.

Nature’s morphine molecule—found in the opium poppy—works because it penetrates the barrier of protective fat surrounding the brain, locks onto the receptor, and stifles feelings of pain. But it does this slowly and inefficiently. Half the morphine molecules don’t make it through the fat barrier to the brain.

On fentanyl, patients could be conscious during surgery, with blood pressure normal. Fentanyl was short-acting and could be reversed quickly with naloxone. People were in and out of it, without lingering aftereffects.

Janssen knew fentanyl’s potential for abuse. It created the same euphoria in users as heroin, the same tolerance, the same withdrawal. In surgery, minute doses of fentanyl—measured in micrograms (a microgram is one-millionth of a gram)—produced helpful drowsiness and killed pain. In only slightly larger doses, it was fatal.

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.

(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.”)

After fentanyl began to hit Vancouver, British Columbia, in 2014, “we saw Magic Bullet blenders all the time,” along with similar brands of blenders, said John Hartnett, corporal in the Royal Canadian Mounted Police Clandestine Lab unit. “There didn’t seem to be any concern [among mixers] about the impact that this might have. This was the easiest way to blend their product and good enough, in their opinion.”

Naloxone is better known today by the brand name Narcan. It stops overdoses to opioids like heroin, fentanyl, or oxycodone. Naloxone immediately revives a person who is overdosing.

Medical studies have found that two-thirds of patients using opioid painkillers for more than ninety days were still using them five years later.

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.

chemical the brain produces called dopamine. Dopamine prods us into an activity that we have learned will produce reward, good feelings. Dopamine rushes to a key node in the brain’s pleasure circuit known as the nucleus accumbens, where it creates feelings of motivation. Do this because it’ll be good—that’s dopamine’s signal.

Receptors are molecules within the cells in our brain and body that govern important functions and feelings. Our brain contains receptors of all kinds. One class of receptors in the brain, for example, governs

pleasure and pain. These same receptors also inhabit our lungs, where they control our breathing, and our gut, regulating our bowels. A second class of receptors governs memory. They allow us to forget things we need to forget, especially in fear and anxiety. They keep us from getting too excited; they spur our appetite, and reduce nausea and vomiting.

Dopamine and noradrenaline are among the brain’s many neurotransmitters. They help transmit messages between different parts of the brain. The way these neurotransmitters do this is by locking onto these receptor molecules, an action that produces these feelings—alarm, desire, pain, pleasure, reward. The list goes on. But the brain, always seeking equilibrium, creates neurotransmitters in only limited quantities.

By some bizarre coincidence of nature, however, some plants produce molecules that when introduced to our bodies activate these receptors as well. Two of the most famous are the opium poppy and marijuana.

Marijuana, meanwhile, produces a chemical called THC that attaches to the second class of receptors (discovered in 1988).

THC in marijuana overwhelms the cannabinoid receptors and produces ravenous hunger and faulty memory. The morphine molecule locks with the opioid receptors to produce euphoria and numb pain. Opioid receptors in our lungs govern breathing; too much morphine molecule shuts down breathing, which is how overdose victims die. The morphine molecule also produces constipation in addicts. In withdrawals, without the drug, addicts suffer diarrhea. (Naloxone, the overdose antidote, is occasionally used to treat constipation.)

As our brains evolved, we lived in places where so much was limited to us. We had limited access to sugar, fat. Life was a constant struggle—kill or be killed. But nowadays you can text your dealer, you can shop to your heart’s content, eat as much sweet and fatty foods as you want. Pretty much any substance you want to engage in you can, and without limit. Our brains tightly regulate how much endorphins they produce. Endorphins don’t last very long in the brain. But when these substances or stimuli are available from the outside, there’s no regulation to keep things in moderation. Our brain is just not strong enough to offer sufficient resistance, and we become addicted to them.”

Dopamine levels, however, don’t diminish when a person uses a drug of abuse. They stay and prod the person to consume more. When the drug is removed, the dopamine plummets far below normal levels, leaving us frantically wanting more. This is part of how cravings are created.

the drug enhances those memories that would lead us to our doom, while the brain, which evolved all the weapons to keep us alive, can barely muster a defense.

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.

Drugs and other addictive products turn us away from that. Heroin addicts retreat into themselves. The addict alone in his hoodie seems an emblem of the Opioid Era. Gambling, first undertaken as a social activity, turns quickly into something one does alone. Same with alcohol. Social media, meanwhile, more resembles prehistoric communication. On social media, we are unable to perceive the differences in tone and meaning that we have learned as a species through eons of face-to-face interaction. We see no facial expressions on Facebook. Nuance is hard to tweet. We mistake a playful phrase for menace or insult. A medium designed for connectivity instead inflames our righteous anger and indignation. Likewise, an addict, with natural communal impulses muted, devolves into an antisocial state. Her sole focus is on self-gratification, obeying her me-first impulse, isolated and alone, even as she lives amid millions of others. Any relationship serves her only inasmuch as it can help her score. In her addicted brain, Me has won the battle over Us.

As I traveled and spoke with neuroscientists, it seemed that one way of thinking of America in the last four decades is that we gradually surrendered—collectively, as a culture—to the brain’s reward pathway. Our prosperity allowed us this luxury. We could follow the nucleus accumbens and the pursuit of dopamine and pleasure. This was one way of understanding the Opioid Era in America. Our epidemic of opioid addiction was just an extreme expression of a culture in which, in so many ways, Me won the battle over Us.

By 2016, fentanyl was coming laced into heroin. Within a year or so, customers could assume that what might be called “heroin” was just straight fetty, as fentanyl came to be known. Every day became a game of Russian roulette. “I don’t know any longtime fentanyl users,” one addict-turned-counselor told me. “They all die.”

The popular image was of an addict suddenly seeing the light. Now “ready” for treatment, she found a path forward and all was good. Barrett found that was hardly ever the case; reality was a lot messier. Most had to be prodded; many rebelled or had no confidence that they could succeed after years of being shunned, stinking, hated, and now stained with tattoos that felt as permanent as their addictions. Life seemed impossible without dope. Amid all this, assuming that hardened street addicts would just suddenly be “ready” for treatment was dangerous folly. Instead, said Mimi Zarzar, Barrett’s court administrator, “you slowly move people to a readiness. They go from, ‘I’m not sure I want this,’ to ‘Maybe I might want this,’ to ‘Yes, I do want this.’ ”

The team’s study, published in 2015, stands as the first to conclude that high-potency doses of engineered food shared properties with drugs of abuse and spurred “addictive-like eating.” Refined sugar and fat together lit up the brain’s reward system. Hearing this, 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. Avena and Gearhardt reached a similar conclusion regarding the combination of sugar and fat in highly processed foods.

[The brain’s] circuits were not designed to solve the day-to-day problems of a modern American. There just haven’t been enough generations for it to design circuits that are well-adapted to our post-industrial life.”

Left unchecked, the brain’s reward system for moral indignation leads to the Spanish Inquisition, to witch trials—and to what goes on daily on Facebook and Twitter. Outrage keeps us engaged better than almost anything. This engagement allows social media apps to sell more ads, fueling their bottom line. In priming our natural outrage, an impulse that evolved to keep us alive, social media apps have us tearing each other apart. Like dope dealers—just peddling outrage.

Waiting for a street addict to reach rock bottom and choose to seek treatment sounds nice in theory. But it ignores the nature of the new drugs on the street. Now, rock bottom is often death. To those facing the epidemic’s grim realities, jail came to be seen as a necessary lever, a tool to force an addict to seek treatment before it was too late. 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.

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.”

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.”

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. “That continuum of care over an extended period of time—that’s where you find success,” said Mike Yow, director of Fellowship Hall, a treatment center in Greensboro, North Carolina. “It takes time. It’s not quick.” It’s also costly and labor intensive.

meth became a fentanyl substitute. You generally don’t overdose and die on meth, you decay. Meth kept withdrawal at bay, thus many seemed to believe meth was some kind of shield from fentanyl. Many users picked up meth, hoping it would keep them high, but alive, instead of dying on fentanyl. And while opiates had them nodding off, one woman I spoke with said meth “gets me off my ass to figure out how to get money: day labor, asking people to mow their lawns.”

Merrick had promised recovery in 90 percent of clients. But the definition of recovery, too, needed changing, he believed. The old definition—abstinence forever—wasn’t realistic, given the battles in the human brain between the reward pathway and the prefrontal cortex, which were messy. Recovery “is different for everybody; it means any positive change,” Merrick said as we sat in his office at the jail one day. People failed out of Unit 104 and the LLC all the time; some took several tries to get it right. The trick was to show that while all this was complicated to orchestrate, it was cheaper and produced better long-term effects on addiction and crime than how jail had been run.

We live in a time when drug traffickers behave like multinational corporations and corporations behave like traffickers. Both seem to understand our brains the way our neuroscientists do and have resources to prod them.

It is a sign of where we are that Wendy’s, Taco Bell, and McDonald’s use the language of drug addiction—hooked, cravings, triggers—as evidence of their products’ tastiness. Any addict, of course, knows the truth: cravings and triggers are torment, evidence of controlled brain chemistry. “Craveable, mind-blowing” is a product description the Sinaloa cartel might come up with.

Indeed, it is folly to attribute this epidemic to one drug, one company, one family—like the bad guys in some soap opera. So much more went into it. We Americans, so many of us, demanded convenience, to be fixed, wanting miracles and unwilling to do the work of wellness, unwilling to change what we bought, ate, and drank. We insisted doctors cure all our pain. Pills seemed to fit the bill. Insurance companies stopped reimbursing for therapies that did not involve pills, leaving doctors with fewer tools to address pain.

“At first you could see them thinking they still had control of their lives because they still had their clothes, dragging around suitcases and backpacks,” Norman told me. “Then you see them day by day. It goes from three backpacks and a suitcase to a suitcase and a backpack, then they don’t have nothing, just a backpack—complaining about how their stuff got stolen.”

That had been the model for years: get people housed, then treat their drug use. But P2P meth changed the model. These folks invited other users over, and together they tore up the apartments. Ortenzio watched this and realized that the new meth required places for users to detox, then spend time recovering—six weeks at least. Otherwise, “these people are unhousable,” he told me. “They can’t be managed. It’s not sane to just put folks in housing when they’re in this condition.”

The world Gary Henderson predicted when he coined the term “designer drugs” in 1988 is now with us. Counterfeit pills laced with fentanyl and made in Mexico now dominate the market and have replaced the sloppy Magic Bullet blender in a dealer’s kitchen and the powder fentanyl coming from China. In Los Angeles, DEA agents seized 120,000 of these pills crossing the border in 2017, and 1.2 million of them in 2020.

The British Empire has rightly received history’s condemnation for pushing its colonies’ opium on China—waging the two Opium Wars to do so in the nineteenth century. Those supplies took what had been a minor problem in China and created a drug scourge that would afflict that country for a century. Today in our hemisphere, Mexican traffickers’ role in creating and spreading these drugs is just as undeniable and corrosive. Mexico’s response has more than just failed. On the contrary, a new book by historian Benjamin Smith, The Dope: The Real History of the Mexican Drug Trade, shows that elements of the Mexican government have often controlled, guided, exploited, and aided those traffickers since the 1950s as they morphed from illiterate rancheros to criminal capitalists, even as these government officials went through the motions of battling the drug trade.

The problem is, I don’t trust American capitalism to do drug legalization responsibly. The last fifty years are replete with examples of corporations turning addictive services and substances against us, fine-tuning their addictiveness, then marketing them aggressively. Remember when social media was going to be the great technological connective tissue, bringing people together, inaugurating a new era of understanding? Instead, it midwifed an era of virulent tribalism. The opioid epidemic began with legal drugs, irresponsibly marketed and prescribed. The Sacklers are only one example of a tendency that nestles into every corner of American capitalism when it is allowed to extract maximum profit from products and services that neuroscience shows our brains are vulnerable to. Meanwhile, alcohol and cigarettes kill more than any other drug by far, because they are legal and widely available. Alcohol also drives arrests and incarceration more than any other single drug. Our brains are no match for the consumer and marketing culture to emerge in the last few decades. They are certainly no match for the highly potent illegal street drugs now circulating.