November 19, 2021

It’s tempting to think about America’s opioid crisis in the past tense. The Sackler name — which belongs to the family that owned and ran Purdue, the pharmaceutical company that flooded America with addictive painkillers — has long been removed from the walls of the art galleries and museums they showered with money. Lawsuits have been settled. Dozens more are ongoing. Stories of addiction in Appalachia and rustbelt overdose deaths fill bookshop shelves. You can watch the same tale play out on Hulu’s TV series Dopesick.

But America’s lethal addiction crisis is far from over. In fact, it’s worse than ever. According to data published by the Centers for Disease Control published this week, more than 100,000 Americans died of a drug overdose in the 12 months between April 2020 an April 2021. It is the first time the figure has reached six figures over a year-long period and represents a 28% jump on the previous 12 months.

As I have reported before for UnHerd, the pandemic quickly undid what limited progress had been made in the fight against opioids before 2020. Lockdowns left recovering addicts alone and starved of the human contact that is so central to staying sober. Relapses spiked, and with them deaths. “Isolation is the opposite of what you need for recovery,” one pastor in West Virginia told me.

But the pandemic is only one dimension of what amounts to a serious public health emergency. And the prescription pills peddled by Big Pharma that most people think of when they hear the words “opioid crisis” aren’t the biggest problem. Today’s battle is against two synthetic drugs: one that kills with terrifying ease, another that creates zombified and desperate addicts almost overnight. These have transformed America’s drug landscape, and rendered obsolete a lot of conventional wisdom about drug use, addiction and the proper policy responses. They are not the drugs fondly remembered by ex-hippie Boomers.

“I don’t know any longtime fentanyl users,” one addict-turned-counselor tells the journalist Sam Quinones in The Least Of Us, his new book on America’s metastasising addiction crisis and the two drugs at its heart. “They all die.”

Today, fentanyl is responsible for the majority of drug deaths in America. In tiny doses it gives users a high that resembles the blissed-out pain relief delivered by heroin or prescription pills. But it is far stronger and more deadly. In anything other than those microscopic quantities, it will kill you. The other drug central to the latest phase of the addiction crisis is methamphetamine, in particular a kind cooked up using a method known as P2P, which uses phenyl-2-propanone.

This new meth isn’t like the old meth. “I wouldn’t even call it meth anymore,” an addict-turned-councillor tells Quinones. Some gangs refer to it as “weirdo dope”. One user, Kirsten, explains that it was not the party drug that used to cause her to chat endlessly and crave companionship. After using the new meth, she “had trouble talking, unless it was to herself. She heard voices.” She struggled to eat and rarely left her home: “Her once-pretty smile faded along with the enamel on her teeth, which turned black and abscessed. Her head jerked uncontrollably. She gave her son to her family to keep him safe. By 2016, she was seeing angels and demons… She began barking like a dog in public.”

Users across America were all experiencing the same thing: paranoia, hallucinations, isolation, uncontrollable limbs, memory loss and garbled speech. Together, fentanyl and meth, Quinones writes, now form “an unmercifully addictive, mind-twisting, and deadly concoction that no one demanded”. That point is crucial. No one asked for this. These designer drugs were not devised with a particular set of consumer tastes in mind.

As The Least Of Us makes clear, they are first and foremost, supply-side innovations. The supply chain found a way of making drugs that were easier to produce than their naturally occurring equivalents; far more addictive, far cheaper. The results have been immensely lucrative — and devastating.

Fentanyl was initially imported with the click of a button from unregulated Chinese producers. After a government clampdown, that then switched to Mexico and domestic production, where the raw ingredients for the rudimentary production process were imported instead of the finished product.

The story with P2P meth is a little more complicated. For years, producers had preferred the method of production that extracted ephedrine, an ingredient used in over-the-counter drugs. Meth was churned out on an industrial scale in Mexico this way, and on a smaller scale in the US, where ephedrine could be found in drugs such as Sudafed. But a clampdown on that substance on both sides of the border led to a different, messier technique. The advantage of the so-called P2P method is that the ingredients are easier to come by: a list of legal and widely available chemicals. The disadvantage is that the methamphetamine it produced is — to simplify a little — a lot dirtier, filled with all sorts of noxious stuff. But the producers didn’t care: it was cheap and easy and meant they could deliver addicts a highly addictive fix with minimal fuss. Again, supply-side issues, not consumer tastes, explained the change.

These are drugs for the age of the gig economy. You don’t need capital, you don’t land, you don’t need armed guards. You just need an internet connection and, for fentanyl, a magic bullet blender (the brand of choice, apparently). As Quinones writes, the gadget “fit snugly with fentanyl’s disruptive allure, which was this: that with minuscule investment of learning and money, anyone — even someone in boxers in his mother’s basement, without education nor connection to mafia or trackers — could now making a killing. And beginning in about 2015, they did.”

In spite of this brave new world of synthetic drugs, we are stuck in the shadow of the Sixties and Seventies and the idea that drug use is “a form of adventure, particularly for a young man who had intellect and a thrill-seeking soul”. But that culture was formed in an era when the drugs were a far cry from the “highly potent marijuana, corrosive methamphetamine, and powerful narcotic pain pills in unprecedented supply”.

The big argument in The Least Of Us is that drugs explain the drugs crisis. That may sound fatuous, but it’s important. Yes, demand matters, but pontificating about the root causes of American unhappiness — post-industrial decline, family breakdown, listlessness and so on — misses the point. The lethal addiction crisis is, first and foremost, about receptors in our brain and the horrifying availability of chemicals that attack them with overwhelming force.

We are dealing with a chemical assault: a woeful mismatch between 21st-century compounds and our stone-age brains. In other words, it’s the drugs, stupid. Put simply, this is a fight for what it means to be human. As Quinones puts it: “Our brains are wondrous, mystifying, complex organs. From them have sprung awesome creations, innovations, inventions. Drugs dim those gorgeous lights to gray obedience. Our brain on drugs resembles the regime that imprisons its great writers, artists, and scientists.”

By messing with the pleasure circuits we have evolved in order to eat, have sex, socialise in a group and pass on our genes to the next generation — things that have kept us alive and helped us thrive for millennia — drugs diminish what makes us human, and kill all sense of community. (Understand this and you understand how the pandemic has made the problem so much worse.)

Our blindness to the potency of modern drugs also means we have ignored the spillover effects of addiction. The proliferation of homeless encampments in American communities of all sizes, Quinones argues, is first and foremost a consequence of the new meth: “Homelessness is different now — more prolific, more stationary, less transient,” he writes. “Much of it now is rooted in the voluminous supplies of meth that Mexican traffickers’ switch to the P2P method made possible.” In light of this insight, the focus on “housing-first” approaches to homelessness miss the point.

Ultimately, the twin meth and fentanyl assault on America scrambles conventional debates about drug legalisation and decriminalisation in unpredictable ways. An addiction crisis largely started by over-prescribing addictive pain pills before has become a story of deadly illegal synthetic drugs made with ever-changing combinations of widely available substances. The question of what the law proscribes feels besides the point. On the one hand, Oxycontin and the other addictive painkillers pushed by pharmaceutical companies starting in the Nineties undercuts the legalisers’ claim that a regulated market saves people from abuse. On the other, the restrictionists will never be able to keep up with the labs, who will always be one step ahead in the hunt for cheap, easy-to-manufacture addictive chemical compounds.

First and foremost, the problem is one of supply: the challenge is to find ways to prevent the aggressive marketing, and dramatic increase in supply, of highly addictive, very dangerous drugs — legal or illegal. Here, the emergence of Big Weed and its campaign to sell high doses of THC as part of a healthy lifestyle is surely an ominous development.

For his part, Quinones says his instincts are with the liberals, but is cautious about the consequences. In particular, he believes in the need for continued criminalisation “not as a reason to send someone to prison” but as “leverage we can use to pry users from the dope that will consume them otherwise”. It is not good enough, he argues persuasively, to wait for someone to “hit rock bottom” and seek help. Today, people “are living in tents, screaming at unseen demons, raped, pimped, beaten, unshowered and unfed”.surely  If that’s not rock bottom, what is? When it comes to fentanyl, the answer is death. Coercion must be part of the solution.

The Least Of Us is a bleak wake-up call, but Quinones ends on an upbeat note. Perhaps, he argues, the misery of the drug wave sweeping America will do what other crises haven’t done and bring about much needed community reconstruction.

I’m less optimistic. Not because America’s communities, from small Appalachian towns to big coastal cities, lack resilience. But because of the mismatch between our stone-age brains and terrifyingly addictive drugs. Even as the latest overdose numbers make headlines, America is yet to properly come to terms with the seriousness of what it is up against. However, despite all the bleak headlines and grim statistics, I’m left with the horrible feeling that the country hasn’t quite hit rock bottom.