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The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth. Sam Quinones. Bloomsbury Publishing: New York.

For much of 2018 and 2019, I reported on the opioid epidemic and drug treatment while also working in San Francisco as a public health researcher interviewing people who injected drugs. Back then, fentanyl, a synthetic opioid up to 50 times more potent than heroin, was just beginning to flood the city. Suddenly it began showing up mixed with heroin, meth, opioid pills, cocaine (both powder and crack) and even marijuana, resulting in deadly accidental overdoses. 

It never made sense why such a deadly drug would be mixed with all those others. People had ideas – from accidental contamination occurring in transport or storage to a sinister plot to increase profits by hooking more people with fentanyl. While likely true in some instances, these theories were unsatisfying. Only after reading The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth did I finally begin to get some answers to these burning questions that have nagged at me for years: how fentanyl came to flood the drug market and lead to the deadliest drug epidemic the country has ever known. 

The author, Sam Quinones, journalist and former Los Angeles Times reporter, paints a compelling picture based almost entirely on interviews that track the rise of cheap and very potent synthetic drugs – fentanyl and meth – that came from China and Mexico to neighborhoods across the nation, spreading addiction, havoc and death.

“Fentanyl was a boon to traffickers and street dealers,” Quinones writes. “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.” 

Bloomsbury Publishing

The entire book is not just despair and sadness – though most of it is. Quinones wants us to believe that there is hope in the tragedy. That the drug epidemic has spurred compassion and resilience. Speaking with people from Southern California to the rust belt, Quinones heard individual stories of change and hope. Though taken alone, these glimmers would hardly dent the carnage of the fentanyl devastation, taken together and over time, they might help mend the country.  

“Those conversations convinced me that our opioid-addiction crisis, because of its devastation, was also a great force for change,” Quinones wrote. “No other issue brought together Americans who didn’t agree on anything else.”

The Least of Us is the sequel to Quinones’ Dreamland: The True Tale of America’s Opiate Epidemic, which was published in 2015 and became the defining book of the opioid epidemic. In Dreamland, he employed narrative and reporting skills to recount how uninhibited opioid prescribing practices in the 1990s, combined with ruthless marketing and sales tactics by Purdue Pharma, the maker of Oxycontin, led to the opioid epidemic. 

In The Least of Us, Quinones picks up where he left off in Dreamland, exploring the next stages of the opioid crisis, going from prescription pain pills to heroin, to fentanyl and meth. Quinones posits that drug cartels and traffickers capitalized on the opioid epidemic by flooding the market with fentanyl, which was much easier to acquire, stronger and cheaper than heroin. Unlike heroin, which needs poppy plants to produce, fentanyl is fully synthetic and needs only certain chemicals to make it. Around the same time, meth cooks were moving away from the ephedrine-based model – mainly because of the US and Mexico’s crackdown on the main ingredients – toward a more versatile meth called phenyl-2-propanone meth (P2P), according to DEA agents he interviewed. 

Quinones reports that unlike its predecessor, this new meth, no longer reliant on ephedrine, could be made in vast quantities. While not causing massive death like fentanyl, he writes that the “new meth gnawed at brains in frightening ways” and led to more intense and severe symptoms of schizophrenia, including paranoia, delusions and hallucinations. 

Mental health workers told him people addicted to the new meth were almost impossible to reach at first, with some unable to remember who they were or what had happened to them and needing up to 14 months in treatment to recover. In southwest Virginia, former drug counselor Eric Greene reported that people addicted to P2P meth had caused a crisis in the state mental health system because they were pouring into state hospitals “grossly psychotic.” Greene concluded that “it’s been difficult to help the truly mentally ill to get help because the facilities are full of people who are on meth.”

“The way I saw myself deteriorating, tripping out and ending up homeless, that’s what I see out here…These people had normal lives.”

Eric BArrera, former marine, drug counselor and ex-meth addict

Quinones spoke with a neuroscientist who recounted an experiment in which researchers discovered that rats that consumed sugar water for an extended period had their brains altered to be more susceptible to addiction. Quinones sees a parallel: The abundance and intense strength of synthetic drugs may prime the brain for addiction, with people switching from meth to fentanyl, or vice versa, depending on what’s available. “Once a person is addicted to one drug, trying another, and another after that, is easier. We are not so different, it turns out, from those sugar-dependent rats,” he writes. “One drug consumed long enough primes us for another.”

With a penchant for using Silicon Valley lingo, Quinones calls fentanyl a disrupter, democratizing drug dealing like “Amazon and Uber upended retail and taxis,” he writes. “Fentanyl upended the dope world the way tech disrupted business. No farmland needed – no pesticides, no harvesting, no seasons, no irrigation,” he writes.

While these anecdotes aren’t too different from what I heard on the street years ago, reading about them and seeing the connection to the larger context of the rise of synthetic drugs gave it new meaning and sold me on Quinones’ main argument: “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.” 

The book is largely a collection of interviews the author conducted with frontline addiction workers, drug users, attorneys, judges, physicians and some brain scientists – coupled with good old-fashioned street reporting. As such, the book’s premise is based almost entirely on anecdotal data, and Quinones has few hard facts to bolster his claims (in part because little research has been done on P2P meth). 

Tent city in Los Angeles near entrance to freeway, 2018

His claim that a new super-strong meth may be driving homelessness has been the fodder for critiques questioning his lack of proof. New York Times columnist  Jay Caspian Kang, for example, notes that while West Virginia has the highest rate of drug overdoses in the country, it also has one of the lowest rates of homelessness, “in part because housing is so cheap there.” 

Quinones agrees that soaring housing costs also contribute to homelessness, and that our drug epidemic is fueled by larger societal problems, such as jobs transferred overseas, the increasing concentration of U.S. wealth, and Fortune 500 corporations that pay no federal income taxes “while many American families worry about rent and food.”

But some critics worry the book will stoke fears about another “super drug” – P2P meth in this case – and could lead to increased criminalization of drugs and homelessness, much like the panic over crack cocaine that resulted in “sentencing disparities that put hundreds of thousands of Black people in prisons for lengthy terms,” as Kang put it. Others worry it will undo years of efforts by advocates to reduce the stigma associated with addiction.  

If you’ve ever looked at the Nextdoor app, you know there are plenty of people looking for any excuse to bring the hammer down on addicts and those accused of petty theft, which often go together. Yet a close reading of The Least of Us suggests a more compassionate community response is occurring, and that is what Quinones is advocating. The book’s title comes from a phrase in the Bible that warns society we are only as strong as the least of us. 

Quinones suggests the only way to stall the epidemic is to cut off supply, which means Mexico needs to crack down on drugs and corruption. He also opines that courts and probation should play a bigger role in fighting addiction but have been hamstrung by laws like California’s Proposition 47, passed by voters in 2014, that reduced drug possession from a felony to a misdemeanor. Without the threat of serious punishment, he maintains, courts have less leverage to compel drug users into addiction treatment.  

The book’s title comes from a phrase in the Bible that warns society we are only as strong as the least of us.

The Least of Us does not make a convincing argument that P2P meth is driving the homelessness epidemic or that the threat of serious punishment will compel more drug users into addiction treatment. Nonetheless, it paints a vivid, compelling picture of the impact that fentanyl and meth have had on the nation. Quinones is a masterful storyteller, and his writing shines the brightest when telling the heart-wrenching stories of individuals torn down by fentanyl or meth. The book is not for the faint of heart, but the stories he unearthed through his indefatigable reporting are beautifully told. Although most of the stories in the book are tragic, he manages to tell these stories in ways that inspire a sliver of hope. 

Eric Barrera, a formerly homeless ex-Marine addicted to the new meth, received treatment through the Veterans Administration and is now a drug counselor on Skid Row in Los Angeles. He also has a home he can hold onto, now that he is no longer doing meth. He is part of a Skid Row running club that jogs through the encampments to model wellness. He sees his former self in the people on the street ranting and terrified by paranoid delusions. “The way I saw myself deteriorating, tripping out and ending up homeless, that’s what I see out here…These people had normal lives.”

Some of us who have followed the drug epidemic from the inside have heard these stories of pain, loss, degradation and (sometimes) recovery untold times. But Quinones connects the dots in drug trafficking in a way that offers a powerful journalistic account of how fentanyl came to ravage our country – and how people addicted can recover. The book is a must-read for anyone who works in behavioral health and addiction treatment or is concerned about this terrible epidemic.

Brian Rinker

Brian Rinker, M.S., is a freelance writer, journalist and storyteller who writes about public health, child welfare, and venture capital. He has been published in Kaiser Health News, Health Affairs, The...