One Pill for All the Pain: On the Devastating Consequences of the Nationwide Opioid Epidemic

Not long after my last book, Dreamland, came out, I was speaking in the small town of Portsmouth, Ohio, where part of that book is set.

After my speech, an older couple—thin, short, and pale—came up to a table where I was signing books. We were alone. Quietly, so only I could hear, the man said that their daughter was in prison for many years for a crime related to her opioid addiction. He said they were raising her young daughter and didn’t know what to do. They were exhausted. They were concerned they wouldn’t live long enough to see the girl through to adulthood. He was a man of few words and no tears. He looked shell-shocked.

“It’s so hard,” he said.

I was new at this and didn’t know how to respond. We each held the other’s hand, frozen in mid-handshake, this man and I, and stared into each other’s eyes as his wife stood by in silence. I squeezed his hand finally, and I think I said something about them not being alone. That I was sorry. They moved on, and I can still see the man looking back at me and nodding.

This book grew from that moment and others like it.

In Dreamland, I had endeavored to tell the complex tale of our nationwide epidemic of opioid addiction—pain pills and heroin at the time. Doctors were pushed and pressured into an idea that wasn’t always true: that virtually every pain patient could be prescribed bottles of narcotics without risk of addiction. This, in turn, led to the idea that pills could be prescribed in large amounts for long periods to almost anyone. As a species, we have 5,000 years of experience with the opium poppy. It contains a substance that is both the best pain killer we know and the most intensely addictive. Yet beginning in the mid-1990s and for years after we decided that only one of those was true.

This was the Opioid Era in America, characterized, from what I could tell, by a search for convenience and comfort and thus easy answers to complicated problems—among them, one magical pill for all human pain. This era was also about our own isolation and destruction of community in areas both rich and poor. It was about an unqualified belief in the private sector.

Opioid pain relievers in unprecendented number year after year were prescribed from coast to coast. They were overlaid on American populations riven by trauma or generational poverty, or well-to-do areas with large houses and barren sidewalks. They spilled over a culture in which so many addictive legal substances and services were already finely tuned to attack our brains. Predictably, narcotic pain relievers turned out to be addictive for a lot of patients the longer they used them. The pills sloshed across the country and onto street black markets, where many others grew addicted. Some of these newly dependent users moved on to heroin. As years passed, that market grew large enough to awaken Mexican drug traffickers.

This crisis spread and intensified nationwide. Still, I found that few people wanted to talk about it. Families were ashamed of their loved ones’ addictions. Believing they were alone, families made mistakes trying to help their addicted loved one. They depleted finances; trust dissolved and marriages ended. When these loved ones died, their obituaries’ cause of death were fabrications. Families isolated to hide the truth. So the scourge continued to spread like a cancer, devouring people and places across the country, abetted by a national silence.

I assumed Dreamland too would be ignored when it came out in April 2015. Instead, I watched public awareness ignite. Obituaries began to tell the truth. Parents came out of the shadows. I was surprised to be invited to speak around the country, and the invitations multiplied to more than 200 speeches in four years. I spoke to conferences of public health nurses and narcotics agents, by social workers and addiction counselors, by doctors, judges, and to at least two dozen colleges. Perhaps most fulfilling of all, though, were the dozens of small towns where I spoke: Bluffton, Indiana; Chillicothe, Ohio; Spartanburg, South Carolina; Worcester, Massachusetts; Peoria, Illinois, and many more.

From the road, I watched the story change. After years of escalating, doctors’ pain-pill prescribing fell, though not before creating an enormous new population of opiate addicts who would use anything that kept withdrawal away. Now the drugs came mostly from the underworld, piggybacking on the consumer market that the epidemic created. Heroin took the place of pain pills—for a while.

As I traveled, I then watched the dawning of the era of illegal synthetic drugs. Traffickers discovered that making drugs in labs was far more profitable than growing them. Synthetic drugs had been made before, of course, but nothing on the scale of what was underway by 2016.

Fentanyl was the era’s poster drug. A wonderful medical tool, the hyperpotent synthetic emerged as the underworld’s hyperprofitable heroin substitute. Supplies of it came from China, then from Mexico, as well. Fentanyl upended the dope world the way tech disrupted business. No farmland needed—no pesticides, no harvesting, no seasons, no irrigation. It shrank the heroin supply chain—from dozens of people down to two or three, none of whom were likely to be scary cartel types.

Illicit fentanyl spread first through the midwestern and eastern states. By 2018 it was all over the West as well. Overdose deaths shot farther north; more Americans died yearly than in the entire Vietnam War. Cuyahoga County, where Cleveland is located, saw overdoses double from 2014 to 2017—from 353 to 727, with almost 500 deaths involving fentanyl. San Francisco saw a similar increase between 2018 and 2020, when three times as many people died of overdoses as of COVID-19. Philadelphia had long been a heroin town, but by 2019 90 percent of 1,150 fatal overdoses were due to fentanyl.

Traffickers, meanwhile, had discovered a way to make methamphetamine in harrowing new amounts. While I was on the road, their meth reached all corners of the country and became the fourth stage of the drug-addiction crisis. Opiate addicts began to switch to meth, or use both together. This made no sense in the traditional drug world. One was a depressant, the other a stimulant. But it was as if their brains were primed for any drug.

This stage did not involve mass deaths. Rather, the new meth gnawed at brains in frightening ways. Suddenly users displayed symptoms of schizophrenia—paranoia, hallucinations. The spread of this meth provoked homelessness across the country. Homeless encampments of meth users appeared in rural towns—“They’re almost like villages,” one Indiana counselor said. In the West, large tent encampments formed, populated by people made frantic by unseen demons in Skid Row in Los Angeles, Sunnyslope in Phoenix, the tunnels in Las Vegas. This methamphetamine, meanwhile, prompted strange obsessions—with bicycles, with flashlights, and with hoarding junk. In each of these places, it seemed mental illness was the problem. It was, but so much of it was induced by the new meth.

Fentanyl and this new meth were in the interest of traffickers, not their customers. Traffickers had unlimited access to world chemical markets, and the population of American drug users had expanded coast to coast. These drugs could be made year-round, in greater quantities, cheaper and more addictive than anything grown from the ground, and thus could create or shift demand.

Their meth and fentanyl ended the notion of recreational drug use. Now anything could kill or mentally maim. What started as an epidemic of opiate addiction became, as I traveled, simply an epidemic of addiction, broadened by staggering supplies of corrosive synthetic dope.

I began writing Dreamland believing it to be about economic devastation. But I soon saw this addiction wasn’t confined to the Rust Belt or Appalachia or tribal reservations. It found its way into well-heeled suburbs of Orange County, suburban Charlotte and Indianapolis, Fort Lauderdale. Unlike every drug scourge of the past, this one was essentially uniracial. It touched Black and brown communities relatively lightly. Instead, it involved White people in the great majority, including those who had done best in the economic expansions of recent decades.

They were getting addicted and dying from drugs used to numb pain. People with no criminal record—workers, star athletes, pastors, and cops, the kids of mayors and judges—all got addicted. Parents who’d imagined some glowing life script for their newborns were, as those kids reached young adulthood, confronted with lying, stealing, conniving children, their bodies occupied by some mutant beast. Then came a felony record. Suddenly parents were cosigning for apartments, driving their addicted beloveds, now 30, to a GED class.

The story wasn’t at heart only about economic devastation. It wasn’t just about those at the bottom. Not just hotel maids or supermarket cashiers or single moms. It was all of us.

This made more sense as I read what neuroscience can now tell us: that every human brain has capacity for addiction. Isolation is part of why some people get addicted and some do not. So was trauma. Abuse, rape, neglect, PTSD, a parent’s drug use were as unspoken in America as addiction and as prevalent. The epidemic was revealing this. I also connected the epidemic to consumer marketing of legal addictive stuffs: sugar, video games, social media, gambling.

Attorneys general and county commissioners filed suits against drug companies to recoup the costs of this addiction crisis. When I finished writing Dreamland in mid-2014, I knew of three such lawsuits; now there were 2,600. Their subpoenas dislodged company records, foremost among them from Purdue Pharma and the Sackler family, who owns Purdue. While I was writing Dreamland, both seemed so impenetrable. Now, through those subpoenaed records, a fuller story could be told of their role in all this.

I saw America through the people I met at these speaking events, and the stories they told. Among the first was the couple in Portsmouth, Ohio. Most of the encounters were similarly brief. But like haiku, they encapsulated so much—such pain, power, sadness, and resiliency. Mothers told of their addicted children who had died. Addicts said they were lucky to be sent to jail. One woman was raising her deceased nephew’s son; another family was raising a child they called their grandson, though they didn’t know if their deceased son was his father.

A teacher regularly washed a student’s dirty clothes because the girl’s strung-out parents didn’t have a washer, and she missed school because she was too ashamed to wear them. Some judges had almost become social workers, yet they rarely found addicts willing to, in the words of one, “get into treatment if they’re not facing the threat of incarceration”—such was drugs’ control over their brains. Chronic pain patients told me how pain mangled their lives, and doctors wouldn’t now prescribe the pills they needed.

On every trip I also saw the capacity to rise up. Groups assembled in county after county to fight the problem. They comprised more than just police, prosecutors, and probation officers. They also included insurance agents, the Kiwanis Club, PTAs, hospital administrators, college presidents, coaches, chambers of commerce, recovering addicts, doctors, and clergy. “Three years ago, you never would have gotten this group together in the same room,” said one man in Scottsburg, Indiana.

None had done a pilot project. There wasn’t time. They just formed up and groped for answers. There were no silver bullets. So they worked together quietly, making small changes. That was healthy, I thought. We had created this catastrophe, after all, by demanding one big, easy solution for a complicated problem: one pill for all pain.

When I visited these counties, I was often asked: “What places have you seen that are doing the right thing?”

“Right here.” That became my response. People everywhere were leveraging talents and energies, reminding themselves how to work together. They learned each other’s names and cell phone numbers, went out for pizza. They formed an antidote to the community destruction that got us into this in the first place.

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

Some of them may have wanted a magic bullet. I don’t have one. I told them I thought maybe we just needed to have faith in daily work and small steps. That innovation comes through collaboration with others. By doing that, they were refuting the cynicism of our age. Watching them, it occurred to me that I needed to find stories that reflected that—the unnoticed tales of community repair. That, in part, also led to this book.

The addiction crisis pushed new thinking that crossed political boundaries. In red states, I came upon experiments in new ways of doing jail—as centers of recovery instead of as the centers of recidivism and addiction they always had been. I spent time in drug courts, which use prison terms as leverage to pry addicts away from the potent street drug that has imprisoned their minds.

I was winding up this book when COVID-19 arrived. The virus forced us apart and showed us how we needed each other. It also re-created the conditions that spawned the opioid epidemic: isolation, widespread job loss. Alone, addicts overdosed and died. “Sitting with somebody, looking at them eye to eye—‘We’re going to get through this’—that piece is missing,” a drug counselor told me. A narcotics officer in southern Ohio told me of a young man sober for eight months. Then he lost his new job at an IHOP, had a criminal charge from his past refiled against him; alone, he started using heroin again and overdosed.

The 12 months ending September 2020 tallied the highest number of overdose deaths in the country’s history—87,000, according to a preliminary estimate by the Centers for Disease Control and Prevention. Much of that was due to illicit street fentanyl. By the time this book is published, we will likely have learned that close to 100,000 Americans died of drug overdoses in 2020—dwarfing any annual tally the country previously produced.

Then the Black Lives Matter movement gained renewed urgency from protests over what a jury later decided was the murder of George Floyd by a Minneapolis police officer.

These seemed separate moments, yet I came to see all three as connected. The opioid epidemic was about the destruction of community and the agony we create as we seek to avoid pain. COVID-19 instructed us on the importance of community, now that we had suddenly lost it, and how essential were those who nursed us and picked our lettuce. BLM showed that a sense of community was not possible without recognizing pain long ignored. BLM’s point was also to reveal privilege. Part of our privilege was to relegate to police the jobs that we preferred to forget or not pay for—like dealing with the mentally ill on our streets, whose numbers multiplied due to methamphetamine.

Each was about who in America could breathe and who could not. George Floyd’s final words were those, too, of the addict dying under the overpass, and the trucker expiring from COVID-19. Each asked us to consider who was worth our attention. With the face mask, we—many of us, anyway—accepted individual limits to spare our frontline doctors and nurses, to keep safe essential workers like paramedics and farmworkers so all could breathe.

The addiction epidemic jolted us into reexamining customs, beliefs, and how we lived. It seemed that COVID-19 and Black Lives Matter did the same, in equally impolite fashion.

Each insisted that we see our fellow Americans. That we are only as defended as the restaurant cook, the hotel maid, the grandparent on Social Security, the prison inmate. “Asking for grace—we’re all asking for grace with each other. It’s going to be a little messy,” said Dr. Amy Acton, then director of Ohio’s Department of Health, who became my go-to public official and philosopher early in 2020. “80 percent of us will be fine. Everything we do is to protect the most vulnerable.”

Perhaps these jolts had to happen in succession. Perhaps the path to national reassessment begins when things fall apart. The addiction epidemic was already doing that. Nationwide death from abuse of the most isolating of all drugs was pushing Americans to come together in county after county. People I met were breaking down silos, acting on the idea that it was through reliance on each other, through community—which we had done so much to destroy—that we would most likely find some way out of this. Whether that attitude would survive COVID-19, I didn’t know. But if it did, we would be better for it, I thought.

I came to see that addicts, gripped by drug-induced self-centeredness and isolation, are just extreme examples of each of us and our time. Once freed, they discover what we all need. They discover grace, patience with others. A feeling of being part of something bigger than themselves. Optimism and gratitude. A recognition of themselves in others. If we’re lucky, we’ll come out on the other side of all that besets us as Americans as I write, with the insight recovering addicts receive, and with wisdom enough to glimpse ourselves in them. If so, we’ll be better for it.

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Excerpted from The Least of Us: True Tales of America and Hope in the Time of Fentanyl and Meth. Used with the permission of the publisher, Bloomsbury. Copyright © 2021 by Sam Quinones.