The Opioid Crisis Is Not the Opioid Crisis

Most folks who talk about “Appalachia” have never actually visited. They romanticize us all as Loretta Lynn or Dolly Parton, growing up in isolated log cabins surrounded by tall trees, with scruffy but wise and kind moonshiners in every holler. They think the air is full of the sounds of church choirs or trains passing us by for more cultured locales.

The simple truth is that Appalachia is a study in contrasts, with subtleties that the uninitiated can not see. For every log cabin, there are two dozen trailer homes. For every moonshiner holler, there are tens of malls and dozens of flea markets. For every church choir, there are business meetings and revitalized downtowns and tourist traps and historic neighborhoods and microbreweries.

The very simple truth is that Appalachia is much less a place than a people.

If you ask an outsider what they know about Appalachia these days, one of the top three answers usually relates to the opioid crisis. We are well known for our addictions to heroin, synthetics (e.g., fentanyl, methadone), and prescription painkillers (e.g., oxy, hydro, morphine, codeine), plus the extremes that we will go to get our fixes, and the money we can make by fixing others.

And boy, do we need fixing.

Compared to everyone else in the US, Appalachians struggle significantly more–and I do mean clinically significantly more–with poverty, chronic medical conditions, unemployment, disabilities, injuries, suicides, depression, substance addictions (though interestingly not alcohol dependence). We work longer hours and travel farther for jobs (when we can get them), depend more on Medicare than private insurance, and experience more Adverse Childhood Experiences (ACEs). But none of this is particularly dependent on whether we live in a lonely mountain holler or on a fancy downtown street with historic homes; wherever we are, we suffer from big barriers to being mentally and behaviorally healthy.

The problem with focusing on the opioid crisis as the problem in Appalachia is that we truly face unique and disproportionate challenges, compared to the rest of the US. Some of these certainly stem from trying to build productive lives in the mountainous, difficult-to-travel terrain, but many of these originated with historically disenfranchising and undermining treatment of Appalachia by corporations looking for a workforce to control and politicians using us as profitable pawns in whichever chess game was foremost at the time (today, it’s tourism and poverty fetishizing, both urban and rural, fyi).

The real “real problem” is that Appalachians have never been provided the mental and behavioral health resources we need to reinforce us as we push against the wind–literally and figuratively. Sometimes this was because outsiders came and stayed a few days and found us unenthusiastic for outside help, misreading hesitance and even bravado as refusal rather than resignation. Other times this was because we are our own worst enemies, trying (but failing) to present our best, self-sufficient selves to the world, in an absolute farce of addicts brushing off intervention because we don’t want to ask for help (but do actually want help all the same). In any event, Appalachia was labeled as a too-difficult diva who did not immediately express improvement and gratitude for the things that could have shored up a robust but hurting people, ignoring the very different sets of challenges faced here.

Even today, we are brushed off as too independent for outside help, yet we sustain widespread, deep connections to family and community, even over hundreds of miles–where is our independence then? We are chastised for superstitiously using OTC and home medical remedies “off label,” yet our creativity and co-existence with nature is celebrated. We are scorned for unemployment when there are no jobs available that are easy to get to and that pay a living wage, yet we are feted for our handicrafts and resilience. These are the contrasts. These are the subtleties that outsiders can’t see.

When most people look at the opioid crisis in Appalachia, they overlook real issues with how and why we are introduced to opioids and then develop dependencies on them. Some factors not considered:

There is a shortage of available mental/behavioral healthcare providers and facilities across the entire region.
The ones that are available are not easy to travel to for much of the population, and they are incredibly crunched for appointments and usually overbooked.
Many providers have no-show dismissal rules that might be reasonable in parts of the country with reliable and affordable public transportation or non-profit transport organizations, but in Appalachia these rules disproportionately harm the most vulnerable, whose lengthy and difficult roads are exacerbated by less access to reliable vehicles…or reliable drivers.
These providers experience excessive staff turnover, meaning that clients must “start over” more frequently, and treatment plans are not properly implemented and evaluated.
Appalachians legitimately experience more chronic medical conditions and more chronic pain, for a wide variety of reasons, including higher rates of heart disease, cancer, chronic obstructive pulmonary disease (COPD), injury, stroke, and diabetes. These are all associated with increased risks for depression, anxiety, and substance abuse–putting risk on top of risk.
Many Appalachian clients are prescribed opioids as pain intervention methods, particularly when other options such as massage, physical therapy, or regular in-office procedures are not widely available.
Pain management with opioids might not be closely monitored and titrated due to a lack of providers and appointments.

Ultimately, the opioid crisis in Appalachia is like everything else about us: very complicated and very simple at the same time. We are in a healthcare crisis, and widespread opioid addiction is a symptom of a much bigger problem. Until the corporations, businesses, and politicians who have the means come together to advocate for more healthcare resources–in spite of low profits–we will not be fixed. Until our developer partners find a way to provide infrastructure without destroying the beauty that makes people want to live, work, and shop here, we will not be fixed. And until those from outside stop buying into fatalist stereotypes about us, we will not be “fixed”.

REFERENCES:

The Opioid Crisis Is Not the Opioid Crisis

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