Cassandra in the Coal Mines

By: Marcus J. Hopkins, Blogger

A friend pointed out to me, recently, that issues of disease and health aren’t really “I told you, so” moments – that it is somewhat poor form to point out that warnings have been ignored, recommendations disregarded, and preliminary results unheeded. While I appreciate his perspective, there’s no small part of me that doesn’t sit in bemused horror that, despite the continued warnings over the past two-to-three decades from healthcare professionals, social scientists, and advocates, both HIV and Hepatitis C have reared their heads in Appalachia, and states are scrambling to catch up to an estimated 364% increase in new infections in the region (Capelle, 2015).

This was not, however, something that came without warning. The Appalachian region, recently deemed the “Painkiller Belt” (Lowes, 2012), has been grappling with opioid abuse for nearly twenty years, and few efforts to stem the tide of prescription drug abuse have been met with more than marginal success.

To trace this recent spate of infections back to its roots, we must, keeping with the theme, go back to the initial Trojan Horse – the FDA approval and release of OxyContin (Perdue Pharma) in 1996.

Image of a bottle of OxyContin

Photo Credit:

Prior to the 1990s, strong opioid medications were reserved primarily for those in severe pain or those who were dying (Bourdet, 2012); at some point between the late-1980s and mid-1990s, however, physicians and “pain management specialists” had managed to lobby enough support for the FDA to approve the indication of prescription opioids for the use of chronic and/or moderate levels of pain in a way that had never been seen in the American healthcare paradigm.

When I was in high school, in the late-1990s, I remember being in a mandatory Health Education classroom when we were shown an investigative report on the aftermath of OxyContin testing in a small town in rural West Virginia. In the report, the journalist chronicled how this small town, in the grips of dealing with chronic pain related to decades spent in the coal mines, became the “Ground Zero” for pharmaceutical testing.

Residents who were experiencing moderate-to-extreme levels of pain were used as guinea pigs – where better to test your drug, than in a small, isolated market that can be easily monitored and controlled for results? – and how those tests quickly burgeoned into a town-wide epidemic of prescription drug abuse.

The reporter did their due diligence, showing a teenage boy whom, without the managed proper use of OxyContin, would be unable to lead a normal life as a result of a chronic arthritic condition that rendered him all but immobile. In juxtaposition, the journalist told the story of a parent whose teenager had raided their medicine cabinet in search of “pills,” leaving the parent without their prescribed medication and dealing with a child gone off the rails into a world of opioid abuse.

What was once a peaceful, rural town quickly devolved into a wasteland of OxyContin abuse, leaving schools dealing with addicted students, homes and businesses being robbed, and families shattered. The “easily monitored and controlled” testing ground turned out to be not so isolated, and the issue of prescription opioid abuse swept across the region with the ferocity of a forest fire.

The problem quickly spread to the surrounding areas and states, and OxyContin soon became known as “Hillbilly Heroin.” With the spread of prescription drug abuse came a wave of crime – shoplifting, petty theft, and prescription fraud – and many small towns saw their rates of theft triple (Borger, 2001).

At the heart of the issue was Purdue’s lucrative bonus system to encourance sales representatives to increase sales in their region, combined with the overt obfuscation of the addictive nature of OxyContin (Van Zee, 2009).

By 2001, OxyContin sales representatives averaged annual bonuses of $71,500, on top of the annual average sales rep salary of $55,000/year. This created an incentive for sales reps to aggressively pursue prescription increases all around the country, primarily through two methods: promoting the use of OxyContin in the “non-malignant pain market” and using sales reps to distribute coupons to be distributed to patients offering a free limited-time prescription for a 7- to 30-day supply of OxyContin. When the coupon program was ended by Purdue in 2001, rougly 34,000 coupons had been redeemed nationally (Van Zee).

Purdue’s Trojan Horse, while not solely responsible for the sharp increase in prescription drug abuse, was, perhaps, the key event to which we can point when looking for how Appalachia became the Painkiller Belt. By the time Federal, state, and local governments caught on to the emerging epidemic, it was too late to unring that bell.

Pharmaceutical companies rushed to find “less addictive” pain management solutions, creating high-dollar products whose slow-release nature helped to reduce long-term dependence, but in so doing created another “unforeseen” result – addicted patients turned away from high-dollar pills, and went, instead, to heroin.

In 2010, Purdue released a reformulated version of OxyContin that contained chemical safety nets meant to render it less easily abused – the pills no longer dissolved in water, making the drug less easy to cook and inject.

A study of 2,500 OxyContin addicts conducted from July 2009 to March 2012 found a 17% drop in OxyContin abuse; 66% of participants switched to heroin (Bourdet).

Which brings us to the present. In May 2015, the CDC reported that the rate of HCV has tripled in Kentucky, Tennessee, Virginia, and West Virginia between 2006 and 2012 (Parent Herald, 2015). The vast majority of healthcare professionals and observers point to injection drug use as the source of these new infections.

Healthcare professionals and advocates have been warning of this coming epidemic for nearly two decades, particularly in rural Coal Country – the veritable Cassandra in the Coal Mines, if you will. Those warnings have largely gone unheeded.

“There’s a sense of inevitability about it,” quoted Newsplex of University of Kentucky epidemiologist Dr. Jennifer Havens who has been tracking 503 drug users since 2008, she reveals 70 percent of her participants now have Hep C. “Some say, ‘I’m surprised it took me this long,'” she added (Parent Herald).

With this spate of new HCV infections, officials are now suddenly concerned about another coming epidemic – new HIV infections. These fears are rightly based upon the recent HIV infection epidemic in Scott County, Indiana, and healthcare advocates, organizations, and providers should be preparing plans of action to respond to this coming wave.

Sadly, I’m not holding my breath for a measured, premeditated response in these states. Stigma related to drug use (as well as sexual minorities and HIV), lack of financial resources, and political gridlock will likely leave the Painkiller Belt unprepared to deal with the ramifications of an explosion of new HIV cases. Given that many of the people who will test Positive for HIV will likely already be enrolled in Medicaid programs, I am left to wonder if they will be able to cope with a mass increase in new prescriptions, either for HCV treatments or their exponentially cheaper HIV-related counterparts.

And so, we wait…



Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.



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2 responses to “Cassandra in the Coal Mines

  1. Pingback: New River Valley Region Reports Sharp Rise in Hepatitis C | communityaccessnationalnetwork

  2. Pingback: Prescription Opioid Diversion and Its Role in HCV Transmission | communityaccessnationalnetwork

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