Why Appalachia’s Substance Use Problems Have Systemic Roots

Please welcome guest author Amanda Winstead. Winstead is a writer from the Portland, OR area with a background in communications and a passion for telling stories. Along with writing she enjoys traveling, reading, working out, and going to concerts. If you want to follow her writing journey, or even just say hi you can find her on Twitter.

The Appalachian region is renowned for its beauty and its wilderness. Its forests and mountains are romanticized as an enclave of escape from the bustle of the modern world. And that’s why its breathtaking landscapes and quaint rural communities attract tourists from around the world. Indeed, the Great Smoky Mountains National Park, nestled along the border separating Tennessee and North Carolina, is the nation’s most visited, and one of its oldest, parks.

But there’s another side, one that is far less beautiful. Those same outsiders who proclaim the pristine glory of the Appalachian mountainscape rarely accord the same positive sentiments to the mountain people who reside there. 

Rather, Appalachian natives, many of whom are the descendants of America’s first true pioneers, are often subjected to stereotypes that only perpetuate the region’s marginalization. They are repudiated as ignorant, impoverished, and irredeemable drunks and drug addicts. They are fingered as the ultimate culprits in their own suffering, the final arbiters of their own destiny and the destinies of their children and grandchildren.

But, like all stereotypes, these narratives present a partial and highly distorted version of the truth. In this skewed version of reality, the true agents of blame absolve themselves of their responsibility. The guilty parties create a story of their own absolution.

The story of addiction in Appalachia is one such narrative of blame-shifting. The reality is that, contrary to the stereotype, Appalachian peoples are not more “prone” to addiction than any other regional, cultural, ethnic, or socioeconomic demographic. 

Addiction in the region has deep, complex, and multigenerational roots. It is a systemic plague that will only be addressed through comprehensive interventions. 

Poverty and the “Diseases of Despair”

The Appalachian region is not only renowned for its beauty, but also for its immense natural resources. From its fertile farmlands to its prolific reserves of coal, timber, and natural gas, the region has generated untold wealth across the centuries. 

However, as is so often the case, it has been the investors headquartered in the major metropolitan areas who derive the lion’s share of the benefit. Poverty in Appalachia has contributed both to a lack of access to quality health care and disproportionate rates of uninsured and underinsured adults and children in the region.

In Southern Appalachia, for example, the number of uninsured adults under the age of 65 significantly exceeds the national average, despite the advent of the Affordable Care Act (ACA). In high-poverty areas, low-income workers often find themselves unable to afford ACA premiums but ineligible for Medicaid or other benefits.

In addition to the lack of sufficient health coverage, the Appalachian region is also characterized by a dearth of healthcare providers. Mental health care, including addiction recovery services, is particularly lacking. Indeed, the number of mental health care providers is more than 35% below the national average in many parts of the region.

In addition, generational poverty, combined with the inaccessibility of affordable physician and mental healthcare has given rise to an epidemic of the so-called “diseases of despair” in Appalachia. This includes not only excessive rates of suicide but also significantly higher risks for substance use disorders. 

As sufferers self-medicate with alcohol and drugs, they instigate a generational cycle that continues even when the original catalyst (poverty, lack of healthcare access, etc.) ends. And so the diseases of alcohol and drug addiction go untreated, and children grow up in a home with substance-abusing grandparents, parents, or siblings. A family legacy of dependency is born. 

The Economics of Addiction

Contrary to the stereotype, neither indolence nor addiction are distinguishing characteristics of the Appalachian people. Farming, especially tobacco farming, and coal mining have long been the principal industries, and one of the few sources of stable work, in the region for generations. This is, in most cases, laborious, dangerous, and backbreaking work. 

Though these industries are a vital component of the economy in many parts of the region, they exact a profound toll on workers, residents, communities, and the environment. Coal mining, for example, is an enormously profitable industry, but the impacts on public and environmental health are often devastating. 

Job-related injuries and illnesses are common in the Appalachian region, a reality that has been egregiously exploited by the pharmaceutical industry. The origins of the opioid epidemic may be traced to Appalachia and the push by Big Pharma to increase opioid drug prescriptions for the treatment of chronic pain. 

The  region was being flooded with prescribed opioids even as evidence was emerging (and often being concealed) regarding the addictive and lethal potential of the drugs. Government regulations arose far too late to stem the tide of addiction, and opioid dependency became endemic to the region.

The Legacy of Big Tobacco

Coal mining is not the only industry for which Appalachia is known. Farming, too, plays a pivotal role in the history of the region. Historically, one of the region’s most important crops has been tobacco. 

The prevalence of tobacco in the economy and culture of Southern Appalachia, in particular, has given rise to generations of smokers and snuff users. From chewing tobacco to cigarettes, tobacco products remain ubiquitous in many parts of Appalachia. 

However, the increasing stigmatization of smoking and the skyrocketing cost of cigarettes has led large numbers of cigarette smokers to turn to vaping as a smoking cessation aid. This transition has been based largely on preliminary and, as it turns out, erroneous reports of the safe and non-addictive properties of e-cigarettes. 

Amid mounting evidence of the dangers of e-cigarettes, government regulators have sought to decrease consumption through heavy taxation, curtailed advertising, and ingredient restrictions. In response, consumers are increasingly turning to the black market for cheaper and more accessible e-cigarettes in the flavors they want. This only exacerbates the risks already inherent to vaping, as unregulated e-cigarettes are increasingly being laced with potentially lethal substances purchased on the dark web.

The Takeaway

The story of addiction in Appalachia is far more complex than the stereotype acknowledges. It is a pervasive disorder with deep, systemic roots. It is a pandemic that will only end when, as a nation, we confront the economic, political, medical, and cultural catalysts driving it.