In 2015's DREAMLAND, Sam Quinones chronicled the start and rise of America’s opioid epidemic. It began with Oxycontin, created by the Sackler family’s Purdue pharmaceutical company, and morphed into an all-out drug war as users turned to heroin, resulting in harrowing nationwide death tolls and a booming drug trafficking market. But a new "star" has emerged in the epidemic’s third phase: fentanyl.

Fentanyl is a powerful synthetic opioid that is similar to morphine but is 50 to 100 times more potent. Unlike its sisters, heroin and morphine, fentanyl is relatively easy to come by, requires no growing season (and therefore no farmlands or farmhands), and is as instantly addictive as it is deadly. In the first part of THE LEAST OF US, Quinones explains how fentanyl emerged as the leading player in the opioid epidemic, starting with, surprisingly enough, methamphetamine.

Drug traffickers were primed to accept lab-created fentanyl as the next big thing after streamlining meth production --- which once required store-bought medications like Sudafed --- in order to cut back on expenses and wasted time. This change sparked rapid growth in the meth industry, but more surprisingly, it also paved the way for heroin traffickers to ask, “How can we do the same thing?” Enter fentanyl.

At 100 times more potent than heroin, fentanyl poses obvious benefits to traffickers: it can be diluted many more times, resulting in exponentially greater sales, and as a “designer drug” it can turn even average Joes into community kingpins. With a lucrative market, rising demand (and, curiously enough, death tolls), fentanyl seems like an unbeatable enemy for the epidemic’s third --- and hopefully final --- round. In THE LEAST OF US, Quinones once again dives deep into America’s drug culture, but this time he takes his investigation a step further to shine light on the ways that communities are coming together to fight addiction.

"Quinones loves a good story, and his excitement at meeting a new character leaps off every page.... THE LEAST OF US reads like the final puzzle piece to the mystery of opioids and their hold on America."

With his usual kaleidoscopic approach, Quinones divides the book into five parts, returning each time to the topics of individual users; mill, factory and Appalachian towns that have been both decimated and bolstered by opioids; the Sackler family; the production of fentanyl and meth; and, of course, the neuroscience behind it all, the psychologies of addiction, abuse and community. In each chapter, he strives to unpack not only the simpler stories --- how meth is synthesized, how addiction rewires our brains --- but also how each of these stories fits in to the tapestry of the epidemic at large.

Through Quinones we meet Starla Hoss, a former user who lost almost all brain function after an overdose; Lou Ortenzio, a beloved small-town physician who now delivers pizzas after suffering his own battle with addiction; Mike “Bird” Kissick, an agoraphobic man who single-handedly formed a community center for struggling children and adults after his city’s budget collapsed under the weight of a poor economy and too-readily-available drugs; and more memorable characters, all of whom have been touched in one way or another by the epidemic.

As Quinones explains it, fentanyl is unlike its predecessors in that it is so cheap to produce, so easy to smuggle and so immediately addictive that it has turned users of even other varieties of drugs (who so rarely cross the upper vs. downer boundary) into addicts. We are in a new era where Oxycontin has ushered in heroin, which opened the door for fentanyl, which has come riding on a wave of meth addiction that is creating an entirely new epidemic of homelessness, mental illness and users of more drugs than ever before. Writing on fentanyl’s ability to cut or enhance other drugs, like cocaine, Quinones says that for a while, “dealers didn’t dare not mix it in.” This demand turned users of cocaine into opioid addicts often without their knowledge, and certainly without their consent. But opioids --- and especially fentanyl --- can rewire a user’s brain so successfully that they can never stop chasing that initial high, bypassing all of the brain’s self-preservation mechanisms, the pleadings and warnings of their loved ones, and often their own reality.

The chapters on neuroscience delivered some of the most shocking takeaways of the book, most notably the neuroscience researcher who learned that rats fed with sugar water not only act exactly like addicted humans, but even demonstrate the same results when treated with naloxone (or, more commonly, Narcan), a drug used to stop an overdose. Just as traffickers were primed and ready to accept a new synthetic drug, so too were Americans primed and ready to become addicts. But, as Quinones points out, one cannot become addicted to a drug without trying it, and so he argues often for the enactment of policies that restrict the availability of drugs, rather than the criminalization of users. This brings us to the driving argument behind the book: America’s desperate need for bolstered communities.

Just as DREAMLAND was the story of pill-pushing doctors and heroin traffickers, THE LEAST OF US is also a story of two ends of a spectrum: the global economy producing catastrophic amounts of potent opioids, and the quiet, groundbreaking attempts of individual Americans and communities to save their addicted neighbors, friends and family members. Both storylines are, in Quinones’ hands, hard, stark examples of the message that “the least of us lies within us all,” and clarion calls for Americans to speak up and take new approaches to the opioid epidemic (which could really be called the “pain epidemic”) --- be they honest obituaries, thriving community centers, or a stronger focus on mental illness and treatment.

Quinones loves a good story, and his excitement at meeting a new character leaps off every page. But I thought some chapters would have been better suited for DREAMLAND (most notably his history on the Sackler family, which already has been adequately explored and chronicled in his and other books, like EMPIRE OF PAIN), and others cut altogether. Though some chapters feel like they stray from his central narrative, THE LEAST OF US reads like the final puzzle piece to the mystery of opioids and their hold on America. Quinones finishes what he started in DREAMLAND by offering not only warnings for the future phases of the epidemic, but the beginnings of a new era of hope.