What is happening in Appalachia?
The Appalachian region of the United States stretches from Southern New York into Northern Alabama and Georgia, and it has historically been the target of negative stereotypes and sensationalistic journalism tactics that taunted various aspects of its culture. When policymakers need a description of rural poverty, Appalachia is the default destination to paint the portrait of stereotypical poverty:
“Children in sepia-toned clothes with dirt-smeared faces. Weathered, sunken-eyed women on trailer steps chain-smoking Camels. Teenagers clad in Carhartt and Mossy Oak loitering outside long-shuttered businesses.”
As the Appalachian region receives negative perceptions, there are widening gaps in the problems here compared to the rest of the country such as generational poverty, environmental pollution, and health disparities. These health disparities consist of a higher mortality rate in “death by poisoning”, infant mortality rate, likelihood of chronic disease, and lower life expectancy.
In particular, due to the growing opioid epidemic, Appalachia has a death rate by poisoning, which includes drug overdoses, that is 37 percent higher than the rest of the country. This percentage is unacceptable as the area has long been neglected by those in power to keep their workers vulnerable and powerless. It is time for Appalachia to be noticed and valued as citizens of America and for them to receive adequate access to healthcare that will sustainably pull them out of cyclical poverty and toward the mend from high numbers of opioid overdoses.
What is the Opioid Epidemic?
The first wave of the opioid epidemic in America began in the 1990s with increased prescribing of opioids and overdose deaths involving prescription opioids, natural and semi-synthetic opioids, and methadone. The second wave began in 2010 with a rapid increase in heroin deaths, and the third wave began with significant increases in overdose deaths involving synthetic opioids, particularly those involving illicitly manufactured fentanyl, which can now be found in combination with heroin, counterfeit pills, and cocaine.
The opioid overdose crisis was ushered to the forefront when pharmaceutical companies promised the medical community that patients would not become addicted to prescription opioid pain relievers. In turn, healthcare providers prescribed them at greater rates. Widespread misuse of these medications ensued until it became clear that opioid medicine was indeed addictive.
In 2019 alone, an estimated 10.1 million people misused opioids. Specifically, 9.7 million people misused prescription pain relievers and 745,000 people used heroin. From 1999 to 2019, the CDC reported nearly 247,000 deaths in the United States from overdoses involving prescription opioids. Overdose deaths involving prescription opioids more than quadrupled from 1999 to 2019. The COVID-19 pandemic created concern about increased opioid overdose deaths around the country as isolation and high unemployment affected many in the nation.
Why is this Prominent in Appalachia?
Though opioid addiction stretches across many parts of rural America, this is more prominent in Central Appalachia for a variety of reasons. The overall generational poverty and the lack of access to quality healthcare have spread opioid use and dependence throughout the region.
First, generational poverty within the region has prohibited progress from being made in many areas regarding health and safety. Lower household incomes and higher poverty rates, which are both social determinants of health, reflect worse living conditions in the region than in the nation as a whole. Upon eight measures of living conditions, such as heart disease, cancer mortality, and education levels, Appalachia has seen a slow improvement in seven of them, though the region still trails behind the country. Poverty is the only measure in the region that did not improve in the past two decades. Poverty often increases addiction risk factors, as stress and hopelessness are increased and access to healthcare, self-esteem, and social support decrease.
As Appalachia was primarily settled by English, Scottish, and Irish, they were frontiersmen who desired independence, which turned into staunch individualism. As the rest of the country saw growth in commerce, industry, and education, the same progress didn’t make its way into Appalachia. Because they desired independence in the early settlement, the Appalachian people became existence-oriented as opposed to improvement-oriented. This resulted in receiving little money or attention from the state to build an education system for many years despite their need. Politicians and the wealthy, living in predominantly urban areas, held the real power in the state and completely ignored the Appalachians experiencing poverty who were asking for assistance.
This history has spiraled into the situation in Appalachia today, where the employed population earns significantly less in wages compared to the rest of the United States. In 2014, the per capita income of the Appalachian region of Kentucky was only $30,308, while that of the entire US was $46,049.
As many who live in Appalachia are in the working class, their rate for workplace injuries increases because they are doing physical labor for low wages such as construction or coal mining. In these workplace-related injuries, they are regularly prescribed opioids for their chronic pain, and this increases their likelihood for addiction. The effects of substance abuse make it nearly impossible to keep working, thus perpetuating financial struggles.
Additionally, Americans were targeted by Purdue Pharma when they mobilized lobbyists to persuade lawmakers and doctors to provide courses and increased prescriptions of their product, OxyContin, stating that it wouldn’t be addictive, though the company was aware it was addictive, as they stated in a 2007 lawsuit.
Americans experiencing poverty are affected by this because when the high of the opiates they are addicted to wears off, they still want more. Heroin has been found to be an easy substitute for opiates, as it is cheaper and it is known to produce a better “high”. Heroin dealers are aware that more money is to be made in Appalachia because as the addiction rate is so high, an individual in Appalachia would pay more for the same amount than someone in streets of a busier city, so they push to sell more in the region.
Next, there is little access to adequate healthcare in Appalachia. The region has lower supplies of healthcare professionals when compared with the United States as a whole, including primary care physicians, mental health providers, specialty physicians, and dentists. Lack of healthcare resources have been associated with the lack of specialty care providers in the area and unavailable times for appointments, at times up to three months for outpatient visits
Higher numbers of primary care physicians are a significant element for increasing access to primary medical care, and the Appalachian Region has 66.8 primary care physicians per 100,000 population, which is 12 percent lower than the national average of 75.6 primary care physicians per 100,000. Additionally, there are 130 mental health providers per 100,000 population in the Appalachian Region, which is 35 percent lower than the national average of 201 per 100,000 population.
When Appalachians experience the feelings of hopelessness and low self-esteem mentioned earlier that accompany poverty and opioid abuse, they have fewer options than the rest of the country for therapy to help them. When Appalachians have medically related effects to their opioid use, they may have to wait months to see a primary care physician if it isn’t urgent enough for a hospital visit.
Since people in Appalachia have more obstacles to overcome when it comes to opiate use and addiction, it is crucial that action is taken to provide the area with better resources that will reduce opiate use and its effects.
What can be done about the opioid epidemic?
A solution to this problem will consist of multiple parts, as this issue is too large for a one-size-fits-all solution. Policies at the state and federal levels need to be passed to ensure that the government supports Appalachia in catching up to the rest of the country. But actions, such as education implementation and stronger medical aid resources, also need to be taken to assure that the policy is effective in preventing opioid misuse, increasing access to treatment for opioid misuse, and implementing strategies to reduce negative consequences of opioid use.
Policy and Education
Legislation must be passed that would enable more resources concerning education and medical aid to the areas of Appalachia that need it. As there are already various education programs related to preventing substance abuse in West Virginia, such as Handle with Care and Bright Spot Case Study Community, it is the best way to ensure more immediate results because the laws would enable permanent change.
With funding from the legislation passed, education programs addressing risks of opioid misuse and ways to prevent youth from developing opioid use disorder could be implemented in the school systems in the areas most affected by opioid deaths. These are typically low-cost programs that serve a whole population regardless of individuals’ risk factors.
These courses focus on school-based interventions that teach youth skills to resist substance abuse for the future. Additionally, the education would address the medical resources available in their area to students in case they know someone who overdoses or are in a situation in which they are introduced to substances.
For example, Handle with Care is an education initiative already implemented in various West Virginia schools that aids students in preventing dealing with existing trauma in their lives. As this could be applied to effects of opiate use, the current structure of training law enforcement, schools, and counselors on how to deal with the issue of child trauma would be useful in the setup of the specific substance abuse education programs.
Because substance abuse education increases awareness of the issue and ways to resolve it, creating substance abuse courses and resources in the area would empower residents of Appalachia to be more aware and mindful about potential effects of opioid abuse going forward.
Healthcare Initiatives
Access to healthcare must also be adjusted in order for this to work. With few options for healthcare systems discussed earlier, legislation and education are not the only viable steps for the opioid crisis in Appalachia to reduce.
A large factor of the solution is preventing opioids from being overprescribed and misused at the beginning, and having closer access to health professionals would do so. The overall goal is to make accessing safe medication more accessible to individuals living in the areas, and if more healthcare professionals were closer in proximity when residents obtain their prescription drugs, they would be able to answer questions and describe how to go about using them.
Similar to the government forgiving loans for teachers after completing postgraduate education, a program could be implemented for almost or newly licensed medical professionals to work with longer-practicing doctors in the Appalachian region. Clinics could be established and spread in harder to reach areas. This would bring quality care closer to the people, and it would encourage use of these resources.
Medical drones have been used recently to aid people in rural Virginia in obtaining their medicine when they can’t make the far drives or the clinics are overpopulated with patients. People in the mountains often have to drive at least one hour to get to their closest pharmacy, so with this drone drop, pamphlets with instructions for the medicine being dropped and the actual medicine itself would be dropped directly to the patients.
In Charlotte, NC, Zipline introduced contactless drone medical supply delivery at the beginning of the COVID-19 pandemic. This program has the longest drone range approval from the government ranging from 20 to 30 miles, but the maximum is 100. However, Charlotte is a city with ample resources, so Appalachia would need more technological and medical resources from legislation in order to make this idea work.
Finally, a call-in or telehealth resource could be established. SImilar to the 911 number, a phone number could be established for a service that is specific to overdoses and substance abuse problems. If people find a friend or a loved one in the position of being in an overdosed state, they could call the resource for instructions on what to do next.
Instead of frantically researching what to do on the internet or training 911 dispatchers in dealing with this issue, as they already have many issues to deal with, there will be people specially trained to deal with overdoses who can instruct the caller on what to do next while an ambulance is sent to their area. This creates a more specific solution to deal with overdoses as soon as possible instead of prolonging the care the patient won’t get until they arrive at the hospital.
For centuries, the people of Appalachia have been neglected by politicians, the wealthy, and by the rest of the country, and it’s time they should be given the resources to catch up to the rest of the country. By targeting the problems of generational poverty and lack of access to healthcare through implementing educational systems and new ways to receive medical care such as drones or telehealth resources, the death by overdose rate may start to decrease in Appalachia.
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