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Americans have used and abused opiates* for as long as America has existed. Opium was administered to Revolutionary War soldiers, and for much of our history it was one of the only medicines available, given to colicky babies, the dying elderly, and everyone in between. Misuse may even have been more common in previous centuries than now, and the problem grew particularly acute after the Civil War, during which morphine was used to soothe the injured. In fact, the term soldier’s disease was coined to describe opiate addiction. At the dawn of the twentieth century, one could buy opium from the Sears, Roebuck catalog, yet addiction was so widespread that President Theodore Roosevelt appointed an opium commissioner in 1908. During the industrial revolution the problem ravaged the United Kingdom as well, and the country sought to balance its trade deficit by using its British East India Company to ply opium in tremendous quantities to the Chinese, causing a pair of wars.

Never, however, has an opiate—or any other drug, for that ­matter—killed so many annually as the fentanyl epidemic. It is the next phase in the opioid crisis that began with the overprescription of opioid painkillers, which was catalyzed by a short letter published in a 1980 issue of the New England Journal of Medicine. Written by a doctor named Hershel Jick and his graduate student, Jane Porter, the letter discussed the thousands of cases they had examined in which patients received opioid narcotics. In only four cases had anyone become addicted, they claimed, and only one of those was troubling. “We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”

The above sentence was one of only five in Jick and Porter’s letter, which was far from comprehensive. It referenced only patients who received small doses and were closely monitored by their doctors, not outpatients taking home bottles of ultra-strong prescription drugs. Nonetheless, the letter had great influence; academics cited it in more than six hundred studies, and doctors and pharmaceutical companies pitching their products deferred to it as well.

During the 1990s another sea change swept American medicine: the desire to treat patients more humanely. Traditionally, doctors focused on four “vital signs” when caring for patients: their temperature, breathing rate, blood pressure, and pulse rate. But in the mid-1990s the American Pain Society called for pain to be considered a new “fifth vital sign.” Whereas doctors were previously hesitant to prescribe opioids because they considered them addictive, the ramifications of the Jick-Porter letter caused their thinking to shift: if opioids were, in fact, safe, patients should not be consigned to agony. “It was not only okay, but it was our holy mission, to cure the world of its pain by waking people up to the fact that opiates were safe,” Boston pain specialist Dr. Nathaniel Katz told journalist Sam Quinones for his book Dreamland: The True Tale Of America’s Opiate Epidemic, describing the new conventional wisdom that took hold. “All those rumors of addiction were misguided. . . . My fellowship director even told me, ‘If you have pain, you can’t get addicted to opiates because the pain soaks up the euphoria.’ ”

The Sackler family, the owners of the company responsible for OxyContin, became billionaires many times over thanks to this new perspective. Long before the drug’s creation, Arthur Sackler, a physician by training, had been a pioneer in the field of pharmaceutical advertising. In 1952, Arthur and his brothers, Raymond and Mortimer, purchased the company that became Purdue Pharma. With the inherent conflict of advertising and pharmaceuticals in its DNA, Purdue brought OxyContin to market in 1996, touting its benefits as a slow-release pill that contained high doses of the opioid oxycodone—contin means “continuous.” Since the pills lasted twelve hours, the company claimed, patients would need only two per day, fewer than comparable medicines. Addiction, it promised, was extremely rare.

Purdue launched a huge marketing blitz, deploying hundreds of salespeople to sway doctors and dispense free promotional items, including pedometers, headgear, and even an OxyContin-branded music CD, Swing Is Alive, with a pair of dancing geriatrics on the cover. Purdue sent doctors to tropical locations for “pain management seminars;” those who attended these events in 1996 were more than twice as likely to write OxyContin prescriptions as doctors who did not. Although originally OxyContin was promoted for use by cancer patients, according to internal reports, the company saw that market as too small. Annual sales might top out around $260 million, whereas if Purdue was able to sell to patients with a host of chronic conditions, the annual market was closer to $1.3 billion. Sales rose from just under $50 million in 1996 to more than $1 billion by 2000. Oxycodone became the most prescribed drug in the United States.

Yet for many patients, the dosages didn’t last an entire half day, and they began experiencing withdrawal symptoms when the pills wore off hours early. And while Purdue salespeople told doctors that less than 1 percent of OxyContin patients would become addicted, Purdue’s own study from 1999 found the rate to be 13 percent.

Misuse became rampant. Many users crushed the pills, known by some as “hillbilly heroin,” into powder form to snort or make into an injectable solution, so they could get high faster. Others fashioned themselves into drug dealers and sold them; the going rate on the street for OxyContin was one dollar per milligram, meaning that an eighty-milligram pill sold for eighty dollars.

For some, using OxyContin as directed caused anguish. Patients recovering from knee surgery or a root canal, or experiencing chronic pain from a condition like rheumatoid arthritis, gained temporary relief but soon confronted a new problem: when their prescription ran out, they were addicted. Many tried to “doctor shop” for more pills, but some who couldn’t do that, or couldn’t afford the pills, turned to heroin, which is cheaper—as low as five dollars a dose in some places—and satisfied their opioid cravings. Before they knew it, they were regularly visiting dangerous parts of town to meet heroin dealers.

This is a complex problem. The vast majority of legitimate users of OxyContin and other opioid medicines receive the intended benefit. For the most part, people dying from oxycodone overdoses tend to get the pills on the black market, not their doctors. Nonetheless, Purdue bears “the lion’s share” of the blame for America’s opioid crisis, according to Andrew Kolodny, the codirector of the Opioid Policy Research Collaborative at Brandeis University. “If you look at the prescribing trends for all the different opioids, it’s in 1996 that prescribing really takes off,” Kolodny said, referencing the year OxyContin debuted. “It’s not a coincidence. That was the year Purdue launched a multifaceted campaign that misinformed the medical community about the risks.” The company, found guilty of playing down OxyContin’s abuse potential, paid $600 million in fines in 2007. Considering the billions it had earned, and would continue to earn, this seemed a pittance. No one from the company received jail time, causing then US senator Arlen Specter, from Pennsylvania, to take issue with the sentence. “I see fines with some frequency and think that they are expensive licenses for criminal misconduct,” he said at a Senate hearing. “I do not know whether that applies in this case, but a jail sentence is a deterrent and a fine is not.”

In 2010 Purdue released a new version of OxyContin that couldn’t be crushed up and injected, which the company believed would help stymie abuse. The FDA agreed. However, this new pill may have worsened the opioid crisis. In a 2015 study, psychiatrists at Washington University in St. Louis interviewed 244 people who had sought treatment for addiction to the new version of OxyContin. The study showed that while many were able to kick their OxyContin habit, about one-third of the subjects migrated to other drugs. Seven out of ten in this group started taking heroin. Further, in the early 2010s, prescription narcotics became harder to obtain. This, along with heroin shortages, likely accelerated fentanyl use in the United States, concluded a 2018 study at the University of California, San Francisco. (Fentanyl is an odd case, the UC San Francisco researchers noted, since its rise wasn’t driven because people wanted it—they just feared withdrawal and didn’t have access to other opioids. As one indication of this, unlike most drugs, which develop street names—smack, weed, Molly—fentanyl doesn’t have much in the way of nicknames.)

Purdue got most of the bad publicity, but the DEA found that a less-known pharmaceutical company called Mallinckrodt manufactured 36 billion opioid pills between 2006 and 2014, more than anyone else. The Washington Post spotlighted a national sales director for the company named Victor Borelli, who told a distribution 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.