The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth, by Sam Quinones (Bloomsbury, 432 pp., $28)

Lots of bad books have been published about America’s drug crisis. One hundred thousand overdose deaths in a year—what the CDC recently recorded for the 12 months ending last April—attract considerable attention. But just because a topic is popular doesn’t mean that books about it are invariably worthwhile. The common theme of bad drug-crisis books is a fixation on the past. They endlessly recapitulate the lives of the Sacklers, the wealthy family that owns Purdue Pharma, the firm whose Oxycontin pills helped ignite the crisis. They talk at length about iatrogenic addiction (caused by medical treatment) and the toll of domestic production, treating foreign drug cartels as an afterthought. They tell and retell the story of the drug crisis as it was ten or 15 years ago, not as it is today.

By contrast, journalist and author Sam Quinones has long been on the cutting edge of the crisis. His 2015 book, Dreamland, is the canonical study not only of how American pharmaceutical firms created a wave of addiction but also of how Mexican drug cartels and Chinese pharmaceutical manufacturers turned it into the highest drug-overdose death rates ever recorded. Late last year, Quinones released a sequel of sorts, The Least of Us, documenting both how the drug crisis has changed and how communities across the country have tried to combat it.

Quinones offers the best summary to date (though beaten out in timeliness by 2019’s Fentanyl, Inc.) of how the drug market has come to be dominated by “synthetic” drugs—intoxicants produced entirely in labs, no longer restricted by the production constraints imposed by field-grown opium or coca. Dreamland ends just as the synthetic opioid fentanyl begins to appear on the scene, but the near-doubling of OD deaths between 2015 and 2020 is attributable largely to the introduction of the drug and its effective replacement of the heroin supply.

The dramatic shifts in the supply side do not stop with the introduction of fentanyl. As Quinones documents, the disintegration of pre-fentanyl cartels has effectively created a free drug market in Mexico, as abundant chemists and few constraints drive supply up and prices down. In addition, The Least of Us is one of the first books to acknowledge the swelling methamphetamine crisis—meth OD deaths are the only category of drug death in which recent increases cannot be attributed exclusively to fentanyl adulteration. The meth scourge is driven by the same dynamic of synthetization and a dramatic increase in supply.

In his reporting, Quinones turns up details nowhere previously reported. Street dealers use “magic bullet” blenders to dilute fentanyl, thereby imperfectly mixing powders and creating deadly doses. Quinones also floats a theory—the most controversial part of the book—that a change in the illicit methamphetamine manufacturing process makes today’s street meth more likely to induce psychosis. He blames this change for surging homelessness in many large cities.

That theory awaits further empirical validation, but the general picture that Quinones paints of the drug supply is accurate and grim. Thanks in large part to an interconnected world, illicit drug manufacturers now enjoy access to the hardware and the know-how to make incredibly potent drugs, in such supply that they are cheaper than ever before. This shift in the supply structure of the drug economy explains why the OD death rate has quintupled since the turn of the millennium.

What are we to do about this wave of death? The other half of The Least of Us—the eponymous half—takes up this question. Intermingled with the story of surging supply is Quinones’s account of how communities have fought back, finally coming together to take the crisis seriously. These parts of the book manage to be affecting while avoiding the sentimentality so common to reporting on those recovering from drug addiction. And while Quinones embraces some of the approaches most in vogue among “harm reduction” aficionados—widespread naloxone access, for example—he avoids the ideological nihilism of insisting that there is no place for coercion in drug treatment, reporting positively on drug courts and jail-house treatment programs. He also emphasizes the power of faith and the importance of churches as a bulwark of social capital against the storm of drugs.

Yet even amid these uplifting stories, it’s hard not to see a more pessimistic possibility. American drug crises move in cycles: a drug emerges and takes the public by storm; addiction and death set in; the drug’s appeal wanes as the public turns against it. This was the pattern of America’s first drug crisis, when soldiers came home from the Civil War hooked on morphine (administered on the battlefield with the recently invented hypodermic syringe). It happened for cocaine in the early twentieth century and again in the 1970s and 1980s; it happened for amphetamines in the 1950s and again in the mid-2000s.

If the pattern holds, the current crisis will burn out only when the allure of the latest generation of drugs is outweighed by a collective understanding of their effects. The difference is that this time, because of the synthetization of the market, the magnitude of the wave is far greater—far more people will die before death rates go down. In fact, a deadlier drug supply means that even the “base” rate of OD deaths will remain far above what it was decades ago, well after deaths begin to decline.

We can and should do much more to try to stop people from dying from drugs. The interventions that Quinones endorses may save lives or rescue people from addiction; securing our porous border with Mexico is also an imperative. But we should not fool ourselves: there is no going back to the pre-synthetic world. Tens of thousands of Americans will die yearly from drug overdoses, despite every effort to prevent it.

Quinones tries to remain optimistic, but his reporting on the supply side of the drug crisis casts doubt on the possibility of curbing the damage. Policy, the late political scientist James Q. Wilson once wrote, requires “a sober view of man and his institutions that would permit reasonable things to be accomplished, foolish things abandoned, and utopian things forgotten.” Against the drug crisis, such sober resolve is needed: to do what we can, even knowing it cannot possibly be enough.

Photo by Tayfun Coskun/Anadolu Agency via Getty Images


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