A journalist and former colleague of mine was so worried about the epidemic’s chilling effect on painkillers that she emailed me an X-ray of her back, showing a sixty-four-degree curve in her lumbar spine—from the front, it resembled a question mark—and slipped disks that caused severe arthritis pain. Painkillers had allowed her to work and actively pursue gardening, cooking, and beekeeping, and they precluded risky and potentially debilitating surgery.
And yet her scoliosis specialist had recently discontinued her pain management “without any notice and with no discussion during appointments to come up with a pain management strategy” because the new CDC guideline “frightened him into abandoning his patients,” she said. (For her arthritis, she takes the synthetic opioid Tramadol; for neuropathy, she takes the seizure medication gabapentin, which is increasingly sought on the black market for its sedative effects.) “My life is not less important than that of an addict,” my friend wrote, in bold letters, explaining that her new practitioner requires her to submit to pill counts, lower-dose prescriptions, and more frequent visits for refills, which increase her out-of-pocket expense.
“The system taking shape treats me like an addict, like a morally dubious person who must be treated with the utmost suspicion,” she said.
The CDC guideline had become so controversial among pain patients that the two employees charged with drafting it received death threats.
To follow the physician’s imperative of “Do no harm” in a landscape dominated by Big Pharma and its marketing priorities, the medical community only recently organized behind renewed efforts to limit opioid prescribing, teach new doctors about the nuances of managing pain, and treat the addicted left in the epidemic’s wake. The number of residency programs in the field of addiction medicine has grown in recent years from a dozen to eighteen.
“We live in an era where for a century now the pharmaceutical industry has invested enormous capital investments in new drugs, and there’s no turning back that clock,” said Caroline Jean Acker, an addiction historian. “So, as a society, we’re going to have to learn to live with possibly dangerous or at least risky new drugs—because Big Pharma’s going to keep churning them out.”
*
The birthplace of the modern opioid epidemic—central Appalachia—deserves the final word in this story. It is, after all, the place where I witnessed the holiest jumble of unmet needs, where I shadowed yet more angels, in the form of worn-out EMTs and preachers, probation officers and nurse-practitioners. Whether they were attending fiery public hearings to advocate for more public spending, serving suppers to the addicted in church basements, or driving creaky RVs-turned-mobile-clinics around hairpin curves, they were acting in accordance with the scripture that nurse-practitioner Teresa Gardner Tyson had embroidered on the back of her white coat:
Verily I say unto you, inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me. (Matthew 25:40)
One three-day weekend every summer in far southwest Virginia, Tyson plays host to the nation’s largest free medical outreach event. Held at the Wise County Fairgrounds, Remote Area Medical serves the uninsured, from children with undiagnosed diabetes to adults on walkers with infected teeth, some caused by lack of dental coverage and others by years of meth use. It’s where I crossed paths with people like Craig Adams, a construction worker and recovering opioid addict, who brought his wife, Crystal, to RAM so they could both get their teeth fixed: They’d used so many tubes of temporary dental repair glue, he told me, they’d lost count. Craig had spent eight years in the state prison system for breaking into Randy’s Gateway Pharmacy in nearby Richlands, trying to steal OxyContin. But he was taking Suboxone now—“responsibly,” he told me, “because my wife wouldn’t have it any other way.” Having lost scores of people to opioid overdose, including his mom and grandmother, he hadn’t used illicit drugs in more than three years. “I had put off going to RAM for years because I figured they’d make you feel like shit about yourself, like ninety percent of the social service people do,” he said. “But everyone was just…so…kind.”
If there’s an argument to be made for a single-payer health care system with mental health and substance abuse coverage, this is the lumpy ground on which to make it, a gravel lot in which upward of three thousand Appalachians camp out for days in 100-degree heat to be treated in exam rooms cobbled together from bedsheets and clothespins. Behind a banner for the virginia-kentucky district fair & horse show, patients wait in bleachers while volunteers pass out bottles of water as they triage them to pop-up clinics for medical, dental, and eye care.
I interviewed Tyson several times in the spring and summer of 2017, before and after the July RAM event that her organization helps plan and host. In the weeks leading up to it, she liaised with media from as far away as Holland and made frantic phone calls, once when her assistant struck out trying to secure enough bottled water for the RAM crowds. A nonprofit they usually counted on said this year’s pallets were already reserved for natural-disaster relief. “If this isn’t a disaster, I don’t know what is!” Tyson said, managing to sound both desperate and upbeat.
In rural America, where overdose rates are still 50 percent higher than in urban areas, the Third World disaster imagery is apt, although the state of health of RAM patients was actually far worse. “In Central America, they’re eating beans and rice and walking everywhere,” a volunteer doctor told the New York Times reporter sent to cover the event. “They’re not drinking Mountain Dew and eating candy. They’re not having an epidemic of obesity and diabetes and lung cancer.”
I had made a similar comparison two years before, when Art Van Zee drove me through the coal camps on my first visit to Lee County, just west of Wise. Though I’d covered immigration in rural Mexico and the cholera epidemic in northern Haiti, I told him, never before had I witnessed desolation at this scale, less than four hours from my house. Most of America would be shocked by the caved-in structures, with their cracked windows and Confederate flags, and burned-out houses that nobody bothered to board up or tear down. It felt completely out of scale with the rest of the nation I knew. But these conditions were hardly limited to St. Charles or Wise County, Van Zee pointed out. “On the other side of the cities [many Americans] live in, there’s poverty and poor health probably just as bad,” he said.
In Appalachia, he conceded, poverty and poor health were not only harder to camouflage; they were increasingly harder to recover from. For decades, black poverty had been concentrated in urban zones, a by-product of earlier inner-city deindustrialization, racial segregation, and urban renewal projects of the 1950s and 1960s that decimated black neighborhoods and made them natural markets for heroin and cocaine.
Whites had historically been more likely to live in spread-out settings that were less marred by social problems, but in much of rural America that was clearly no longer the case. These were the same counties where Donald Trump performed best in the 2016 election—the places with the most economic distress and the highest rates of drug, alcohol, and suicide mortality.
The national media’s collective jaw-dropping at the enormity of needs displayed at the RAM event underscored the fact that the outside world had zero clue. As the Appalachian writer and health care administrator Wendy Welch noted: “We’re not victims here, except for when it comes to Purdue Pharma. But when one of us makes a mistake, it tends to be a fatal one.”