just asking questions

One Million Dead

Dreamland author Sam Quinones on the opioid epidemic’s toll and why it’s time to attack cartels.

Gabriella Santamaria, 9, holds up a picture of her uncle Stephen who died from a heroin overdose during a candlelight vigil on Staten Island. Photo: Spencer Platt/Getty Images
Gabriella Santamaria, 9, holds up a picture of her uncle Stephen who died from a heroin overdose during a candlelight vigil on Staten Island. Photo: Spencer Platt/Getty Images

For the past few years, figures illustrating the nation’s overdose death toll, driven largely by opioids like Oxycontin and fentanyl, have been appearing in headlines with jaw-dropping frequency. In 2019, drug overdoses eclipsed car crashes as the leading cause of accidental death in the United States. For much of 2020, the daily death toll surpassed that of car accidents and gun deaths combined. Then, at the end of 2021, the CDC released a study showing that the U.S. had officially surpassed 1 million overdose deaths since the agency began collecting such data in 1999. It was a grim milestone that passed unceremoniously, perhaps because it was  overshadowed by the COVID-19 pandemic or because Americans are by now well-aware of the toll opioids have taken on the country.

That awareness is thanks, in part, to a string of best-selling books on the opioid epidemic, chief among them 2015’s Dreamland, by Sam Quinones, a reporter who spent most of his career at the Los Angeles Times. In Dreamland, Quinones chronicled the history behind America’s addiction to heroin and Oxycontin by reporting on the corporate and criminal forces fueling their rise, and painting a compassionate portrait of the everyday victims addicted to the drugs. The book earned him a National Book Critics Circle award and was recently featured on GQ’s 50 best narrative nonfiction books of the century. Then came Beth Macy’s Dopesick, made into a popular series on Hulu, and Patrick Radden Keefe’s Empire of Pain. In November, Quinones published The Least of Us, a follow-up to Dreamland that dives into the ever-more addictive, dangerous, and widely available fentanyl and methamphetamine killing people across the country. With no farming costs, synthetic drugs are significantly cheaper to produce than heroin, and far more potent, which it’s often mixed in with other drugs, with deadly consequences.

“Nine years ago, I got into this thinking it would be a very neat story about drug companies and doctors prescribing opioids on one hand and Mexican trafficking of black-tar heroin on the other,” Quinones told Intelligencer. “But along the way, I came to the conclusion that this was a much deeper, broader story about who we had become as Americans, what we had become as a country.”

Intelligencer spoke with Quinones about how opioids and methamphetamine are both a symptom and result of America’s 21st-century culture.

What is the significance of 1 million overdose deaths over the past two decades?
When you look at that figure, it shows you what supply has done. When I lived in Mexico, the thought was that this was all the creation of American demand and I kind of went along with that because I hadn’t really studied it too closely. I don’t believe that anymore. If you look at what is behind all this, it’s the supply of drugs. The opioid epidemic started with the supply from a new source, which was doctors and pharmaceutical companies. Massive over-prescribing, endless refills, with no care about to whom doctors were prescribing these drugs. In the last several years, the supply has been taken over by the Mexican trafficking world. Modern consumer-product corporations understand the importance of supply. That’s why they put fast food at every offramp. That’s why they fight for space in grocery-store aisles. They know that ease of consumption will lead to more profit. Right now, there’s a steady supply of the most deadly drugs we’ve ever known. There are a lot of different issues going on here — I write about the conditions in our culture that make us very vulnerable to this stuff — but the massive supply of very potent opioids, in one form or another, is how you get here. If the drugs were less powerful, potent, prevalent, it’s hard to imagine we’d see 1 million dead Americans over 20 years.

Reading about synthetic drugs during COVID, I couldn’t help but think about them as the ultimate variant that will overtake all other drugs, and whose spread feels all but unstoppable. You come down in favor of efforts to really reduce this supply, which is like stamping out COVID. I’m wondering how policy makers can stem the supply without repeating the sins of the war on drugs.
I don’t see how we can do much with treatment until there’s some relenting on the part of the supply. Any addict who gets out of recovery today faces a scary array of very cheap, very potent, and easily available dope. I believe that one thing this is calling on us to do is to develop the kind of relationship with Mexico that would allow us to collaborate together on this issue. When you apply the power of well-organized, motivated law enforcement, you can do a lot of things to enforce the rule of law. We saw this in New York City with the five Mafia families. For something like 50 years, the FBI, led largely by J. Edgar Hoover, didn’t really touch the Mafia. It allowed them to do what the trafficking world in Mexico is now doing, which is digging deep into the legitimate economy. The Mafia knew they could get away with not just prostitution and the numbers racket, but interfering with unions and waste management. Hoover died and the FBI went through a very necessary modernization. We enacted RICO statutes. All of a sudden, those Mafia families get taken down. Those families were believed to be more powerful than any police force and when you put an array of forces against them, they faded and spent the last years of their lives in prison.

The Mexican trafficking world is more advanced and scarier, but that’s a direct result of the Mexican government’s failure to stop this and our failure to stop the flow of guns that are purchased so easily here in the United States, which are smuggled south and provide traffickers the impunity that they enjoy.

In November, New York opened the country’s first safe-injection sites for drug users and other cities are following suit. Is that putting the cart before the horse?
Maybe. I don’t know. I’m interested to see what effect they have. I don’t believe we should be saying no to anything right now. Every form of treatment needs to be tried. The problem that I think may happen with the safe-injection sites is that they will be evaluated with the statistics of how many people they revive, and I’m sure they will revive many. But that shouldn’t necessarily be the barometer of whether or not the sites are successful because eventually someone who is revived five, six, or eight times at a safe-injection site is going to keep on using and they may be using when they’re not near a safe-injection site and die. The key barometer for those safe-injection sites is going to be how many of those folks who come to them and are revived are then channeled effectively into treatment. Saving a person one time is wonderful and it is absolutely a good thing, but if all you’re doing is postponing the inevitable, then I’m not sure that actually works as a solution.

I say postponing the inevitable because there’s really no such thing as a long-term fentanyl street user. They all die. I was speaking with a judge in West Virginia who runs a drug court, and I asked him, “Hey, what are you seeing? What’s going on in your area?” He goes, “Well, really, all of our clients are meth addicts.” I said, ‘Really? You don’t have any fentanyl users? Why is that?” He goes, “Um, they all die. They don’t stay using fentanyl long enough to become a client.” That reflects things I’ve heard across the country. There’s an idea in drug-addiction recovery that you need to develop the gift of desperation to really fuel your own desire for recovery. You’ve been through so much junk and crap and humiliation and grinding by these drugs that you develop a desperation. It’s a gift for recovery, for sobriety. Fentanyl doesn’t allow the time for you to develop the gift of desperation. It kills you too quickly.

Methamphetamine appears to very quickly create mental illness. And then with it, it’s becoming clear, brain damage. Many people who I’ve talked to are telling me that just because someone stops using this methamphetamine does not mean they return to some kind of baseline at which they are coherent and in control of all their faculties. I spoke with a woman who is still in anguish because after two years of sobriety and her brain still hasn’t returned to the same acuity it had before this methamphetamine. She can feel it.

You put forth a theory that draws a direct line between the sharp increase in homeless tent encampments and a 2008 decision by the Mexican government that forced traffickers to change their meth formula.
First of all, I kind of bridle against the idea of it being a theory. I’m not upset about the word choice, but it’s based on street reporting. Sure, there is no neuroscience, rat or mice studies, that shows that the stuff seized on the streets of the United States today creates these problems. I understand that, and said that in the book. However, there is ample evidence that wherever this meth goes, it is accompanied by rapid onset, very severe, symptoms of schizophrenia, mental illness, and then quickly homelessness and tent encampments. This isn’t just in cities like L.A. I’ve talked with people all across the country, including areas where the cost of housing isn’t high. Three chapters in the book talk about what happened when that meth came to a small Rust Belt town, Clarksburg, West Virginia. They didn’t have homelessness in Clarksburg before this meth came. I’ve spoken with people in Bernalillo, New Mexico, also a town where there is absolutely no problem finding cheap housing. They now have homelessness. They didn’t have it in Salem, West Virginia, either. What I’m saying is that this meth is not just in the big cities where they’ve had this famous problem of homelessness, like San Francisco or Los Angeles. This meth is now reaching pretty much the entire country.

Photo: Bloomsbury

In terms of reaction and general interest, how does the experience of publishing a book about a deadly, addictive, and widely available drug in 2021 compare with publishing one in 2015?
I would say that there’s far more awareness now of this whole issue than there was back then. When I was writing Dreamland my wife and I were convinced that it would fade immediately. And the reason for that was because, during the writing and reporting, I found very few families with addicted loved ones who wanted to talk about it. It was all very hidden. Everyone was mortified, ashamed, embarrassed. I found five families to quote, and that was trying pretty hard. There was this national silence around this issue. When the book came out, we watched as awareness grew. Then, I began to get more and more invitations to come speak about it. That was something I was positive would never happen. When the book came out, there were actually only three lawsuits against Purdue Pharma and other drug companies. Three. Within a couple of years, there were like 2,600 lawsuits.

What has it been like for you personally to watch the Sackler family’s fortunes change so dramatically?
That was another thing I could not imagine. I remember walking in a neighborhood called the Bottoms in Lucasville, a small town in southern Ohio. The Bottoms is right next to the Scioto River. It’s a neighborhood of trailers and folks that have been taking it rough. A lot of people were addicted to Oxycontin. I walked through that neighborhood and I remember thinking there’s no way these people have the voice or the power to ever force an accounting of Purdue Pharma or the Sackler family. I just couldn’t imagine it because the people who were so hammered by it, their lives were in complete turmoil. I have been amazed to watch how that has changed over the last six years. Nobody knew who the Sacklers were. Watching the change in fortunes has been remarkable. Nobody will take their money. Their last name is being removed from universities and museums. As I said, when I was out there writing Dreamland I felt very, very alone, like nobody else was telling the story.

You write and talk a lot about how the opioid epidemic is an outgrowth of the way we live in the 21st century — suburban isolation, “silo-ization,” even stuff like our addiction to sugar. I’m wondering if there are key moments in history, or decisions, that got us here. This is a bit of a vague question, but can any of those 21st-century forces be undone to change the way we live, with an aim toward reducing people’s reliance on drugs?
Those are great, great, great questions. I don’t think I’m the sociologist who can answer all of that. I do believe that a lot goes into what has created what we have today. On the one hand it’s the whole Rust Belt phenomenon, and it’s not just that jobs went overseas. It was an attitude in our culture among Americans who said, “Oh well, those communities are the losers. Let them fend for themselves.” In one sense, you have a lot of communities that are just hemorrhaging people, and energy, and are very isolated. Walmart’s run all of the mom-and-pop stores out of town. Sure, those stores were three times more expensive than Walmart, but that money was staying in the community, being donated to Little Leagues and junior-high theater projects. Now, that money is no longer there, nor are the people who owned those businesses.

At the same time, at the other end of the economic spectrum, we see a lot of very scary isolation. To me, it’s very unappealing stuff. We built this intense isolation into our suburbs, so it’s very difficult to actually go outside and meet neighbors. A loaf of bread requires a two-mile drive. A good amount of it has to do with our urban planning stripping away anything that brought us together. Of course we are “connected” more than any humans have ever been connected, and yet it’s the most superficial kind of connectivity. We’re constantly connected on social media and we’re constantly misunderstanding each other. You don’t have the nuances of tone on Twitter or Facebook that you have when you’re speaking face-to-face with a person. Something that ought to bring us together actually has us tearing each other apart.

We have destroyed the very bulwark of defense that has allowed human beings to survive for eons now. What allowed us to survive was not that we viewed community as a nice thing to have around, but as something that was absolutely essential. Our brains evolved to require it. We die when we’re isolated far more quickly than when we’re with other people. Multiply that by an entire society and you get to a place where we are once again dying because we are isolated. In this case it’s drugs. As a society, we have stripped away all that stuff that brought us together. The common denominator isn’t economics or race. It’s isolation.

So, how do we deal with all that? My feeling is, in my own personal life, I cut down significantly on isolation. I have software that stops the internet. I try to walk a lot and be outside a lot. I try to not eat crappy food that I keep being pressured to eat by every soda, junk-food, and fast-food manufacturer. I don’t gamble. I don’t do pornography. All of that is opting to steer away from the forces using addiction, companies fine-tuning their products to more completely addict us. I stand up to them in my own personal way. Is it saving the world? Of course not. But I feel it’s an appropriate response from someone living in this culture. Another way of dealing with it is in the title of the book. Paying attention to the smallest solutions, to the daily work, to understanding that we are only as strong as the most vulnerable in our society. We’re only as strong as the least of us.

Sam Quinones on the 1 Million American Dead From Opioids