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client that the pills were “Just like Doritos.”

      “[K]eep eating, we’ll make more,” he added.

      Charges have also mounted against Insys Therapeutics, makers of the prescription fentanyl spray Subsys. The company has been sued by many parties, including state governments and individual patients, and its executives have been indicted (and in some cases pled guilty) of bribing doctors to prescribe Subsys. The spray is approved only for cancer patients, but individual doctors have been accused of prescribing it for lesser ailments and accepting gratuitous kickbacks. A former Insys sales rep named Maria Guzman detailed in her 2013 whistleblower lawsuit that the company provided doctors with stock options, trips to a gun range, fancy dinners, and even hired a woman specifically “to have sexual relations with doctors in exchange for Subsys prescriptions.” The FDA had information about doctors prescribing Subsys and other fentanyl medications for noncancer patients but did little to stop it, according to documents obtained by Johns Hopkins public-health researchers.

      Operating under the public radar as the crisis ramped up were drug distributors like Cardinal Health, AmerisourceBergen, and McKesson, which filled gigantic opioid prescription orders from corrupt doctors operating pill mills. For example, a drugstore in the small West Virginia town of Kermit (population: four hundred) received nine million hydrocodone pills in only two years. A 2017 investigation by television news program 60 Minutes and the Washington Post outlined this practice and helped expose how Congress allowed it—and even encouraged it. As laid out by whistleblower Joe Rannazzisi, the former head of the DEA’s Office of Diversion Control, a 2016 law called the Ensuring Patient Access and Effective Drug Enforcement Act, signed by President Barack Obama, made it harder for the DEA to freeze suspicious opioid shipments by these drug distributors. The law had been sponsored by Pennsylvania representative Tom Marino, who, at the time of the investigation’s publication, was President Trump’s nominee for drug czar. He was forced to withdraw.

      Did Obama realize the law—which Congress quickly green-lighted, without debate—would have such devastating consequences? No, concluded an October 2017 Washington Post story: “Few lawmakers knew the true impact the law would have,” it reads, adding that the White House was also unaware. Nonetheless, according to a 2019 Washington Post analysis, the Obama administration did not take sufficient measures to stem the fentanyl crisis as it developed.

      Pharmaceutical companies making opioids, among them Purdue, as well as others along the supply chain, including distributors, find themselves facing major lawsuits from states, cities, and other groups, supported by the US Justice Department. The groups seek something similar to the big tobacco settlement of 1998, which required cigarette companies to pay billions annually to the states, and limited the industry’s marketing, to compensate for the heavy costs of dealing with the health effects of smoking.

      The state of Florida has also included the country’s biggest chain pharmacies—Walgreens and CVS—in its lawsuit, because of their roles in selling opioids, and Oklahoma is targeting Johnson & Johnson for its role in the crisis, including selling fentanyl through its Janssen subsidiary.

      By the mid-2010s prescription pill deaths in the United States began leveling off, but “for every life we save from a prescription overdose,” said Joel Bomgar, vice chairman of the House Medicaid Committee in the Mississippi House of Representatives, “four more are dying from switching to heroin and fentanyl.”

      Fentanyl is frequently cut into heroin but, increasingly, fentanyl is also being pressed into pills that look exactly like name-brand prescription tablets. Raids across the United States have turned up operations in houses and apartments that turn fentanyl powder into tablets using specialized presses. Both the drugs and the machines are bought from China. These operations can make thousands of pills per hour. They stamp the pills with the OxyContin or Percocet logo, making them indistinguishable. This trend has quickly gained steam. In Arizona alone, the DEA reported seizing more than 120,000 fentanyl pills in 2017. And in May 2018, three twenty-one-year-old brothers from Raleigh, North Carolina—identical triplets named Atsouste, Etse, and Atsou Dossou—were arrested, accused of running a vast drug operation, which included making and selling thousands of fake Xanax bars cut with fentanyl.

      A 2019 DEA report noted that more than one in four seized counterfeit prescription pills contained a potentially lethal dose of fentanyl. The amounts vary greatly. One might have ten times as much fentanyl as the next. Investigators believe such counterfeit pills were responsible for the death of music star Prince in 2016; about one hundred white pills found on his property looked exactly like Vicodin but actually contained fentanyl. He may not have realized he was taking inauthentic medication.

      Since then other music stars have also died from fentanyl, one after another, including Tom Petty and the rappers Lil Peep, Mac Miller, and Lexii Alijai. In most of these cases, fake pills cut with fentanyl were suspected.

      Cocaine can also be spiked with fentanyl. American cocaine overdose deaths remained fairly steady throughout the first decade of the 2000s—ranging from roughly four thousand to seven thousand—but in the second decade began to surge, exceeding fourteen thousand in 2017. Fentanyl is part of the reason for this. Cocaine production is at an all-time high, and the product is flooding the market, but it’s far from pure. Because they are both white powders, cocaine and fentanyl can be mixed easily, and fentanyl sometimes “contaminates” cocaine parcels, where the drugs are prepared in the same space. Fentanyl was involved in two of five cocaine overdose deaths in 2016, the most recent year for which such statistics are available. This trend disproportionately affects African Americans, who are nearly twice as likely to die from cocaine overdoses as white people.

      In New York City in 2016, more than one-third of all fatal drug overdose victims had both fentanyl and cocaine in their systems. By the end of 2017, in Massachusetts, cocaine used in conjunction with fentanyl was killing more people than heroin spiked with fentanyl, and in Ohio, cocaine was often mixed with carfentanil, a tranquilizer used to subdue rhinos and elephants (sometimes shot from dart guns) that can be one hundred times more potent than fentanyl. In July 2018 the director of the Centers for Disease Control and Prevention, Robert Redfield Jr., revealed that his thirty-seven-year-old son had nearly died from cocaine laced with fentanyl. In December, 2018, Vine and HQ Trivia cofounder Colin Kroll was found dead with heroin, cocaine, fentanyl, and an analogue called fluoroisobutyryl fentanyl in his system. Fentanyl’s rapid growth in the drug economy is putting users, from recreational to deeply addicted, at risk of grave consequences. Until recently young people could often take drugs at parties without risking much more than a bad hangover. Now, however, any black market pill or powder could contain a lethal dose of fentanyl.

      * Opiates generally refers to drugs derived naturally from the opium poppy, like morphine, while opioids generally means similar chemicals made synthetically in labs, like fentanyl.

       Two

      Humanity has long mined psychoactive chemicals from the natural world to worship gods, to feel bliss, to commune with the dead, to heal, to avoid problems, to escape ennui, to make art, or to just go on a little adventure of the mind. At first, people ingested these chemicals directly from living things, eating mushrooms, cactus buttons, and morning glory seeds; chewing coca and khat leaves; inhaling tree snuff; smoking cannabis, opium, or even the venom of toads; fermenting grapes and barley; curing tobacco; steeping leaves; and roasting beans.

      Historically, only a few handfuls of different compounds have been used reliably to get people high, but over the past hundred years or so, humankind has learned to synthesize the active chemicals in laboratories and to manipulate chemical structures to invent new drugs—the numbers of which began growing exponentially in the 2010s. Anyone with computer acumen can acquire hundreds of psychoactive compounds that didn’t exist even a few years ago.

      According to the European Monitoring Centre for Drugs and Drug Addiction, 150 new illicit drugs were bought and sold between 1997 and 2010. Another 150 appeared in just the next three years, and since then, in some years as many as 100 new chemicals have appeared, with synthetic cannabinoids especially

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