ch 10 - at the graves edge

The Devastating Impact of the Opioid Epidemic in KY-5

• Statistical Breakdown of Overdose Rates (2021-2022):     * The national rate of drug overdose deaths in the United States in $2021$ was $32$ per $100,000$.     * In the state of Kentucky, the rate was significantly higher at $56$ per $100,000$.     * Specific county hit rates recorded in $2022$:         * Bath County (Wyatt Blair’s native county): $156$ per $100,000$.         * Pike County: $91$ per $100,000$.     * Primary Victims: A disproportionate number of victims were prime-age, white, high-school-educated men living in rural areas.     * Community Impact: Between $2016$ and $2018$, Kentucky had the highest rate in the country of children living with relatives other than parents at $9 \%$, with another $5 \$ in foster care.

• The Proximity of the Crisis in Pike County:     * A study commissioned by Purdue Pharma revealed that $29 \$ of Pike County residents personally knew someone—either a family member or acquaintance—who had died from an overdose of OxyContin.     * Tommy Ratliff noted that his own first psychotherapist was indicted for trafficking in OxyContin.

Corporate Malpractice and the Rise of Purdue Pharma

• Deceptive Marketing Tactics:     * Purdue Pharma marketed OxyContin as a "nonaddictive" solution to pain, a claim that was later proven to be a lie.     * In reality, OxyContin produced withdrawal cravings and symptoms similar to heroin in habitual users.     * Aggressive Sales Force Expansion:         * In $1996$, Purdue had $318$ sales representatives.         * By the year $2000$, this number increased to $671$.         * $78$ representatives were dispatched to Kentucky alone, despite the state only containing $1 \$ of the total U.S. population.

• Sales Incentives and Growth Metrics:     * Purdue offered massive bonuses to salespeople for increasing OxyContin sales.     * In $2001$, while the average annual salary for a sales rep was $55,000$, annual bonuses ranged from $15,000$ to nearly $240,000$.     * In the same year ($2001$), Purdue paid a total of $40 \text{ million}$ in incentive bonuses.     * Revenue Growth:         * $1996$: $48 \text{ million}$.         * $2000$: $1.1 \text{ billion}$.     * By $2004$, OxyContin was the leading drug of abuse in the United States.

• Targeting and Regulation Avoidance:     * Purdue used "prescriber profiles" on $94,000$ doctors and pharmacists, tracking their volume of prescriptions, zip codes, counties, and states. They targeted high-prescribers for frequent visits.     * The "Three-Copy" Regulation Effect: Purdue focused on "regulation-averse" states that required only two receipts for drug purchases (one for the pharmacist, one for Purdue). States requiring a third copy for state medical officials (mostly blue states like New York, California, and Illinois) saw OxyContin distribution rates that were $50 \$ lower than in loosely regulated states like Kentucky, Tennessee, and West Virginia.

• Cultural Insensitivity and Mockery:     * In a lawsuit against the drug distribution company AmerisourceBergen, internal emails revealed salespeople mocking the addiction crisis. They shared a parody of the Beverly Hillbillies theme song regarding Florida's "pill mills":         * "Come and listen to a story about a man named Jed, / A poor mountaineer, barely kept his habit fed, / Then one day he was looking at some tube, / And saw that Florida had a lax attitude. / About pills, that is, Hillbilly Heroin, 'OC' [OxyContin]. / Well the first thing you know ol' Jed's a drivin' south, / Kinfolk said Jed don't put too many in your mouth, / Said Sunny Florida is the place you ought to be, / So they loaded up the truck and drove speedily. / South, that is. / Pain clinics, cash n’ carry. / A Bevy of Pillbillies!"

The Journey of James Browning: Abuse, Addiction, and Recovery

• Childhood Secrets and Trauma:     * James's childhood was fractured by two secrets. The first was a series of deeply shaming events perpetrated by two adults on James between the ages of eight and eleven.     * Because of local traditions of resolving matters privately to avoid community shame, James told no one, fearing his father would go to prison for murdering the perpetrators if he found out.

• The Escalation of Addiction:     * James's drug use began at age $14$ with marijuana, moving to pain pills in high school.     * The Illusion of Control: James maintained a hierarchy in his mind to preserve pride:         * He first told himself, "If you snort, you're okay, but if you shoot up, you're a junkie."         * He eventually moved to heroin when he became "dopesick" (experiencing withdrawal symptoms).         * He initially snorted heroin but eventually asked a girl to shoot it into him so he could tell himself he wasn't doing it himself.         * Two years after starting heroin, he began shooting it himself, finally identifying as a "junkie."     * Out of his five close friends from his drug-using years, three are dead. One friend’s parents told people he died of a "heart condition" to hide the truth.

• The "Shame Cycle":     * James describes using drugs to suppress original shame (from childhood abuse), which then created new shame regarding his addiction, disappointment to his mother, and the destruction of his marriage and relationship with his children.

• Recovery and the "Carrier Ant" Metaphor:     * James was revived from his fourth overdose by paramedics who performed CPR.     * His sister, Ashley, helped him enter Southgate, a recovery facility where he met Tommy Ratliff.     * Tommy shared a story about seeing a line of ants where one live ant carried a dead ant. James viewed Tommy as the "carrier ant" who saved his nearly dead life.     * James and Tommy bonded over their shared love of punk rock bands from the $1970s$, such as The Ramones ("I Want to Be Sedated"), Black Flag ("Nervous Breakdown," "Fix Me"), and The Misfits ("Scream!", "Die, Die, My Darling").

Socioeconomic Parallels and the "Pride Economy"

• Punishment Disparity:     * In $2022$, a local drug dealer in Pikeville was sentenced to $20 \text{ years}$ in prison for a single overdose death.     * In contrast, no member of the Sackler family (owners of Purdue Pharma) has ever gone to prison. The text notes that the farther down the class ladder one is, the heavier the punishment and the greater the subsequent shame.

• The Comparison to Black Communities (William Julius Wilson):     * James observed a connection between the plight of Appalachian whites and the Black inner-city unemployed of the $1970s$ and $1980s$.     * Just as the offshoring of factory jobs impacted Black men, mine closures in the $1990s$ impacted Appalachian whites, leading to "deaths of despair" in both populations.     * James noted that midlife deaths from drugs and alcohol spiked in Black communities in the $1980s$, while white rates began to rise after $2000$, with Black rates dropping until $2013$, when they began to rise again.

• Appalachia as a Domestic "Mexico":     * The text suggests KY-5 functions as a "Mexico" within the domestic U.S. economy—a poorer region from which people migrate for better lives while facing prejudice for their accents and dress.     * James finds it ironic that people in his region are asked to look down on migrants when many of them are leaving their own region for similar reasons, stating: "We don't like it when people look down on us."

Cultural Traditions and the Status Threat

• Family and Gender Roles:     * James’s father’s pride was built on independence from government authority (refusing to reach out to "Uncle Sam") and strong family ties.     * Traditions: The family stays up with the dead for three days and digs their own graves to avoid having "strangers" do it. In social settings, men sit and are served first, though James notes Appalachia is functionally a "matriarchy" because women must often raise families alone due to mining injuries or deaths.

• The Origin of "Redneck":     * Ashley explains that in the coal wars, union men wore the company uniform with a red scarf to show loyalty to the union. During this era, white, Black, and immigrant miners were seen as "union brothers," making "redneck" a label of pride.     * Historical Violence: The Battle of Matewan ($1920$) resulted in ten deaths, and the Battle of Blair Mountain involved private planes bombing union headquarters, with at least sixteen deaths.

• The Friction of "White Privilege":     * When Ashley raised the term "white privilege" at a family dinner, it caused a "conniption fit."     * The family interpreted "privilege" as meaning a person of leisure or someone "hoity-toity," which erased their own history of suffering and hard manual labor (e.g., her father starting work at $15$ and not owning a toothbrush until $16$).

Subsequent Drug Scandals: Suboxone and Invidior

• Competitor Behavior post-Purdue Lawsuits:     * A study by David Tan (University of Washington) found that when Purdue’s marketing budget for OxyContin fell by $94 \$ in $2015$, competitors increased their budgets for similar opioids by $160 \$ in the same areas.

• The Suboxone Controversy:     * Suboxone (a combination of buprenorphine and naloxone) is used to treat addiction and advertised as "nonaddictive."     * James and Tommy noticed many addicts felt the need to stay on it long-term. James pointed out that while heroin leaves the system in $7$ to $14$ days, Suboxone takes $30$ days.     Manufacturer Legal Issues: Invidior, the manufacturer of Suboxone, has been sued for false advertising regarding the drug's addictive nature.     * Purdue Pharma also explored entering the addiction treatment market in $2014$ and $2015$, which James termed "Big Pharma is at it again."

Questions & Discussion

• Question from Interviewer: "Where did you grow up?"     * Response from James: "Turkey Creek. A tiny holler of ninety-eight, and they are basically good, good people."

• Question from Interviewer regarding the 1919 expulsion of Blacks from Corbin:     * James's Response: James recalled finding a box of letters from the $1940s$ and $50s$ in a friend’s great-uncle’s house that revealed the uncle was in the KKK and that a Black family’s house had been burned down in Burnwell.

• Question from Interviewer regarding the 2017 white nationalist march in Pikeville:     * James's Response: "No, at the time I hadn't heard of it. And if I had, I wouldn't have cared. I was a homeless heroin addict who had overdosed three times and was heading toward a fourth."

• Interviewer asking about tattoos on James's hands:     * Left Hand: Tattooed with "NTTS." James tells people it means "never trust the system," but it actually stands for "never trust the stuffer," a reference to his time as a "mule" for a dealer named William, where women addicts would hide dope to avoid police detection.     * Right Hand: The "pride hand" featuring four rings: a tree of life, a twelve-step fellowship ring, a high school class ring, and an onyx gem ring for healing.