The Wizard of OxyContin – where is he now? That nickname, revealed in leaked documents, belonged to an employee of Abbott Laboratories, which partnered with Purdue Pharmaceuticals to sell the drug. Starting in the late 1990s, he and his colleagues canvassed clinics around the country, hard-selling doctors on their flagship product. Purdue wooed doctors taught to distrust pain medications with steaks, vacations, and a stunning range of swag: Oxy-branded clocks, pens, beach hats, even swing music compilations. They were told that, unlike other opioids, OxyContin was addiction-proof; its time-release coating assured a steady, measured dose and would thwart attempts at abuse.
Unmentioned by those reps – but known by their bosses from day one – was the ease with which this coating could be removed. As doctors began prescribing the drug in ever-larger numbers and Oxy’s sales soared into the billions, this glitch would devastate families, ravage towns, and before long spark the worst drug crisis in US history.
Purdue eventually gestured toward fixing this problem, after 14 years of lucrative dithering. In 2010, a few years before its patent was set to expire, the company prolonged it with a new formula. This revamped Oxy was harder to abuse, and while its effectiveness has been debated, rates of prescription drug abuse have declined, aided by “pill mill” raids and stricter prescribing guidelines. But the wreckage that Oxy left behind is still being felt: In 2017, more than 47,000 Americans have died of opioid overdoses, the highest number on record. That same year, fentanyl became a household name, surfacing in local news segments, policy-website explainers, and thousands of toxicology reports. When the original Oxy vanished from the streets, many of the people addicted to it turned to heroin—and now it emerged that much of the heroin available in the United States (along with fast-rising quantities of cocaine) was laced with fentanyl. The advantage, for dealers, was price: Fentanyl costs less than heroin and is easier to acquire. It also happens to be 50 times more potent.
Often lost in the early news reports was the fact that fentanyl alone wasn’t killing people; many different kinds of fentanyl were. Since its invention in 1959 by the Belgian chemist and doctor Paul Janssen, fentanyl has seen more than 1,400 analogues: twists on the original formula whose origins and effects vary widely. Carfentanil, for instance—100 times stronger than fentanyl—was until 2018 FDA-approved for use as an elephant tranquilizer. It is here that the opioid crisis intersects with (and amplifies) a newer scourge: NPS, or new psychoactive substances, molecularly tweaked stand-ins for traditional street drugs. The best-known of these is probably K2, or Spice, the ostensible marijuana substitute whose high bears little resemblance to the real thing and whose side effects include blood-clotting, kidney failure, and instant death. But there are hundreds more, and likely thousands in development. Mini-pandemics have erupted across the country, as when, in the course of a single week last year, over 100 people in New Haven overdosed on what was later determined to be AB-FUBINACA, yet another synthetic cannabinoid.
Ben Westhoff, in Fentanyl, Inc.: How Rogue Chemists Are Creating the Deadliest Wave of the Opioid Epidemic, charts this progression in harrowing detail. We are now dealing, he writes, with “the harshest drug challenge in our history.” His book is one of the first to address what the Centers for Disease Control has called the “third wave” of the opioid crisis: first OxyContin, then heroin, and now fentanyl and its analogues. Earlier accounts of this crisis – Sam Quinones’s Dreamland: The True Tale of America’s Opiate Epidemic or Beth Macy’s Dopesick: Dealers, Doctors, and the Drug Company That Addicted America – had in Purdue Pharma the benefit, structural and dramatic, of a villain. More or less everyone can agree that pharmaceutical companies should refrain from wantonly pursuing profit at the expense of public health. Dopesick is rarely a pleasant read, but Macy’s account of Purdue’s first major court battle – which culminated in criminal convictions for three executives and $600 million in fines—provided at least some measure of catharsis.
Westhoff, reporting from the flayed, despairing center of this crisis, can’t offer any comparable relief. Purdue Pharma is now dead, and responsibility has devolved, in this third wave, to thousands of loosely affiliated actors: Dark Web distributors, small-time dealers, chemists whose skills and moral scruples vary widely. Like the cryptocurrencies that mask countless NPS transactions, these networks are decentralized: Members taken down are just as quickly replaced. But there is consolation in clarity, and the achievement of Westhoff’s book is to press this sprawling cast and the forces that gave rise to it into something like a coherent narrative, forming legible patterns out of widespread chaos.
As Westhoff points out, many of the most dangerous NPS were developed under completely legal circumstances, by tenured professors at prestigious universities. These experimental compounds—as well as the steps taken to produce them—were written up in small, peer-reviewed science journals and more or less forgotten, until the underworld began to repurpose these articles as recipes for recreational drugs. David Nichols, the utopian chemist who once dreamed of a drug that would end all war, now finds himself faced with the grief of parents like Eric Brown, whose son Montana overdosed on 251-NBOMe, which was brought into the mainstream through his research.
If Fentanyl, Inc. does have a primary antagonist, it’s the Chinese government. Virtually all of the fentanyls that have flooded the United States in recent years have been manufactured in China, where many NPS are legal, an arrangement that allows legitimate businesses to churn them out on a scale inconceivable to illicit drug makers in North America. This process has been heavily underwritten, as Westhoff demonstrates, by “lucrative tax incentives, subsidies, and direct financial support” from the Chinese government, as part of its breakneck bid to expand the country’s biotechnology sector.
The extent to which Chinese officials are aware of what they’re funding is unclear – some of these companies produce hundreds of products, churning out fentanyls alongside collagen, pesticides, and erectile-dysfunction meds – but the blind eye they’ve turned toward the export of these chemicals has yielded a number of complaints from the United States. The companies, meanwhile, know exactly what they’re doing: Fentanyls and NPS that are legal in China but banned in the US are often shipped in disguise, packaged as dog food or high-gluten wheat flour bread. In addition to an urgent public health crisis, this is an issue of international trade, which means that President Donald Trump seems authentically to care about it. In April, under pressure from his administration, China instituted a blanket ban on the production of all fentanyl variants. The majority of Westhoff’s reporting was conducted before this announcement was made, but, as he argues and as recent developments have borne out, it is “far from clear” if these new regulations have had any impact.