My grandmother is a drug addict.
She still refuses to admit it even though most everyone around her knows that her dependence on opioid painkillers drives nearly every part of her life. At first glance, she might look like a typical little gray-haired lady, but she lies, she cons, and she uses others in ways most of us couldn't fathom just to get the money to buy more Vicodin.
At this point, most all her family is estranged, and I am not certain she really cares. For her, the only priority is the pills. It has been this way for at least twenty years, and I’m not sure if the drug abuse made her selfish and hateful, or if she was that way before the drugs. I suspect the former. I want to believe the former. I probably need to believe the former.
As much as I would like to help her, the hard truth is that it has proven nearly impossible for any of us who are related to her to try to help her without being pulled into miserable situations ourselves. I don’t know what the answer is because I know that even as hateful and selfish as she is, she didn’t choose to be a drug addict. Circumstances beyond her control dealt her a life so terrible that she came to think of drugs as the only solution. As much as I want to be angry at her, I know in my heart that she is suffering in ways I cannot begin to understand. And frankly, I consider myself blessed, lucky, whatever you want to call it, that I cannot understand myself what she is going through.
While it might seem rare, or even a bit of a novelty, for an elderly lady to be a drug addict, it really isn’t that unusual in Appalachia. Addicts come in all ages here in the mountains. They come from rich families and from poor families. Addiction in Appalachia is not limited by race or by education level. It afflicts the Baptists and the Methodists and the Pentecostals and the agnostics. If you live in Appalachia, you almost certainly know someone who is, or was, an addict. In fact, you most likely know someone who died as a result of their addiction.
While addiction reaches both the rich and the poor in Appalachia, the stark reality is that addiction thrives in these mountains in large part because of poverty. The poverty came first. The drug addiction came later, often as a desperate response. The poor are disproportionally destroyed by addiction. They have the least access to treatment options, and they are more likely to escape addiction through death than through recovery. Most remain addicted all their lives, and their lives are usually cut tragically short.
Over the past few years, the opioid epidemic that is plaguing rural America has finally begun to get a bit of national attention. The evening news shows have run a few specials, and some documentary filmmakers have made important films about the crisis.
Today, prescription opioids have largely taken the place of heroin, methamphetamine, and crack cocaine in bringing heartache and desperation to Appalachia. These opioids don't come across the southern border or from a clandestine lab or even from a trailer park chemist. They come from multi-national corporations. They are prescribed by physicians, and purchased and dispensed, at least initially, from licensed pharmacies. The most popular form is called Oxycodone. You might know it by one of its brand names: OxyContin, Roxycodone, or Percocet. A closely-related drug, hydrocodone, is sold under brand names including Vicodin, Lorcet, and Norco. In much of Appalachia, these drugs, all of which are opioids, are household names.
While many Americans encounter these drugs only while recovering from a surgical procedure, OxyContin and other prescription opioids are responsible for thousands of deaths per year in Appalachia. According for the Centers for Disease Control, more than a thousand people per day seek treatment in US emergency rooms because they have misused prescription opioids. In 2014, the most recent year for which statistics are available, over 2,000,000 people in the United States either abused or were dependent on prescription opioids.
It all sounds so clinical and official, really, when we talk about “prescription opioids” and data compiled by the CDC. The reality, however, is that many people who abuse opioids in Appalachia buy them illegally, and getting a fix isn’t cheap. In many parts of Appalachia, especially in eastern Kentucky and in West Virginia, a sort of illicit economy has developed around the widespread abuse of opioids. While the pills are manufactured by multi-national companies, prescribed by health practitioners, and dispensed by pharmacies, those to whom they are prescribed often sell them illegally. In most parts of Appalachia, street-level dealers, some of whom are addicts themselves and sell pills to support their habits, are able to get more than a dollar per milligram for the pills. A thirty milligram OxyContin, for example, will usually fetch $30. For addicts in advanced stages of addiction, a single 30 mg pill is barely enough to stave off withdrawal symptoms. It takes substantially more than that for them to get high.
Those who buy these prescription opioids illegally rarely take them in the ways intended by the manufacturers. While some addicts simply take the pills orally, many eventually end up crushing the pills and snorting them or, worse, shooting them up intravenously. It is a mind-boggling journey, really, from the tightly controlled manufacturing laboratory of a major pharmaceutical manufacturer to the vein of an addict in central Appalachia, via what might be a secondhand needle. No matter how the OxyContin gets to its final destination, however, its initial sale is still added into the black side of the manufacturer’s balance sheet. As Appalachia is slowly rotted from the inside by this dangerous poison, drug company executives and shareholders are making billions.
I have always wondered: do they know? Do they care? When Mark Timney, CEO of Purdue Pharma, the maker of OxyContin, sees his direct payroll deposit hit his bank account, does he think about the hundreds of people who die every year because of his product? Does Timney think about the moral implications of running a company that makes a product that has destroyed lives and homes and towns? I suspect that Timney doesn’t think about the unfortunate and hopelessly addicted end-users of his products any more than the CEO of Raytheon thinks about the collateral damage on the receiving end of the Tomahawk Missiles his company manufactures. Perhaps the world would be a better place if these aloof and isolated executives were forced to step outside their bubbles and see the gut-wrenching destruction their products cause.
If Timney had to walk through the alley behind Cumberland Avenue in Middlesboro, Kentucky and see the dirty needles lining the gutter, he might be forced to consider his moral obligations to folks other than his board or Purdue's stockholders. If he had to ride along with police officers who have to remove malnourished babies from the homes of parents who have died from OxyContin overdoses, perhaps he would understand the full implications of what he willfully does for a living. He has a choice. Those who become addicted to his product are deprived of choices by the chemistry Purdue Pharma has worked so hard to perfect.
For those of us who have seen opioids destroy families and communities and lives, it isn't much of a stretch to equate the CEO of a big pharma corporation with the CEO of a weapons maker. In the parts of Appalachia most destroyed by prescription opiates, it sure feels like a war is happening around us even if there are few gunshots and no bombs. I have lived in a community where OxyContin has drained away hope and life and dignity. I have served as foreperson of a grand jury that indicted hundreds of drug traffickers who served as middlemen between Purdue Pharma and addicts. I have witnessed the hopeless desperation of drug addicts, including members of my own family, who would do anything – anything – for another pill.
In so many parts of Appalachia, prescription opioids are as much a part of the landscape as the mountains that surround us. I lived in Middlesboro, Kentucky, for seven years of my adult life. Even having grown up around a grandmother who has for years been on a slow march toward the grave via Vicodin, I was stunned by how much a part of the local culture prescription opioids were in eastern Kentucky.
I moved to Middlesboro in 2004, just as the meth epidemic was beginning to be addressed with tougher restrictions on the sale of precursor ingredients. As meth ebbed, OxyContin became the drug of choice.
In those days, it was easy to get. Local drug traffickers would pack busses and vans full of people from the hollers and hills. They’d head down I-75 to Florida where unscrupulous health practitioners would, with a wink and a nod, diagnose patients they’d never see again with chronic pain and give them a prescription for whatever opioid cocktail they’d like. Upon request, they would even throw in prescriptions for the popular sedative Xanax for good measure. The scripts could be conveniently filled by the on-premises pharmacy. The addicts would hop back on the bus and head back to Kentucky. They’d give half their pills to the drug dealer who organized the trip, as payment for the ride and the office visit charges, and keep half for themselves.
At the time, Florida lacked a statewide tracking system for prescription drugs. The same addicts could make weekly trips to different parts of Florida for month-long supplies of pills. They could have a dozen active prescriptions for OxyContin or other powerful opiates, and absent a statewide tracking system, no one in any official capacity would catch the duplication. On more than one occasion, authorities in Kentucky caught drug traffickers with thousands of high-powered opiate painkillers in just-filled prescription bottles and were not even able to arrest them. Even though consuming just a fraction of the total number of pills prescribed per day would have killed the drug traffickers, every single pill was lawfully prescribed to the person in possession of the pills, so law enforcement in Kentucky couldn’t charge them because they had not technically broken the law. The officers knew the pills would be on the streets in hours and in the veins of addicts minutes after they were sold, but the officers had no recourse.
By 2010, the problem had become so severe that some elected officials from Kentucky were lobbying their counterparts in Florida to adopt a computerized prescription drug-tracking database. However, Florida governor Rick Scott fought against the implementation of such a system citing privacy concerns and opposed funding it even though the Florida legislature approved it. Scott even went so far as to turn down a $1,000,000 contribution from Purdue Pharma to fund the database. Finally, in 2011, after pressure from members of Congress and the Obama administration, Scott relented and approved a database.
Even with tightened restrictions on opioid prescriptions and better monitoring databases, the problems persist in much of Appalachia. The solutions, it seems, are slow in coming. I have written previously that lawmakers often turn a blind eye while their contributors systematically exploit the poor for profit. I note that while payday lenders and rent-to-own retailers have plenty of money for lobbyists and political contributions, the poor often can’t even get their congressional representatives to pick up the phone. The result is that lawmakers often tailor their rhetoric to put the blame on the drug addicts themselves rather than the companies that supply the drugs. Even the prescription tracking databases focus on finding patients breaking the law rather than on addressing the root sources of the pills. These politicians talk a whole lot about the importance of eliminating drugs from their communities, but they rarely mention the companies that created the products to begin with and spent millions of marketing dollars getting them into the hands of the people who became addicted to them.
Congress could get high-powered opiates off the streets in short order if they had the guts to do it. I might be jaded or naïve, but it seems like it would be straightforward to stop the abuse of powerful narcotics made by legitimate manufacturers. They operate from clean state-of-the-art facilities and skyscrapers, not from makeshift labs hidden in trailer parks or South American jungles. Perhaps because of the legitimacy of their businesses, the companies that make opioids seem to have more political and social cover even though their products destroy communities in the same way that meth and heroin do.
With prescription drugs, most politicians are clearly in the corner of drug companies despite their lofty rhetoric. In the healthcare debates unfolding around the United States now, many point out that drug prices in the US are substantially higher than in other developed nations. Congress, it seems, is hesitant to clamp down on drug manufacturers, and perhaps it is for good reason. In the same way that many in Congress are not willing to regulate prescription prices, they are also often unwilling to consider dramatic changes in public policy that would put a dent in the legal opioid business because such solutions would hurt the bottom lines of their corporate donors.
It’s no wonder that elected representatives, even those with constituents dying every day from opioid overdoses, might think twice before taking action to cut off the flow of OxyContin to Appalachia. Big Pharma spends a lot of money to buy influence both in Congress and in state legislatures. Cartel leaders who smuggle crack or heroin can’t pay congressional representatives to turn a blind eye, but through campaign contributions and lobbyists, pharmaceutical companies can.
In North Carolina, Kentucky, Tennessee, and West Virginia, the states whose mountainous regions make up the core of the Appalachian territory most hurt by opioids, pharmaceutical manufacturers have given nearly $2,000,000 in political contributions to federal-level elected officials over the past decade. From 1986 to present, these drug companies have given over five million dollars to state-level officials and candidates for state legislative seats. $7,000,000 has flowed directly from drug companies to elected officials while thousands of dead bodies are left in the wake of OxyContin.
Incidentally, opioid abuse is not the only pharmaceutical problem that desperately needs to be addressed by these lawmakers. While many in Appalachia are dying of overdoses, many others can’t afford to treat their diabetes or heart conditions or cancer. For an investment of a few million dollars, these pharmaceutical companies are able to make a mint selling deadly drugs to addicts who die because of them, and a second mint selling overpriced drugs to those who will die without them.
While not all that money that flows to politicians comes from manufacturers of OxyContin or other opioid pankillers, the companies that sell addictive opioids do in fact spend a great deal of money to influence lawmakers at the state and federal levels. Over the past 16 years, Purdue Pharma, the maker of OxyContin, has doled out approximately two million dollars in political contributions. One of Purdue’s favorite recipients is Senator Richard Burr of North Carolina, who represents a number of Appalachian counties, including my own. They have given Senator Burr thousands of dollars in campaign contributions even though hundreds of his constituents have died from the products Purdue sells. In fact, during the 2016 election cycle, Burr received half of the $20,000 Purdue gave to federal candidates. I wonder if Senator Burr thought about his constituents who die from OxyContin overdoses when his campaign committee got a $10,000 check from Purdue Pharma last year.
Opioids are big business in the states that make up Appalachia. In TN, KY, NC, and WV, a stunningly high number of opioids are prescribed. The CDC reports the number of opioid prescriptions per 100 residents. In the entire United States, there are almost 83 opioid prescriptions per 100 residents. In NC, the number is 97 per 100. In KY, there are 128 opioid scripts per 100 residents. The numbers are even higher in WV (138/100) and in TN (143/100). If you live in Kentucky, there are enough opioid prescriptions in your community, on average, for every person you know, yourself included, to have at least one. Judging by the numbers, many people have more than one.
When I quipped earlier that OxyContin was a household name in parts of Appalachia, I meant it quite literally. In parts of the region, statistically, every household has a member with a prescription for some form of opioid painkiller.
While OxyContin gets the most attention, it is in many ways a catchall term to describe many other deadly high-powered opiates. There are five major opioid manufacturers: Purdue Pharma, Johnson & Johnson Janssen, Insys, Mylan, and Depomed. These five manufacturers are currently under investigation by the United States Senate. Senator Claire McCaskill, a Democrat from Missouri, initiated the investigation. McCaskill has proven to be one of the few voices in Congress willing to go beyond rhetoric and take direct action to hold opioid manufacturers accountable. In announcing the investigation, McCaskill cited the ways prescription opioids have destroyed communities she represents. Her goal is to determine whether or not the five companies under investigation knowingly contributed to the opioid crisis.
It is wholly proper to call the problem a crisis. Between 1999 and 2014, sales of prescription opioids quadrupled in the United States even though data indicates that the amount of reported pain did not increase accordingly. The drug manufacturers were incredibly successful in pitching their opioid painkillers as a magic solution to chronic pain, and we now know that these drug companies often misled physicians about the addictive properties of the drugs. People who face crippling pain every day do need access to effective treatments. Those treatments should not come at the expense of their sobriety or their lives, and drug companies should be completely honest both with prescribers and with patients about the addictiveness of their drugs.
As sales of drugs like OxyContin have skyrocketed, so, too, have opioid overdose deaths. Between 2014 and 2015, the core Appalachian states all saw double-digit increases in opioid overdose deaths. In West Virginia, opioid overdose deaths increased by seventeen percent. In Kentucky, the increase was twenty-one percent. These stark statistics are a clear indication that the region is facing an imminent threat. Something must be done, and putting an end to this crisis involves a plan more robust and recovery-oriented than the so-called war on drugs that the government, at all levels, has been blundering for decades. It will take more than militarized police and regional task forces and tough sentences to solve the problem. Only a holistic approach stands any chance at all of succeeding.
As we consider potential solutions to the crisis that continues to unfold in our communities, it is essential that we understand just how complicated the problems are. It is easy to blame the addicts themselves. I know many people who take that approach, and I once thought I understood where they come from. In fact, I once held the opinion myself that addicts simply needed to make better decisions and stop using drugs.
As I watched members of my own immediate family succumb to addiction, I began to realize just how firm a grasp opioids have on those who are addicted to them. Those who are addicted to Vicodin or OxyContin or hydrocodone or fentanyl cannot simply wake up one morning and decide to stop taking the drugs. Even if they are able to overcome the immense mental hold the drugs have on them, there are physical consequences when one stops taking opioids.
Though I rarely speak to her and have not seen her in a number of years, I remember times when my grandmother was unable to get the pills she needed to feed her addiction. Within hours of taking her last pill, she would begin to suffer physically from withdrawal symptoms. The physical withdrawal symptoms made it even more urgent that she find a way to get more pills. When there was nothing of value left to pawn for cash, she would resort to begging anyone who would listen.
Those who take fast-acting opiates – those not designed to be time-released – can experience muscle aches, anxiety, fever, and sweats within just six hours when they run out of pills. Those who go three days without a fix experience nausea, stomach cramps, and diarrhea, among other symptoms. These severe withdrawal symptoms can last for over a week. Usually, just one dose of the opioid from which they are withdrawing can curb the symptoms.
For many addicts, their addictions become a process of maintenance rather than pursuit of a high. As they build up tolerance to the drugs, they are forced to take more and more to get high. Building up a high tolerance for opioids makes addicts more susceptible to overdoses. In many instances, addicts who are arrested and go through detoxification in jail or in a rehabilitation facility return home upon release and immediately begin looking for pills. Sometimes, they will take a dose equal to what they would have taken to get high before their detoxification. However, detoxing often lowers their tolerance, and they are no longer able to tolerate the same amount of drugs they were able to just weeks before. The result, in many instances, is an accidental overdose.
So often, those of us who have never been addicts ourselves react by shaming those who struggle with addiction. We hesitate to speak aloud the realities that most others already know when those close to us are addicts. That shame extends for addicts even to death. Rather than being candid when our loved ones die of overdoses, we try to pretend they met a different fate. Rarely does one see an obituary that lists drug overdose as the cause of death. We don't talk about it because we are ashamed to.
Perhaps if we were more candid both with ourselves and with our neighbors, we might begin to understand that we have more in common than we realize. One of the most important parts of recovery, I think, is community. Addicts need to know that they are accepted and loved, not that they are shamed or outcast. Those of us whose family members struggle with addiction need to know that many of our neighbors are struggling in the same ways, too.
We must stop blaming addicts for being addicted. So many cultural, economic, and mental health realities that are far beyond the control of addicts conspire to prevent them from a neat recovery no matter how dedicated they are to healing. Perhaps the most important part of recovery apart from a supportive community and access to proper mental and physical healthcare is hope. In so many parts of Appalachia, there’s little to give addicts hope. In fact, it’s that desperation – that hopelessness – that often leads them to drugs in the first place. As we continue to think through how we should react to this crisis, we have to look deeper than the drugs or the addiction.
Getting pharmaceutical companies out of the community-killing business is a lofty goal. Perhaps we start by demanding that our elected representatives stand up to drug companies instead of just talking tough then taking campaign contributions from big pharma when they think we aren't looking. Some will argue that when prescription opiates go away, addicts will turn back to heroin or meth to feed their addictions. They are likely right. However, it seems disingenuous at best that we use such a terrible excuse to avoid holding multi-national corporations accountable for peddling poison to vulnerable communities.
We must understand that the addiction plaguing our mountains is simply a reaction to a much deeper set of problems. Addicts are usually driven to drugs because they think getting high or dying are the only ways to escape the hopelessness and misery they face every day of their lives. Until we get serious about addressing the systemic poverty in our region, at its roots, our family members and our neighbors stand little chance of beating the cycle of intergenerational addiction. They need hope, and hope comes from being valued as humans. America at large has little use for white trash, and we tend to put drug addicts squarely into this category. Only when we think of our addicted neighbors as neighbors and not throwaway humans will we start to truly understand what we need to do to put our communities back together.
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