Radford
In the summer of 1976, as cyclists rode through the city of Radford, they passed within a few blocks of the community hospital, established in the second world war, and a pillar of the community’s downtown. At the present time, cyclists along this route will see a new facility, built in the late 1990s, from route 76 just southeast of Radford, where Mud Pike Road parallels Interstate 81. This hospital is an example of how Radford, like other cities in predominantly rural parts of Virginia, has become a hub for medical care. The shift from a downtown hospital serving the immediate community to a regional health center on a highway interchange is reflective of broader patterns in small town America as well as the reconfiguration of health services into managed networks. This structural shift also provides a unique perspective to explore the impact on rural and small town America of a major health crisis of the twenty-first century: the costs of opioid addiction. In this case, underlying social, economic, and regional dynamics created vulnerabilities among marginal populations that brought long-term losses to individuals, families, and communities. Understanding southwest Virginia in the present is impossible without an appreciation for the causes and consequences of this devastating health crisis, in Appalachia specifically and more broadly in rural America.
Welcome to episode 22 of the Virginia Bikecentennial Route 76 Podcast. This episode is connected to the city of Radford, located just under 400 miles from Yorktown, the starting point for the westbound route, and about 150 miles from the Kentucky border, where eastbound riders enter Virginia. This podcast is a production of Virginia Tech, a public land grant university located in Blacksburg, just three miles from Route 76 in southwest Virginia. I am your host, Tom Ewing, and this podcast is produced by the digital humanities program in Virginia Tech University Libraries, under the direction of media manager Joe Forte. Plеаse note that this episode contains stories about drug use addiction that some listeners may find disturbing.
Histories of opioid abuse in Appalachia usually begin with the long term consequences of coal mining across this region. For decades, beginning in the early twentieth century, working in coal mines provided men with some of the few opportunities for wages sufficient to support a family across western Pennsylvania, southern Ohio, West Virginia, eastern Kentucky, western Virginia, and eastern Tennessee. Coal mining was physically demanding work that led to injuries, as miners spent long days in cramped tunnels, using heavy equipment that resulted in devastating accidents. Even those who didn’t suffer from catastrophic injuries experienced the long-term consequences of exhausting working conditions. For many coal miners, using painkillers became a necessary preparation for going to work on a regular basis. While men made up most of the coal mining workforce, women also suffered the consequences of living in mining communities, with costly environmental conditions, difficult labor, and the stress and anxiety of living with constant danger from accidents and other disasters.
Many mining families lived in so-called company towns, where the owners of the mines paid wages, rented houses, ran stores, and provided schools. These companies also employed the doctors who treated the miners. In this situation, miners, owners, and doctors had a shared interest in using pain medication to get people back to work: miners because they needed the income, owners because they needed labor to produce coal for the market, and doctors because painkillers suited the priorities of both their patients and their employers. If miners were unable to work, their families faced eviction from their homes and their communities, which reinforced the incentives to use any means necessary to continue working.
Coal production in the United States peaked in the late 1940s, and then began a gradual decline that has continued ever since. Miners and their families remained in company towns, with the structures of dependency outlined above, while unemployed and displaced former coal miners found new dependencies on expanded welfare systems. By the early 1960s, unemployment in the Appalachian region was over 12%, more than twice the national average. In this situation, economic dependency reinforced the potential for dependency on painkillers, as the physical demands of coal mining were accompanied by the emotional and psychological demands of impoverished communities.
The use of painkillers in Appalachian coal regions began in the twentieth century, with widespread use of alcohol and tranquilizers. This situation worsened considerably in the 1990s when Purdue Pharma began aggressively marketing OxyContin. Physicians in Appalachia were intentionally targeted by this company because of their record for prescribing all forms of opioid medicatino. OxyContin, which contains pure oxycodone in high doses, was recommended to deal with a broad range of pains. At the same time, best practices in medicine shifted to address chronic pain in patients with severe and terminal illnesses, which encouraged physicians to expand prescriptions of opioids. By 2000, Appalachian physicians were prescribing OxyContin at five times the national rate.
OxyContin was different then earlier types of painkillers. While the pill was designed to release medicine slowly after it was swallowed, the same pill could be crushed and then snorted or injected, in order to obtain a quicker and more powerful high. These practices greatly increased the risk of addiction, as more frequent doses at higher levels were required to sustain the same effect. People who had been using painkillers for years or even decades without becoming addicted suddenly found themselves dependent on OxyContin, or what some referred to as “hillbilly heroin.”
In rural communities, across Appalachia and the rest of the United States, OxyContin was exchanged within existing family and social networks. So-called “pill mills,” where prescriptions could be obtained with cursory medical exams or forged records, fed into an underground exchange where the lines between dealers and users were often blurred. OxyContin was used to pay for car repairs, rent, groceries, and more. Doctors knew that patients were abusing and exchanging prescription painkillers, but had limited options to deal with the problem.
Crime spread along with the growing abuse of OxyContin. Home medicine cabinets in homes were raided by family members seeking painkillers, while petty theft of goods to be sold or exchanged for drugs proliferated. Physicians suspected of overprescribing faced limited consequences, while those who acquired a reputation for easy access to OxyContin prospered from the money paid by patients and insurance companies. So-called “painkiller profiteers” appeared to have displaced coal barons in their rule over Appalachia.
The situation worsened in Appalachia and across the United States as OxyContin was displaced by synthetic heroin, and particularly fentanyl, which delivered an even more potent high to addicted users. Exchange networks that once delivered OxyContin from pharmacies to users now brought fentanyl into the same displaced populations with deadly consequences. Overdose deaths rose dramatically in the early 2010s.
The crisis in Appalachia came to national attention in the last several years through the remarkable efforts of two writers: Beth Macy and Barbara Kingsolver. As residents of Appalachia, thoughtful observers, and brilliant writers, these two authors provide a first-hand examination of how the opioid epidemic devastated communities and destroyed lives.
Beth Macy worked as a journalist for more than twenty years in Roanoke, where her reporting focused on the stories of marginalized and displaced populations. In her book, Dopesick, Macy explores the impact of opioids in three Virginia communities: Lee County, Roanoke, and Woodstock. These three case studies allow Macy to focus on the human costs of opioid addiction, including the destruction of young lives, the catastrophic impact on families, and the struggles of addicts. Macy also examines the work of those seeking to address the crisis, including physicians who demanded accountability from pharmaceutical companies, counselors who sought the best treatment for addicts, and especially parents who turned their grief at losing children into platforms for meaningful change. After winning numerous awards, Dopesick became an Emmy winning television series, thus further expanding the impact of this remarkable work of original journalism.
Macy has continued her efforts to educate the public about the long-term causes and consequences of opioid addiction. Her most recent book, Facing Lazarus, continued to tell the stories of those struggling against the overdose crisis in America. She also advocates for medically tested treatment methods and reforms in law enforcement that encourage treatment and recovery rather than punishment.
Barbara Kingsolver addresses the same issue of opioids in Appalachia in a novel, Demon Copperhead, which won the Pulitzer Prize for Fiction and the Women’s Prize for Fiction, among other distinctions. Born and raised in Kentucky, Kingsolver has been a resident in southwestern Virginia for decades. Inspired by the narrative framework of Charles Dickens’ David Copperfield, this novel tells the story of Damon Fields, nicknamed “Demon Copperfield,” who grew up in a trailer with his mother in rural Lee County. The novel traces the long term effects of addiction on families and individuals in ways that highlight the human costs of the opioid crisis.
In interviews at the time of Demon Copperhead’s publication, Kingsolver drew direct connections between the impact of opioids on communities and the structural position of Appalachia in the American economic, social, and cultural landscape. In an interview published in Slate, Kingsolver identified the “one cultural characteristic” of Appalachia as “a resilience embedded in community.” Asked about the main character in her novel, Kingsolver said: “I know this character. I own the right to represent Appalachia, even from the inside of a kid like Demon. Plenty of people have usurped the Appalachian experience, but …I bring to the table a level of outrage.” In an interview with West Virginia Public Radio, Kingsolver stated: “So as a writer, I see it as sort of my mission to represent us in a way that is seldom seen and seldom understood outside of Appalachia…I’m interested in the heroism of people who think they’re ordinary, and people who are helping each other, creating families for each other or safety networks for each other, who are aware of their indebtedness to their neighbors and their people.”
In a New York Times interview, Kingsolver described Appalachia in terms both geographical and political: “We are connected by our mountains, our economies, and the fact that, for a couple of centuries, we have been treated almost like an internal colony of the U.S. We have suffered the exploitation of extractive industries, managed by and profited from outside companies that come in and take what they can and leave a mess.” From this perspective, the exploitation of Appalachia by outside business interests prioritizing profit over people began with timber and coal and continued through tobacco and led to the opioid epidemic, “which was, again, quite deliberately perpetrated on us as a vulnerable population.”
This history of the opioid epidemic, as illustrated in the contributions of Macy and Kingsolver, highlight key themes related to communities along Bike Route 76 in Virginia: the costs of extractive industries, the limited availability of health and other services, and exploitation by outside interests. This episode’s focus on opioid addiction along route 76 runs the risk of invoking stereotypes of Appalachia that extend back more than a century to the domestic production of alcohol — so-called “moonshine” — and the distribution networks that evolved to deliver the product to urban areas.
These stereotypes have unfortunately been reproduced in some descriptions by riders traveling through Appalachia, who emphasize visible signs of poverty, despair, and isolation that they think they see as they ride through these communities. In 1976, cyclist Reid Miller offered this first-hand account of how observations confirmed stereotypes: “Heading into Appalachia, our expectations of seeing simple frame houses, moonshine and stills, banjos and porch swings and tiny farms nestled in the bottom of ‘hollers’ are fulfilled.” These perceptions continue into the present day. Less than a decade ago, the standard history of the Transamerica Route describes the route through “the ‘holler’ country of Appalachia” using terms that echo stereotypes about the region: “tar paper shacks, house trailers, and barking dogs.” The “Field Notes” in the most popular map for long distance cycling includes this statement about southwestern Virginia: “The mountain people, long embroiled in feuds and cut off from the rest of the country, are beginning to adapt to the ‘outside’ culture brought to them by modern transportation and communication. In doing this, they are leaving behind important parts of their own hill culture.” These stereotypes have remained remarkably consistent over the fifty years that this route has brought outsiders through the valleys of Appalachia.
The writings of Beth Macy and Barbara Kingsolver illustrate effective strategies to challenge these stereotypes and develop a more complicated and accurate understanding of contemporary Appalachia. Macy demonstrates how telling stories about individuals demonstrates both the commonality of the experience of addiction and the challenges faced by family members and health service workers dealing with these situations over the long term. This approach also provides a basis for evaluating the response of the medical system, law enforcement, and local authorities, thus supporting recommendations about policies and practices with demonstrated effectiveness. Kingsolver’s approach also involved telling the stories of individuals living in a context of addiction, yet she more directly engages with both the structures of inequality and the cultural stereotypes which sustain and reinforce these positions of dependency.
Hospitals are visible evidence of the communities that reside along the Transamerican Bicycle Route 76. In Radford, the old hospital in the heart of downtown and the new hospital at the highway intersection are reminders to cyclists that the people who live along this route face challenges in their everyday lives. While cyclists may think about hospitals along the route only in the event of a medical necessity, the primary purpose of these facilities is to serve the surrounding communities. The same landscape of rural roads, small towns, and beautiful scenery that attracts cyclists also perpetuates the isolation, dependency, and poverty that sustain addiction over generations. The journalistic and literary contributions of Macy and Kingsolver provide a resource for visitors to understand more fully the communities they encounter and observe as they cycle through Appalachian Virginia.
You have been listening to episode 22 of the Virginia Bikecentennial Route 76 Podcast. This episode is connected to the city of Radford, located just under 400 miles from Yorktown, the starting point for the westbound route, and about 150 miles from the Kentucky border, where eastbound riders enter Virginia. This podcast is a production of Virginia Tech, a public land grant university located in Blacksburg, just three miles from Route 76 in southwest Virginia. I am your host, Tom Ewing, and this podcast is produced by the digital humanities program in Virginia Tech University Libraries, under the direction of media manager Joe Forte. To learn more about the stories in this episode, visit our website or follow us on social media, all accessible for the homepage for this podcast.
