By Tamarra Kemsley
Running diagonally from New England all the way down to northern Georgia and Alabama, the Appalachian region of the United States is a treasure trove of scenic trails and roads winding through forest-coated hillsides. Beneath that pristine canopy of leaves, however, many residents are caught in a battle for their lives. From prescription painkillers to heroin, opioids are ravishing the cradle of the nationwide epidemic.
The history of the crisis can be traced back to the region’s reliance on heavy manual labor, be it in its coal mines, farms or forests. With heavy labor often came chronic pain. But while Vicodin hit the market as early as 1978,1 it wasn’t until the 1990s that physicians began prescribing it and other painkillers for chronic pain in non-cancer patients.2 This, compounded by Purdue Pharma’s “unprecedented promotion” of OxyContin, led to a surge in supply.3 Between 1996 and 2000 alone, Oxycontin sales swelled from $48 million to $1.1 billion nationwide. It didn’t stop there. Ten years later, sales of opioid analgesics had quadrupled when compared to 1999.4
From rural countrysides to cities to suburban neighborhoods, the plague spread across the country. Still, Appalachia has remained on the frontlines, with states like Kentucky and West Virginia witnessing a fivefold and eightfold increases in overdose deaths since 1999, respectively.5
“There are many reasons for high rates of opioid misuse in our region,” Dr. James Becker, vice dean for Governmental Affairs and Health Care Policy at West Virginia’s Marshall University, told Black Bear Lodge in this exclusive interview. Among those he cited is the deteriorating economic situation across Appalachia. “We find ourselves in a perfect storm created by the severe economic downturn that has hit the region and a general sense of misery and hopelessness that has hit many of our communities,” he said.
In West Virginia, a 38 percent drop in coal production compounded by a 71 percent drop in coal prices since 2008 “have led to a collapse of the state’s coal economy.”6 Bearing the brunt of this decline is the southern portion of the state, where poverty7 and hopelessness8 have moved in even as thousands have moved away.9 It is also here where the opioid crisis has sunk its claws deepest. The same is true for Kentucky, Ohio, Tennessee and Virginia.10 Coal jobs and revenue disappear,11 poverty spreads and opioid addiction flourishes.
Closing coal mines isn’t the only factor fueling economic decline in Appalachia. Despite Georgia’s reputation as one of the best states in the nation to do business,12 cutbacks on unemployment benefits, a decrease in public-school funding, an increase in public school tuition, and reductions in federally funded scholarship programs have left many Georgians wondering how to make ends meet.13
Compounding this sense of despair is the availability of drugs. Both in Appalachia and across the United States, efforts have been made to limit the supply of prescription opioids in hopes of preventing dependency. But as Becker pointed out, these restrictions haven’t necessarily resulted in a decline in demand, only where people are getting drugs from. “One of the unintended consequences was a rise in the street value of those drugs. That may have triggered the increased use of drugs like heroin and fentanyl, which could be bought for lower prices.”
As Sam Owens writes for West Virginia’s Gazette-Mail, “Follow the pills and you’ll find the overdose deaths.” Within “six years, drug wholesalers showered the state with 780 million hydrocodone and oxycodone pills, while 1,728 West Virginians fatally overdosed on those two painkillers,” according to an investigation by the paper. In perhaps the most extreme example, out-of-state drug companies flooded a town of 392 people with 9 million hydrocodone pills in just two years. The town, known as Kermit, is located in Mingo County, home of the fourth-highest prescription opioid death rate in the country.14
For those who survive, hepatitis rates “have exploded” and many struggle to find work following felony drug convictions. Meanwhile, heroin, a cheaper alternative to prescription pills, undermines efforts to restrict the supply of opioids through official channels. More recently, black tar heroin has arrived in the region.15 Named for its dark, tar-like appearance, the substance adds to the existing dangers of heroin an array of threats, including tetanus and the flesh-eating tissue disease necrotizing fasciitis.16
Efforts to combat these trends vary from state to state, and even county to county. Among the most common approaches is medication-assisted treatment (MAT), where clients are treated with methadone, naltrexone, or other medications designed to mitigate cravings and prevent relapse.
But as Dr. James Becker points out in his article “The Crisis of Opiates in Appalachia,” there are many questions still hovering around the approach, including: “Which patients are most appropriate for MAT with which medication? What criteria should guide the choice of this therapy? Is MAT a life-long treatment approach? Would MAT treatment be effective in rural settings where limited employment options are an additional complication?”17
These questions are particularly relevant to Georgian lawmakers, who have watched with wariness the explosive growth of methadone clinics in their state when compared to its neighbors. Led by Sen. Jeff Mullis, the state legislature implemented a law limiting the number of clinics in different regions of the state. Doing so, they argue, will help ensure quality of care.18
Besides MAT, abstinence programs based on the Alcoholics Anonymous 12-Step program have also sprung up in order to serve those living with narcotic misuse disorders. Meanwhile, on the harm-reduction side, needle exchanges have decreased the spread of hepatitis and HIV, and the overdose-reversing drug naloxone has undergone a nationwide spike in demand — and price.19
Perhaps the most innovative and promising approach is that of North Carolina’s Project Lazarus. First introduced in the late 2000s in a western county with a death rate from opioid overdoses four times higher than the state average, the program shifted the story of addiction and recovery from an individual journey to a community effort. What followed was nothing short of miraculous. Overdose death rates plummeted from 46.6 per 100,000 in 2009, to 29 per 100,000 in 2010.20 In 2011, the rate dropped again, but the celebration was cut short in 2014, when rates returned to peak levels — a fact some blame on a trend toward heroin as the local supply of prescription drugs dropped. That said, evidence remains that there is value to the program: a number of other North Carolinian counties that have replicated the approach have watched their prescription opioid-related ER visits cut by almost a third.21
“I think each of us has a role in promoting responsible use of controlled substances,” Dr. James Becker said, be it supporting local recovery programs or aiding the reintegration of those in recovery into the workforce and community. That said, Becker is clear-eyed about the larger mechanisms at play throughout the region. “Until we can restore job opportunities and hope for the future, we will have a difficult time changing the drug abuse patterns.”