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Opioids are still killing us, now with a new wave of synthetic drugs

Kimberly Boyles/Kimberly Boyles -

You can find the headlines anywhere, any day.

A representative one, from the September 27 Washington Post: “With overdose deaths soaring, DEA warns about fentanyl-, meth-laced pills.” That article notes that 2020 saw a record 93,000 US overdose deaths, an increase of nearly 30 percent over 2019 numbers.

It’s easy to tune this stuff out, especially 2020 statistics. I mean, what a year, right? We all maybe drank or smoked or ate a little more, so it might stand to reason that those further out on the substance-abuse spectrum might have also overindulged, leading to more overdoses than usual.

But it’s not like that at all. As Sam Quinones demonstrates in “The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth,” these overdoses are the result of market forces that have flooded the illicit drug trade with synthetics that are cheaper, more potent, and more abundant than ever.

Quinones has been on this beat for years. In 2015′s “Dreamland: The True Tale of America’s Opiate Epidemic,” Quinones outlined an innovative heroin distribution system run by a not-quite-affiliated group of independent franchisees who mostly hailed from a region of the tiny Mexican state of Nayarit. He called them the Xalisco Boys. All across the country, they delivered heroin “like pizza” — on demand, in tiny little balls carried in balloons they held inside their mouths.


The elegant insight in “Dreamland” — the reason it won the 2015 National Book Critics Circle Award for Nonfiction — was the way Quinones mapped the spread of the Xalisco Boys’ operations neatly onto the map of pill mills across the country, in Appalachia and elsewhere. The Xalisco dealers gained their footholds in new communities by targeting those pill dispensaries and methadone clinics. Heroin was now a rural drug, too — and there was one family to thank.


You might have seen their names on art museum wings and medical schools (including at Harvard and Tufts, among many others), or you might have read Patrick Radden Keefe’s “Empire of Pain,” a fuller account of the family’s malfeasance. But before their names came off those buildings, before Keefe’s book was published, before much of the country had heard of the Sackler family — a pox on all of their (many, expensive) houses — Quinones was on the case.

He documented how the Sacklers through their company, Purdue Pharma, aggressively exploited the late-70s/early-80s movement in health care to treat pain as “the fifth vital sign.”

I bring up “Dreamland” at some length here because “The Least of Us” is very much a continuation of Quinones’ work in the earlier book: “When the 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.”

A breathtaking assertion.

The news here is in synthetic drugs. Around the world, various underground chemists figured out how to synthesize fentanyl and meth on their own. This meant traffickers were no longer beholden to the cyclical nature of the poppy harvest or the difficulties of cooking meth from ephedrine.

And the Sacklers are still very much the villains.

As Quinones summarizes it in “The Least of Us”: “The pills [OxyContin] were sold as time-saving solutions for harried doctors who had been told that there was an epidemic of pain afoot, but who had little time or training to address it.” This was a perversion of what the revolution in pain management had been about. The doctors who urged treating pain as that fifth vital sign also urged a holistic approach — medication plus physical and psychological therapy, diet, exercise, and someone checking in with you along the way.


But guess what the insurance companies agreed to pay for. Of course: pills.

In 2009, after its federal conviction for illegal and dishonest marketing tactics., Purdue brought in McKinsey “to develop strategies to improve brand loyalty to OxyContin.” One solution Purdue arrived at was “smaller doses, 10 mg and 15 mg pills, [which] allowed reluctant family doctors to begin prescribing OxyContin more cautiously — and would lead to higher dose prescriptions in the future … .” This is your classic “first one’s free” dope-peddling.

We are living in the world Purdue Pharma wrecked, and we meet a number of its victims in this sprawling book, people who lost livelihoods, homes, and families. But Quinones also offers what he calls “unnoticed tales of community repair” — in counseling centers, halfway houses, and drug courts.

He describes how in even a deeply-red Northern Kentucky county “[t]he word junkie plummeted from favor. Compassion became the buzzword.”

When people got to know addicts personally, see the hold drugs could have, they softened their stances, and were inclined toward help.


“If there was one thing I found that the opioid epidemic was teaching folks across America about addiction recovery,” Quinones writes. “It was that this small, daily stuff mattered, all of it.”

Quinones has done a marvelous job of cobbling together individual stories to give us a sense of how the systemic failures fall — hard — on individuals. After demonstrating that drug dealers on both sides of the law are responding to the capitalist imperative, he goes on to argue that this is because capitalism, at the end of the Cold War … “lost its competition”? “Without competition,” he says a little later, “[C]apitalism has bent toward the agglomeration of profit and power in the hands of relatively few.”

Sam, this is not a bug, it’s a feature.

“The continuum of care over an extended period of time — that’s where you find success, It takes time. It’s not quick.” Quinones quotes the director of a treatment center in North Carolina as saying, before adding “It’s also costly and labor intensive.”

That everyday stuff — because it’s not valued, because it’s not accounted for is, literally, priceless. And we shouldn’t try to price the priceless; we should demand that capital fork over more of its massive hoard.

Sebastian Stockman is a teaching professor in English at Northeastern University. He writes A Saturday Letter at

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


Sam Quinones

Bloomsbury, 432 pages, $28