Opioids and Appalachia by Sally Satel

 Sally Satel, who has treated patients in Appalachia, writes movingly of the drug addiction problem there. Here's a paragraph that sets the stage.

"The history of opioid pain relievers in Appalachia is a prime illustration of the fact that drug epidemics rarely burst onto the scene out of nowhere. Instead, they find their place in regions that are already home to an established base of individuals who abuse similar drugs. Thus illicit OxyContin, a more potent opioid, efficiently gained popularity over Percocet and Vicodin in the same way heroin would substitute for prescription opioids as the latter grew scarce after 2010."

That's from Opioids and Appalachia by Sally Satel, in the current issue of National Affairs.

The whole thing is well worth reading; here are a few more paragraphs that caught my eye.

"The churn of pills — diverting, using, and selling them — soon had eastern Kentucky, southeastern Ohio, and West Virginia pulsing with crime. Realtors routinely told home sellers not to leave pills in their medicine chests during open houses. Funeral directors and hospice nurses cautioned the bereaved not to mention in obituaries that their loved ones had succumbed to cancer — a red flag signaling that huge bottles of pills were likely on the premises. In eastern Kentucky, local law enforcement was often stymied by close ties between people within communities. Loyalty within large families and fear of retaliation by neighbors made it hard to cultivate informants and to impanel neutral juries that would convict when prosecutors proved their case.

...

"Appalachians seemed to take the corruption in grudging stride. In one survey, 90% of over 100 Kentuckians working in law enforcement, health, and community governance said the rural OxyContin problem in the early 2000s was "fueled by a cultural acceptance of drug misuse." Indeed, many residents tolerated unlawful activity, since it generated revenue for the community from sales of pills to outsiders. This happened in places like Williamson, West Virginia — dubbed "Pilliamson" — where the local Wellness Center was a hub of reckless prescribing. Cash-laden out-of-staters flocked there to buy painkillers and, in a small area near the center, trade and sell those pills.

"Pablo Escobar and El Chapo couldn't have set things up any better," wrote Eyre. "The coal barons no longer ruled Appalachia. Now it was the painkiller profiteers."

...

"Today, opioid pills are no longer pouring into Appalachia as they once did; highly lethal products like fentanyl-laced heroin, methamphetamine, and counterfeit fentanyl pills are what people are selling."