Drug abuse epidemiology and Appalachian regional patterns

¶ … drug use and abuse in the United States and presents differing approaches that are used (or proposed) to get a handle on the problem. There is no doubt that the drug abuse issue is not new and it is not being reduced by any significant amount. This paper presents statistics and scholarly research articles that delve into various aspects of the drug abuse issue in the United States, with particular emphasis on drugs that are abused in eastern Kentucky and generally in the Appalachian communities.

History of Drug Use & Availability

The history of illegal drug use in the United States goes back to the 19th Century, according to the U.S. Drug Enforcement Agency (DEA). The DEA has a Museum in Arlington, Virginia, that illustrates the history of drug discoveries, drug use, and drug abuse through the years. The DEA reports that morphine, heroin, and cocaine were "discovered" in the 19th century, and were considered "wonder drugs" (DEA). The first "drug epidemic" occurred in the early part of the 20th century (use of cocaine and opium), but by WWII, "American drug use had become so rare it was seen as a marginal social problem" (DEA). In the 1960s, the "new generation" of drug users caused an "explosion" of drug abuse and hence, federal laws were passed; in the 1970s, cocaine "reappeared" and then crack cocaine appeared which spread addition "and violence at epidemic levels" (DEA). Hence, the DEA was launched in 1973.

In the 1980s, "…six million Americans" used cocaine on a regular basis, which created a huge market and brought drug cartels in Colombia into the picture (DEA). Today, Mexican and Colombian-based drug cartels smuggle huge amounts of cocaine into the United States. Also, black tar heroin and marijuana are being smuggled into the U.S. -- and methamphetamine is another drug that is trafficked into the country.

Drug Usage in Kentucky

"…There were 7,932 intake/baseline records of clients entering state-funded substance abuse treatment in the [Appalachian area of the] Commonwealth of Kentucky during the 12-month period from July 1, 2006, through June 30, 2007… [and] women accounted for 35.1% (2,786) of the total intake… [which is due in part to the fact that] more women in rural Appalachia reported the presence of chronic pain…" than in other regions (Shannon, et al., 2009).

The Transformation Drugs & Alcohol Treatment Center in Kentucky (using data from the Centers for Disease Control and Prevention and the Substance Abuse and Mental Health Services Administration along with the Kentucky Office of Drug Control Policy) reports that Kentucky has "…one of the highest rates of drug abuse in the country" (Transformations, 2011). Data presented by Transformations shows that in 2007 some 722 people died from drug abuse (compared with 853 Kentuckians who died in highway accidents and 612 who died resulting from firearms). Meth lab seizures show that the growth of that addictive drug is significant: from 2007 to 2009, the seizures of meth labs by law enforcement increased by 138%. Also, Kentucky was ranked number four in the nation in terms of the production of "domestic marijuana" in 2009.

Risks for Drug Users in Rural Appalachian Kentucky

A peer-reviewed article in the journal AIDS Care (Havens, et al., 2011) points out that injection drug use in rural Appalachian Kentucky is on the rise, which is a great concern to healthcare officials because it puts the users at risk for HIV. The study presented in the article was designed to examine injection drug use (IDU) among "a cohort of felony probationers" from rural Appalachia (Kentucky) by surveying 800 rural felony probationers. In the sample, 66.5% of those surveyed were male and 95.1% were Caucasian; the average age was 32.3 years and no cases of HIV were found in the survey. Of the 800 probationers, 22.4% reported "lifetime IDU," and 34.5% reported that they shared "receptive" syringes (RSS) and 97.1% reported "distributive syringe sharing (DSS)" (Havens, 638) (receptive sharing means sharing syringes with others; distributive means getting fresh sterile syringes from pharmacies, etc.);

Sharing needles is "risky" when injecting anything (cocaine, heroin, and oxycodone), Havens explains, because the risk for HIV and "other blood-borne infections" is very high (638). Of the 179 individuals (from the 800 probationary individuals being studied) injecting drugs, "…almost half (49.7%) reported risky injection practices. In fact, injecting cocaine is "significantly associated with risky injection practices" (which are linked to HIV and HCV). The conclusion of this article offers evidence that "prescription opioid injection in rural Appalachia is an emerging problem" which could lead to an epidemic, Havens reports. What is warranted given the data presented in the article is "…education around risky injection and drug use practices" (Havens, 643).

First use of drugs in rural Appalachia -- Eastern Kentucky

Meanwhile The American Journal of Drug and Alcohol Abuse published an article titled "Examining gender differences in substance use and age of first use among rural Appalachian drug users in Kentucky" (Shannon, et al., 2011). In the article the differences in gender and age of "first use" within the rural Appalachian community is explored, which provides a snapshot into the way in which individuals become involved (and addicted) to drugs in eastern Kentucky.

The research in this article used a community-based study in Appalachia (of 400 people) to explore whether or not previously reported differences in age of users and gender (elsewhere) holds when the study is done in Appalachia. The participants averaged 32 years of age and 59% were male; males were more likely to use alcohol, heroin, cocaine, crack cocaine, methamphetamine, marijuana and hallucinogens than females; moreover, males reported using alcohol, marijuana and hallucinogens at "…a significantly younger age than females (Shannon, 98). The reason the study was done in eastern Kentucky included the fact that eastern Kentucky has "…the highest prevalence group when examining illicit drug use other than marijuana" for individuals 12 or over in the United States (Shannon, 99).

The participants were solicited by placing flyers in public locations. Once the initial participants were selected (they had to have been injecting drugs in order to quality) they were then interviewed and asked to bring friends (that were also drug users) into the research project. The way that was done was by giving each initial participant three coupons; each "friend" that was brought in to the study with a coupon put $10 into the pocket of the original participant.

The findings showed that on average, males in eastern Kentucky's Appalachian community first got involved with drugs and alcohol at the average age of 13.6 years; females first got involved at an average age of 15.1 years (Shannon, 101). More males reported using drugs and alcohol for their entire lives, this despite the fact that many Appalachian communities do not sell alcohol. More women reported abuse of drugs in order to "…treat anxiety and sleeplessness" and to deal with chronic pain (Shannon, 102).

Rural Substance Abuse in Kentucky

Marlies Schoeneberger and colleagues conducted research involving drug users in three geographic locations in Kentucky -- eastern Kentucky (206 participants), south central Kentucky (165), and western Kentucky (371). The point was to learn whether or not rural areas are "more sheltered from the problems in mainstream America" and the hypothesis by the authors was that indeed the "severity of their involvement in drugs" would be less in rural areas of Kentucky than in urban areas (Schoeneberger, et al., 2006). Some of the interesting findings included: a) participants from "very rural areas" tended to be older when they first used drugs; b) drug users from very rural areas had as a rule not been in a substance abuse treatment program; c) those in very rural areas with strong religious beliefs and with "chronic medical problems" were more likely to have participated in self-help groups than participants from urban areas; d) because of the recent farm and mining crises in Kentucky those in very rural areas of Kentucky were more likely to have persons admitted to drug abuse treatment centers; e) rural and urban alcoholics were "more likely" to see treatment programs as valuable to them than drug users were; and f) cocaine use is "three times higher in rural areas than in very rural areas" (Schoeneberger, 106).

This study is seen as valuable to healthcare officials in Kentucky because there is a need for more substance abuse treatment centers in rural Kentucky.

Rural Appalachian Women and Recovery from Drug Addiction

Professor Judith Grant presents a research article (published in the peer-reviewed journal Addiction Research and Theory) that examined how 25 rural women in eastern Kentucky (Appalachia) narrated their own recoveries from addition. Given that the resources for recovery from drug addiction in this area of the country are scarce, Grant was interesting in finding out how these women carved out their own recovery programs. What Grant discovered was that the 25 women "…compensated" for the lack of professional healthcare services using their own "cultural contexts" (Grant, 2007, p. 521).

The article presents a good example of self-help; of how individuals can take their lives into their own hands when it is apparent that they may have been out of control with no hope for recovery. The "cultural contexts" that the women used included: use of "family, church, friends, work and school"; and self-help institutions (Alcoholics Anonymous and Narcotics anonymous) (Grant, 521). In conducting the research, Grant delved into these issues: a) how women think about things, perceive things, and create "lines of action as they practice recovery"; b) in what ways they interact with others and how they achieve "meanings of such processes for themselves"; and c) "…how they make sense of their meanings toward an object, such as alcohol and/or drugs, that once was so important in their lives" (Grant, 522).

Grant found that these 25 women overcame not only their additions, but they also overcame other aspects of being a drug user in Appalachia, including these barriers: extreme poverty and desperation; inadequate public transportation; poor childcare facilities; inability to come up with the money for services; violence within families; and "low self-esteem" (524). The way Grant describes the processes that these women embraced -- to achieve "meaningful action" towards change -- entails women facing "…the disgusted self, the aware self, the alternative self, and the stable self" (525).

The "disgusted" self aspect allowed the women to be freely honest with the author about how they hated themselves as addicts; they were no longer feeling good from the drugs and even became suicidal, Grant explains (526). The "aware self" discussion among the women brought out the fact that as they became aware of the "situated identities" they had developed within the context of their addiction; and they understood (thanks to Grant's leadership in their recovery programs) that "…they needed to acquire new selves within new social locations" (529). The women knew they needed to form new connections, make new friends with "non-using others" to be able to fully recover (529). The next step was to create "an alternative self" apart from the self that was steeped in a one-track obsession (some of the women went back to school; others just made new friends); and finally the "stable self" was the new self that they created themselves.

How dangerous is cocaine in terms of a person becoming addicted?

Of course getting involved with cocaine is a very risky behavior, but perhaps the general belief that cocaine produces the same withdrawal symptoms as other drugs (like meth or heroin) is exaggerated. To wit, a study in the peer-reviewed Brown University Digest of Addiction Theory and Application reflects that in a controlled setting when high doses of cocaine were administered to seven males and two females, withdrawal symptoms were present in hours after the doses wore off, but the symptoms "…disappeared 24 hours later" (Walsh, et al., 2009).

Researcher Sharon Walsh from the University of Kentucky in Lexington (and colleagues) sought to better understand the direct effects of "…repeated oral dosing" of cocaine in order to measure "acute and prolonged abstinence symptoms" from use of cocaine. Local newspaper ads were placed and the nine participants were selected because they were not in treatment centers but they all used cocaine. For 23 days the nine participants smoked cocaine (in a 30 day period) and they were not dependent on any other drugs at that time.

The analysis showed that the metabolites found in cocaine (benzoylecgonine, ecgonine, methyl ester and norocaine) were "…virtually eliminated from plasma within 19 hours of the last dose" (Walsh, 7). The point of this research is that for cocaine users there was no evidence of any biological disruptions, albeit the "crashing" once the cocaine was gone from the system (fatigue, lethargy, and depression) was apparent for 24 hours. The value of research like this for drug rehabilitation professionals is that cocaine abusers can be weaned off the drug given the right setting and a willingness on the part of the users to walk away from this wasteful, dangerous habit.

In conclusion, the problems of drug and alcohol abuse in Kentucky -- particularly in eastern Kentucky / Appalachia -- are severe, and there are socio-economic reasons for these problems. This paper shows how some healthcare systems are providing help for those in need of recovery, and also it shows there is a great need for more rehabilitation centers in rural and very rural Kentucky.

Recommendation for Kentucky: the government should take a percentage (perhaps 2-3%) of the millions of dollars it profits from the sale of coal (that is mined by scraping off mountaintops) and put those dollars to use building drug rehabilitation centers in areas where they are most needed. About 73% of the coal mined in Kentucky is sold out of state; that represents a huge amount of money to the state. If Kentucky really cares about the poor people with few resources in the eastern part of the state, it would make an attempt to provide more help in areas of healthcare, and that includes substance abuse issues.