At the Narcotics Farm in Lexington, Kentucky, researchers had once referred to the latter as “the geographic cure.”
The idea of moving away from the site of addiction’s onset appealed to younger people who grew up among addicted family members as well as to the recovering addicts themselves, and it had worked for some, like many of the returning Vietnam soldiers. But opioids are much more available today than they were then—summonable by text or via online cryptomarkets, aka the dark web—and vastly more potent.
“The biggest lesson of the science behind drug addiction is that alternate reinforcers are essential,” Nancy D. Campbell, the Narcotics Farm historian, told me. “If you want to keep people away from drugs and drug-related crime, you have to have rewarding activities. It’s work. It’s play. It’s an emphasis on the kinds of activities and relationships that people build their lives around. If we don’t do something to rebuild these communities, I don’t see this current drug configuration ebbing in the way that drug waves of the past historically have.”
The question echoed louder by the day in rural America: How do you inspire hope in a middle-school boy whose goal in life is to become a “draw-er,” like his parents before him and their parents before them? Did a president who bragged about winning a swing state—telling the president of Mexico, “I won New Hampshire because New Hampshire is a drug-infested den”—win because voters genuinely thought he could fix it, or because too many people were too numbed out to vote?
Voters should judge politicians at all levels on the literal health of their communities, lawyer Bryan Stevenson explained. And while most Americans support federal financing of health care and even a slim majority approves of single-payer, those reforms will likely remain political nonstarters until more voters begin defining themselves in contrast to the billionaire class holding sway in Washington. Also needed are more efforts to court nonwhite voters, including Hispanics (of whom 74 percent are currently registered to vote), African Americans (69 percent), and Asian Americans (57 percent).
“You’ve got too many leaders just not responding to problems,” Stevenson said. “Think about with HIV, with smoking, with Zika, you had this energetic leadership from people who were saying, ‘We’re going to win this.’ The mind-set of ‘This is unacceptable’ has to be brought into the way we think about addiction and the opioid epidemic. But part of the problem now is, we’re so hopeless…that we don’t try very hard.”
America’s approach to its opioid problem is to rely on Battle of Dunkirk strategies—leaving the fight to well-meaning citizens, in their fishing vessels and private boats—when what’s really needed to win the war is a full-on Normandy Invasion.
Rather than puritanical platitudes, we need a new New Deal for the Drug Addicted. But the recent response has been led not by visionaries but by campaigners spewing rally-style bunk about border walls and “Just Say No,” and the appointment of an attorney general who believes the failed War on Drugs should be amped up, not scaled back. Asked in August 2017 why he hadn’t taken his own commission’s recommendation to label the epidemic a national emergency, President Trump dodged the question. He said he believed the best way to keep people from getting addicted or overdosing was by “talking to youth and telling them: No good, really bad for you in every way.” A few days later, he seemed to change his mind, saying he would make the emergency official, even as he remained tethered to a law-and-order approach.
But months later, he still had not followed through. When the so-called emergency was retrumpeted in an October 2017 press conference, Trump sounded bold and even hopeful, but his ballyhoo fell short of an official declaration, and included no additional treatment funding. At the time, seven Americans were dying of overdose every hour.
To be fair, the crisis had been cruelly ignored by both sides of the political aisle. The Obama administration had also been slow to address the crisis and tepid when it did. Caroline Jean Acker, the historian who is also a harm-reduction activist, told me she was scolded during a 2014 NIDA meeting for championing needle exchange and naloxone distribution after a speaker attempted to separate “good” addicts, or people who became medically addicted, from the illicit, or “bad,” users—as if there were no fluidity between the two. “The worst thing for politicians, I was told, was for them to appear they were being soft on drugs. Even under Obama, federal [Substance Abuse and Mental Health Services Administration] employees were told not to use the term ‘harm reduction,’” she said, sighing.
*
No matter where I turned in central Appalachia, the biggest barriers to treatment remained cultural. Stigma pervaded the hills and hollows, repeating itself like an old-time ballad, each chorus featuring a slightly different riff.
At the RAM event in Wise, a kerfuffle erupted when a local judge volunteering at the event accused a pharmacist of giving Narcan training to a local Boy Scout troop without their parents’ permission; she claimed the kids would party harder knowing they had Narcan to revive them. “Just ridiculous,” one trainer told me.
But across the region, where it seemed every family had at least one soul crusher of a story, it would take more than one fairground debate to convince people that harm reduction was necessary to save lives, even as the region had the worst hepatitis C rate in the state. One-third of children in central Appalachia now lived with a nonparent adult, and 96 percent of the adopted kids weren’t orphaned—they’d been removed from their drug-addicted parents by social service workers.
At another Health Wagon event, a man overdosed on meth in the parking lot while his friends took off, running up the mountain, according to the responding EMT, who recognized a familiar unconscious face. “Repeats,” as Giles Sartin refers to many of his overdose calls, saying: “It’s rare you’ll get somebody who’s just now getting hold of it.” Sartin, twenty-one, has been an EMT since the tenth grade. He made the decision to train the day he was sitting in a freshman English class and heard the double thump of two classmates seated behind him hitting the floor.
They’d overdosed on OxyContin during a lesson on grammar and punctuation.
“Last week I Narcanned the same person for the fourth time,” Sartin said. When the man woke up, he punched Sartin’s EMT partner and broke his nose. He’d been speedballing painkillers with meth, which makes users paranoid and gives them “ridiculous strength.” It was such a problem that Sartin’s rescue squad had to adopt a new protocol: Even though people could die, they waited now for police to arrive before they went inside the patients’ homes.
“There’s communities where we’re like an ice cream truck,” Sartin said of the ambulance. “They’ll try to steal our needles, our gloves, everything,” especially in the Lee County hamlets of Keokee and St. Charles.
When I explained that my book began with OxyContin abuse in Lee County in the late nineties, Sartin cut me off with a warning: “Ma’am, there are spots in St. Charles where I would advise you not to be there at night. If they catch ya and don’t know ya, well…I don’t know.”
Tyson had revised the Health Wagon’s safety procedures, too. Whereas in Lebanon she tends to set her RV up outside a Food City grocery, or near the town square in St. Paul, she has learned to avoid residential neighborhoods in smaller communities. In the former coal camp of Clinchco, a close call had persuaded her to switch locales from a neighborhood to the police station parking lot.