Eastern Ky.’s lost generation and echoes that remain: Aftermath of the opioid epidemic, by an expatriate doctor who lost a friend

By Brian S. Barnett, M.D.
Center for Behavioral Health, Neurological Institute, Cleveland Clinic
Published in JAMA Internal Medicine

My friend drew his last breath alone, in the predawn hours of a Tuesday morning this past summer, as his father lay sleeping in another room. He overdosed on fentanyl, silently bringing to a close a life whose final chapters were infused with struggle. His father’s house sits at the foot of a steep, wooded hill, a hundred or so feet up which my friend now rests in the family cemetery, close to home and up high, like most deceased loved ones in Magoffin County’s Appalachian foothills.

Magoffin is in the Eastern Kentucky Coalfield. Lexington, with approximately 324,000 people and nearly a hundred miles away, is the closest metropolitan area in the state. With a median household income of $28,077. Magoffin is one of the poorest counties in the U.S. I was raised there but left in 2004, joining the first wave of Eastern Kentucky’s post-opioid diaspora.

Isolation long inoculated my childhood home against most drugs. But in the late 1990s, oxycodone was injected into its veins, first through pill mills up north on the Ohio River, then via local physicians’ offices. By 1999, disquieting stories of police chases, pharmacy robberies, and exploding theft were filtering in from our county’s hollers.

My friend and I met in high school in 2002. He was charismatic, funny, and a master storyteller. Told by the media since childhood that we were hillbillies destined for either the mines or the welfare lines, neither we nor our friends saw much of a future for ourselves, a situation ripe for the opioid epidemic to insidiously take root. Over the next few years, we saw it come to life firsthand, robbing us of the final years of our youth and saddling our once-resilient community with despair.

Although the epidemic receives regular media coverage today, it had no name then and would not receive one until it had spread to more affluent and valued parts of the country, almost 15 years later. Opioids were all around us, particularly in our physicians’ offices, where we suddenly encountered hordes of drug reps. Too often, we found our physicians chatting with them, collecting the free lunches and logo-emblazoned pens, refrigerator magnets, and clocks they had come bearing.

Magoffin County (Wikipedia map)

On the margins both geographically and culturally, Magoffin never stood a chance against the pharmaceutical industry. Armed with information about how our physicians prescribed and even their personal lives, Big Pharma easily won the one-sided battle, with those gifts and rep visits fueling tremendous opioid sales. The magnets led our physicians to associate opioid prescribing with satisfying their hunger as they retrieved free lunches from the refrigerator, and with each glance at them, the clocks’ hands hammered medication logos deeper into their subconscious. Then, as physicians wrote prescriptions, the pens gave one last potentially decision-swaying nudge.

We also noticed the physical attractiveness of the reps, likely another psychological weapon. Well dressed, well heeled, and exuding a confidence foreign to mountain people toiling near society’s bottom, they evoked our admiration and envy. Soon, many classmates wanted to become reps too.

Opioids turned out to be better for temporarily numbing the traumas of Appalachian poverty than treating physical pain. Selling pills quickly became a steady source of income for many patients long shackled by poverty. As opioids metastasized throughout our hills, newly created demand followed in their wake. Grandparents were left to parent grandchildren, and an already fragile economy was decimated. No family, including mine, was left unscathed.

In 2003, a year before graduation, my friend gave in to one of the handfuls of pills being offered to so many of us. Before long, he had dropped out. As I watched him and others being swept away by the flood of prescription drugs, I saw the writing on the wall for our area and focused on getting out. After graduating, I moved to Philadelphia, Pennsylvania, but returned often. When I could find my friend, we would hang out as he seesawed between sobriety and relapse.

A few years after I left, he was a passenger in a car accident that killed a family member. My friend survived despite a severe traumatic brain injury. He would spend the rest of his short life fighting chronic pain, posttraumatic stress disorder, and survivor guilt. Afterward, he became specterlike, drifting between emergency departments, courthouses, and correctional facilities.

Our friendship lived on though. When he stopped replying to texts, I knew he was locked up again for possession or small-time dealing and tracked him down. I visited him in prison, and when I could not visit, our conversations became written rather than spoken. The most gut-wrenching of the many letters we exchanged was one he wrote me from rock bottom. His mother had died unexpectedly, and he was denied furlough to attend her funeral. I urged him to get mental health treatment. He replied that he was and that he had found healing by renewing his faith in God.

Unfortunately, accessing addiction treatment would prove difficult after my friend’s release from prison. In his last letter, as he prepared to leave, he anticipated this, writing:
"I know that methadone would help me. When I was on it before, it was the best I’ve ever done. It takes the craving away and helps the pain. I’ve beat and banged my body up in car and four-wheeler [all-terrain vehicle] wrecks for years. It’s just so hard to find a doctor that will prescribe it. And I hate to walk into a doctor’s office and tell them I’m an addict. I’m afraid they really wouldn’t give me anything then. I would go to the [methadone] clinic, but I just can’t drive every day and try to hold down a job. I really need to find a doctor that will help me before it’s too late."

Before it’s too late. His words echo in my mind.

Despite my friend’s death, Kentucky is making some headway on its drug problems. Overdose deaths were down from a peak of 1,477 in 2017 to 1,333 in 2018. However, with neonatal abstinence syndrome occurring in 24 of 1,000 births in 2018, the state’s rate dwarfs the national rate of 7 of 1,000. Opioids remain particularly problematic in Eastern Kentucky, though methamphetamine is supplanting them. In a 2017 survey, 14% of Eastern Kentucky residents knew someone struggling with heroin use, compared with 22% for methamphetamine.

The coalfield’s isolation and poverty mean there is little treatment available there. Only five opioid treatment programs operate within its 13,370 square miles, and as of 2016, only 45% of rural Kentucky counties had a physician waivered to prescribe buprenorphine. Those that did had a mean of 0.79 waivered physicians. And even when treatment can be found, stigma often, blocks the path to it, as there is little anonymity to be found in small towns.

Things might have turned out differently for my friend if our society saw addiction as an illness to be treated rather than a failing to be punished. Now, his unanswered pleas for help are joined by more voices—those of his children. Is theirs another generation whose cries will be stifled in a pill bottle or drowned out by calculated sales pitches delivered in between patient visits? Or will the echoes that remain of this first generation lost to the opioid epidemic finally spur us to end it before it is too late?