I Do My Father’s Drugs: Part 1

This morning I pulled up to the the family practice through which I am currently rotating. I stepped out of my car, and across the parking lot perched on a hill top, I saw the sun’s radiance bounce off the frost covered Appalachians, quietly and peacefully reiterating the obvious natural beauty of West Virginia. Standing there, as the winter winds whip my face, lost in the mountains on the horizon rolling like white caps in a stormy sea, I forget momentarily the entrenched pain hidden within those hollers (it’s a word). As I step into the clinic, examining my patients’ medications, the stream of -codone and -morphine suffixes quickly remind me of southern West Virginia’s status as the frontline of opioid abuse. To the unacquainted, the abuse of opioid, prescription and illicit, seems a clear cut dearth of morality. As a society we are splitters, defining people as good or bad, no room for middleground. We are saints or sinners, never both.

Based on the recently popularized dialogue with doctor’s in the trenches of this newly declared war, it is clear our leaders do not understand the context of this battle. To truly understand drug abuse and pain management in Appalachia, America must understand one key fact: America broke Appalachia. On the broken backs of the consistently impoverished blue collar region, we built our industrialized nation. In the coal mines we broke men. With low wages we broke families and fueled the persistence of socioeconomic depression. With our greed and our love instant fixes, we set the stage for drug abuse.

The battle against the rising opioid epidemic, cannot only be fought in the clinics. It is not just a medical problem. It is a problem rooted in multigenerational poverty and a region against which the nation has by and large betrayed. In coming posts, I intend to address the unique components of a phenomenon I call Appalachian Pain from a historical, a clinical, and a sociocultural perspective. In doing so, I hope to offer insight often ignored in the larger societal discussion, and perhaps initiate a conversation less entrenched in stereotype and shed light to the hollers America forgot. As is so sadly true globally, the most beautiful parts of the world, wealthy with the most natural treasures, are also the most tumultous and tortured, and America is no exception.

In the following paragraphs, I offer up anecdotal evidence to the complexity and gravity of this community’s epidemic. In the following posts, I will attempt to reconcile these personal experiences with the conversation that is happening on the policy level.

Mountains of Pain-

The needle tracks ran up her thigh, her skin yellowed from healing bruises of her own addiction. I felt for the femoral vein and was greeted by a hardened, scarred vessel. A life giving route turned delivery mechanism for possibly one of the worst man-made epidemics in history. A disease that entrenches itself, feeding off of a web of multigenerational poverty. A sickness that hijacked the overwhelming pressure on physicians to eliminate pain. In the heart of the beautiful Appalachian mountains, my home of 24 years, dwells this nation’s cancer. As black as the coal ripped from the mountainsides, and as insidious as the worst metastases, the opioid epidemic blites the poorest, most impoverished region of the United States, showing no signs of relenting.

She is a mother, a daughter, and a friend. Consumed by a power beyond her immediate control. An illness as unforgiving of one bad decision as our society. Shaking from withdrawal or the rigors of an acquired infection, she is torn between accepting our care or feeding the demon ripping apart her frontal cortex and flailing wildly in the most primal portion of her brain. The patient is hypothetical, but the clinical scenario is all too real and all too familiar.

As a medical student, I have spent the greater part of my education and clinical training in southern Virginia and West Virginia. An undeniably depressing fact about training here is the less than healthy skepticism one develops for a chief complaint of pain. With even the best intentions of avoiding cynicism, one cannot help but hear the voice of doubt everytime a patient raises the issue of their pain. Given the traction the region’s opioid abuse has gained in Washington, one may be forgiven for being overly optimistic that this disease has run its course. While an important acknowledgement, the true battle to end this national cancer must take into account the underlying socioeconomic factors that permitted the entrenching of substance abuse in the Appalachian community. Like a cancer, this epidemic was preceded by a series of failures, both locally and nationally. Just as multiple mutations in the correct sequence initiate a cancerous growth, so too did a series of systemic break downs and social injustice provide a niche for substance abuse in Appalachia.

In 1960, less than 50 miles from my current training site, the then presidential candidate John F. Kennedy found himself appalled by the glaringly obvious poverty, declaring an “unconditional war on poverty.” Four years later, his predecessor Lyndon Johnson would take up that banner and in doing so, the residents of McDowell County would be the first to participate in a food stamps program, one of the first social safety net programs. In what seems like an act of goodwill toward a people that provided the life blood that was coal for this industrialized nation, but received little in the share of that prosperity, the War on Poverty would be an attempt to reconcile the nation with those left out of the relative economic boon.

I recently embarked on a drive up Route 52 in West Virginia, the most convenient, yet motion sickness inducing route to the heart of McDowell County. Within minutes, my already limited bars vanished and were replaced with the ominous NO SERVICE sign indicating my yuppie life line to the digital world had vanished. Fortunately enough, there is only one main road to which any logical outsider would stick. I passed through unincorporated community after unincorporated community which where mostly clusters of aging miner villages, ironically well maintained churches, and the occasional service station with the all too stereotypical faded Marlboro and Keystone Light ads that I had come to mock in my own hometown visits during college. Essentially following the winding creek down the hollows, the road snaked through narrowed gullies. Single and double wide trailers with electric blue tarps strewn over collapsed roofs stood tucked up against the mountainside. Crumbling concrete steps led up to craftsmen style houses in disrepair. The occasional condemned Victorian abode rested as a sad reminder of a prosperous past long since crushed under the weight of the American dream.

I would like to tell you that the stories of Appalachian poverty are overblown. That non-appalachian lack the understanding of an eccentric and simpler, but no less meaningful way of life. I would be lying, to you and myself. Patients walk in the snow to for 3 miles to be seen by a doctor. Drugs fuel bank robberies and drive by shootings. There is a currency of tobacco, pills, and needles. The gap between the haves and have nots is obvious as you drive through the neighborhoods. Modern, nuclear families inhabit relative palaces in one neighborhood, while aging miner’s houses with busted windows and trailers with no heat fill the next.

My destination was Coalwood, the town made famous by Homer Hickam and the Rocket boys. After an hour and ten minutes and 45 miles of winding roads, I came to Rocket Boys Lane. There stood a faded wooden painted sign. Welcome to Coalwood, Home of the Rocket Boys. The road turned to gravel, a hound dog uttered a deep throated bark as I stood at the edge of that road. The paint pealed from the houses, plastic or boards covered windows. Refuse was scattered across the aging gravel, staggering like the track marks up that patient’s thigh. I felt the mountain’s pain. Pilllaged of the black gold, and left empty, just like so many of the families on which the mines depended. It was in that moment, I sympatheized with the rush of heroin or dilaudid. In the cold, stark, West Virginia winter, I began to understand the appeal of the numbing calm that could wrench one from this reality, if only for a moment.