The Least of Us

A follow-up to Quinones's earlier book Dreamland, which chronicled the origins of America's opioid epidemic, this work of narrative nonfiction traces two intertwined stories: the rise of catastrophically potent synthetic drugs and the quiet efforts of Americans to repair the damage these drugs have caused.

Quinones opens with encounters at speaking events after Dreamland's publication in 2015, where families whispered about addicted loved ones and grandparents raising grandchildren. He watched the crisis evolve through four stages: prescription pain pills, heroin, illicit fentanyl, and a transformed methamphetamine. These synthetic drugs, he argues, ended the era of recreational drug use. Fentanyl, requiring no farmland and shrinking the supply chain to a laboratory and a mailbox, produced overdose deaths exceeding annual Vietnam War casualties. The new meth drove users to symptoms resembling schizophrenia: paranoia and hallucinations. COVID-19, he argues, re-created the isolation that spawned the epidemic.

The book weaves together several narrative threads. One follows fentanyl from its invention in 1959 by Belgian chemist Dr. Paul Janssen, who manipulated the morphine molecule to create a painkiller fifty to a hundred times more potent. Janssen recognized its abuse potential and initially restricted distribution, but he also published a 1968 paper listing dozens of possible fentanyl analogues that underground chemists would later exploit. Pharmacology professor Gary Henderson at the University of California, Davis, identified fentanyl in overdose victims across Southern California in the early 1980s and coined the term "designer drugs," warning that the future of drug abuse would be synthetics rather than plant products.

Quinones recounts how the Sinaloa cartel discovered fentanyl through what Drug Enforcement Administration (DEA) agent Ryan Rapaszky overheard on wiretapped phone calls in Chicago in 2005, a venture called "the Project." A chemist known as El Cerebro ("the Brain") ran a lab near Toluca, Mexico, originally funded to produce ephedrine, a precursor chemical for methamphetamine. Instead, he manufactured fentanyl, which street dealers in Chicago sold without adequately diluting it. Dozens died. Mexican authorities shut down the lab in 2006, and the deaths stopped, demonstrating that reducing supply could be the most effective form of harm reduction. But the cartel had glimpsed fentanyl's profit potential.

By 2014, a fentanyl gold rush was underway. Chinese chemical companies sold the drug openly on the internet. In Akron, Ohio, Quinones tells the story of Tommy Rauh, a young man whose addiction began with an OxyContin prescription for tendinitis in 2002. After more than a decade of struggle, Rauh died in 2015 from acetylfentanyl, one of the analogues Janssen had described. Detectives traced his death to a dealer who had ordered the drug from a Chinese vendor known as Gordon Jin. A federal investigation revealed Gordon Jin to be Fujing Zheng and his father Guanghua Zheng, a Shanghai operation selling fentanyl to at least 35 US states. The US indicted the pair in 2018, but with no extradition treaty, they remain at large.

Fentanyl democratized the drug trade. Amateur dealers mixed it using Magic Bullet blenders, kitchen appliances unsuited for blending potent powders evenly. Counterfeit pills made to resemble prescription oxycodone spread through social media apps like Snapchat, killing young people who had no idea what they were taking. Fentanyl also entered the cocaine supply, pulling African American communities into an epidemic that had previously been almost entirely white.

A parallel thread traces methamphetamine's transformation. Mexican traffickers learned to cook meth using ephedrine in the 1980s and 1990s, scaling production far beyond what American biker gangs ever achieved. When Mexico banned ephedrine in 2008, traffickers switched to the P2P (phenyl-2-propanone) method, which uses widely available industrial chemicals. Hundreds of independent labs sprang up across northwest Mexico, and prices fell roughly 90 percent. Users, counselors, and police described the same symptoms from this new product: violent paranoia, hallucinations, memory loss, and homelessness. Eric Barrera, an ex-Marine in Los Angeles, noticed the change around 2009, when the euphoric party drug turned into what his friends called "weirdo dope." Treatment providers reported that P2P meth damaged minds so severely that patients needed months before they could hold a conversation. Quinones argues that tent encampments spreading across American cities and towns are largely meth colonies.

Running through the book is the story of Purdue Pharma and the Sackler family, whose aggressive marketing of OxyContin beginning in 1996 helped ignite the epidemic. Quinones draws on a lawsuit filed by Massachusetts Attorney General Maura Healey and on an investigation by Tennessee state prosecutor Maggie Rowland and attorney Brant Harrell to show how Sackler board members directed sales strategy, pushed doctors to prescribe higher doses, and extracted roughly $10 billion from the company between 2007 and 2018 rather than diversifying. After mounting public pressure, lawsuits, and museum rejections of their philanthropic donations, Purdue pleaded guilty in 2020 to conspiracy to defraud the United States.

Quinones threads neuroscience throughout, drawing on researchers to explain how drugs hijack the brain's reward pathways. Dopamine, a neurotransmitter associated with motivation and pleasure, is overwhelmed by drugs of abuse. The nucleus accumbens, a key pleasure center, reduces its receptors in response, creating tolerance and cravings, while the prefrontal cortex, which governs impulse control, is silenced. He connects these mechanisms to legal addictive products, from processed food to social media, arguing that America's mass-marketing culture primes citizens for addiction much as sugar primed lab rats for drugs in neuroscientist Nicole Avena's experiments at Princeton University.

Against this landscape, Quinones tells stories of community repair. In Muncie, Indiana, Mike "Bird" Kissick quietly held together a crumbling neighborhood by running a community center without pay until his death in 2017. In Hardin County, Ohio, Judge Scott Barrett opened a Recovery Court and Sheriff Keith Everhart hired someone recovering from addiction as a janitor, watching the man's mind slowly clear over months. In Kenton County, Kentucky, Republican officials reimagined jail as a recovery center where inmates governed themselves and attended classes in behavioral change. In Clarksburg, West Virginia, former doctor Lou Ortenzio, who had lost his license for overprescribing and spent years delivering pizza, urged dying downtown churches to shelter homeless people, many of whom had meth addictions, during a polar vortex, an act that rejuvenated the congregations.

The story of Angie Odom and Starla Hope Hoss threads through the book as its emotional spine. Angie, a Navy veteran from eastern Tennessee who experienced a spiritual transformation on a destroyer tender in the Pacific, adopted the infant daughter of Starla, a young woman left in a vegetative state by an overdose. The child, Bella, grew up with extreme physical sensitivity and extraordinary empathy, visiting her birth mother with cupcakes and singing to her. When Starla died in 2019 at 33, Bella dictated the words for her gravestone: "I Love You no matter what happened" (374).

In an epilogue, Quinones returns to Portsmouth, Ohio, the town that led the country into the opioid epidemic, and finds it becoming a center of recovery. The Counseling Center has expanded into 48 once-abandoned buildings, funded largely by Medicaid expansion, while small entrepreneurs rehabilitate vacant storefronts and hire people in recovery. In an afterword, Quinones reports that overdose deaths surpassed 100,000 in 2021, with fentanyl involved in nearly 70 percent. He argues that the crisis demands both law enforcement leverage and expanded treatment, because the drugs are too potent for people to find their way out alone. He closes with the lesson he draws from neuroscience, the epidemic, and the pandemic alike: "we are strongest in community, as weak as our most vulnerable, and the least of us lie within us all" (371).