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Accessible Appalachia: Chapter 19 Restorative Justice amid Appalachia’s Opioid Struggles

Accessible Appalachia
Chapter 19 Restorative Justice amid Appalachia’s Opioid Struggles
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“Chapter 19 Restorative Justice amid Appalachia’s Opioid Struggles” in “Accessible Appalachia”

Restorative Justice amid Appalachia’s Opioid Struggles

Holly Ningard

In Buncombe County, North Carolina, a mobile van unit operated by the Steady Collective regularly sets up shop to provide syringe exchange services, naloxone, referrals to health care services, and more resources to community members. Steady seeks to help people who use drugs do so safely, while increasing access to information regarding treatment and other resources. The mobile unit was established as an adaptation to restrictions on gatherings following the spread of the COVID-19 pandemic. Also in response to the pandemic, staff and volunteers took up distributing masks, personal hygiene products, and hand sanitizer, as well as educational material regarding how to stop the spread of COVID-19. The Steady Collective is just one of many community-based organizations responding to public health issues, including the opioid crisis, in their backyard.

It’s difficult to talk about crime in Appalachia today without discussing opioids. Rates of opioid misuse and overdose death were already higher in the Appalachian region than any other geographic area in the United States, and initial data indicates these rates have risen further since the beginning of COVID-19 lockdowns.[1] When prescription opioid misuse began to make news headlines, the painkiller OxyContin was nicknamed “hillbilly heroin,” and the face of the social problem became predominantly poor, white, and rural.[2] Addiction of any type is often viewed as a personal moral failure and the result of bad choices made by individuals. Such attitudes reinforce stereotypes of Appalachian people as backwards and unable, or unwilling, to pull themselves out of poverty and make a better life, while neglecting broader social conditions that created and perpetuated the opioid crisis.

Criminalization of substance misuse is one type of response to the opioid crisis in Appalachia. Work done by groups like the Steady Collective and others highlighted in this chapter demonstrates another. Criminologists refer to the different approaches as retributive justice and restorative justice, respectfully. Appalachia is home to a long history of mutual aid, which offers the potential to reframe responses to widespread rates of opioid use and crime reduction strategies more broadly.

A Brief History of the Opioid Crisis in Appalachia

        Opioids are a class of drugs used to reduce pain in the body. Opioids can refer to both illicit drugs, such as heroin, as well as drugs that can be legally obtained with a prescription, such as oxycodone or hydrocodone. Opioids can be taken as a pill, snorted, smoked, or injected using a syringe. Opioid misuse refers to any use of an opioid outside of the direction of a physician, and there are many reasons why someone may misuse opioids. Some do so because they develop a tolerance to the drug they are using, meaning they need to take more of the drug to achieve the same pain reduction. Others do so because the drug produces a euphoric effect. Regardless of the reason, opioid misuse can evolve into opioid use disorder (OUD), or opioid addiction, when individuals are no longer able to stop or control their drug intake and when opioid use impacts their daily life.[3] Prolonged use and misuse of opioids can lead to physical dependency, long-term health problems, and risk of overdose death.

        The opioid crisis or opioid epidemic refers to a period of time in which opioid overdose death rates began to sharply increase in the United States. The Centers for Disease Control (CDC) has identified three waves to this crisis. The first wave began in 1999, when the majority of overdose deaths involved prescription opioids.[4] This wave involved aggressive marketing of prescription painkillers by pharmaceutical companies. In the 1980s and 90s, the United States saw a growing demand for a solution to chronic pain, and companies like Purdue Pharma offered a seemingly easy answer: prescription painkillers like OxyContin. The drawback was that the pills were highly addictive; as early as the 1950s, the World Health Organization issued warnings to physicians about the addictive properties of oxycodone. However, pharmaceutical companies were keenly aware of the lack of regulation regarding marketing for their products, and so they knowingly downplayed the risk of addiction when selling their products to physicians.[5] Opioid overdose is one example of what is known as a disease of despair. Diseases of despair also include suicide and alcoholic liver disease.[6] 

        The second wave began in 2010, marking the point when heroin surpassed prescription opioids as the most prevalent opioid-involved overdose drug. The third wave, which began in 2013 and continues today, has shown an increase in deaths involving synthetic opioids like fentanyl. In 2019, over 70% of all overdose deaths involved an opioid,[7] while 74% of opioid-related overdoses involved a synthetic opioid product. Synthetic opioids are particularly concerning due to an increased risk of accidental overdose deaths. In 2000, 77% of opioid overdose deaths were categorized as accidental, and in 2019, 91% of opioid overdose deaths were deemed accidental. This jump is attributed to the fact that synthetic opioids can vary in strength compared with prescription painkillers.[8]

Beyond the risk of overdose death, opioid misuse and abuse carry a number of social and public health concerns. One concern involves people who inject drugs intravenously, most commonly heroin. People who inject drugs risk infection at the injection site, as well as the spread of disease like hepatitis-C or HIV, particularly when needles are shared. Intravenous drug use is associated with other high-risk behaviors such as unprotected sex.[9] Beyond individual health risks, addiction strains family ties, negatively impacts local economies, and increases rates of incarceration. While prescription opioid use has not been linked to an increase in violent crime, it has been linked to an increase in property crimes. Such property crimes, like theft, most likely occur so that individuals can obtain more drugs.[10]

Opioid addiction has disproportionately impacted Appalachia; opioid prescription medication misuse and abuse, and subsequently overdose rates, are higher here than in any other region of the United States, particularly within Central and North Central Appalachia.[11] Four Appalachian states–Kentucky, Ohio, Pennsylvania, and West Virginia–had the highest rates of drug overdose deaths in the country in 2017.[12] While deaths resulting from diseases of despair have been steadily increasing throughout the United States, they have risen much more sharply in Appalachia. At the start of the first wave of the opioid crisis in 1999, mortality rates from diseases of despair between Appalachia and the rest of the United States were approximately equal. By 2017, the combined mortality rate from diseases of despair was 45% higher in Appalachia than in the non-Appalachian United States. Overdose mortality alone is 65% higher in Appalachia than in other places in the United States.[13] Addiction is often characterized as a personal moral failure. However, individual bad choices cannot account for the concentrated use and misuse of opioids within Appalachia; several cultural characteristics have made this region particularly vulnerable to the opioid crisis.

Many industries within Appalachia, such as logging and mining, rely on physical labor and carry increased risk for on-the-job injuries. Much of Appalachia is a medical desert–i.e., healthcare, particularly in rural areas, is historically understaffed and underfunded. Prescription opioids promise a cheap and easy solution to chronic pain; the demand for pain relief in a way that did not overburden an already thin budget meant that Appalachia was one area targeted by pharmaceutical marketing.[14] [15] [16] Appalachians who receive disability benefits are more likely to engage in nonmedical prescription opioid use, further indicating that opioid misuse is linked to pain management.[17] In short, the demand for pain relief intersected with a lack of access to alternative healthcare treatments and created an environment where Appalachians were over-prescribed with opioid medications.

Once opioids began to spread throughout Appalachia, additional factors enabled or exacerbated rates of misuse. For example, low educational attainment, a lack of access to mental health treatment, and higher rates of persistent poverty are three common predictors of substance use disorders, all of which are higher in Appalachia.[18] People who use drugs often do so in groups of friends and family members, where drug use is normalized.[19] There also exists a lack of access to comprehensive drug treatment and certified drug and alcohol counselors. When drug treatment does exist, community members may face hurdles to accessing the treatment due to the cost or unreliable transportation.[20] Finally, addiction is often stigmatized or seen as a shameful quality in an individual. Stigma can prevent people who use drugs from seeking help, especially in small towns where everybody knows everybody.[21] Each of these factors has contributed to higher rates of opioid use and abuse in certain areas of Appalachia.

The spread of COVID-19 has placed further strain on public health resources and services aiming to respond to the opioid crisis. Early pandemic lockdowns restricted patient access to healthcare providers, especially those who could prescribe treatment drugs such as methadone. Individuals who work in places with hourly employment saw their hours reduced, or perhaps were laid off entirely. Depression and anxiety accompanied guidelines for isolation and social distancing from others, which may increase the desire to use drugs. A lack of access to reliable internet has further isolated especially rural Appalachians from friends, family, and school.[22]

        Addiction is more complicated than an individual’s decision to use drugs. Various social and economic factors create conditions where certain groups of people are more vulnerable to addiction than others. A lack of social and economic support can mean that people who use drugs are unable to access necessary treatment. This culmination of variables raises the question: what can be done to reduce rates of opioid misuse in Appalachia? One immediate response to opioid misuse in the U.S. has been criminalization. Criminalization refers to the process by which a certain behavior becomes a crime, which necessitates discussion of the larger philosophy of retributive justice.

Retributive Responses to the Opioid Crisis in Appalachia

        The United States criminal justice system functions predominantly under the model of retributive justice. Retributive justice is a response to crime that focuses on identifying laws that have been broken, offenders who can be assigned blame for lawbreaking, and punishments that fit the crime. The public entrusts criminal justice professionals (e.g., law enforcement officers, prosecutors, and judges) to facilitate the process of determining whether or not a crime has taken place and who should be held responsible for that crime. Under this model, punishment is the focus: justice is achieved when people who break the law serve a sentence for their transgression.[23] 

        An important concept in retributive justice is the idea of deterrence, or what prevents people from committing crime. There are two types of deterrence that criminal justice professionals are interested in. The first is general deterrence, which is concerned with how threats of punishment influence public behavior, and the second is specific deterrence, which focuses on how a particular threat of punishment may influence an individual’s behavior. An example of general deterrence would be evaluating how a new drug law impacts a state’s drug arrest rate. An example of specific deterrence would be evaluating whether individuals who are on probation reoffend.[24] The overall idea of deterrence is that if the threat of punishment is strict and certain enough, individuals will choose not to offend in order to avoid the negative consequences of lawbreaking.

        Retributive responses to the opioid prioritize law enforcement, the creation of harsh sentences like lengthy prison sentences or large fines, and the building of new prisons. These strategies represent some of the most visible responses to addiction: arrest, trial, and incarceration. Yet, harsh drug laws have done little to reduce rates of opioid misuse in Appalachia. No evidence supports the assumption that imprisonment for drug offenses reduces rates of self-reported drug use, drug overdose deaths, or drug arrests.[25] While research has shown that access to comprehensive drug treatment programs while incarcerated can help inmates with substance abuse disorder,[26] not all correctional facilities receive the funding or are able to hire qualified staff to provide those services, and detoxification alone has not been shown to be an effective strategy for treating substance use disorders.[27] Because jails and prisons often are not spaces where individuals can access treatment, many individuals relapse upon release. Individuals who are released from prison are at a significantly greater risk of drug overdose death compared with the general public.[28] 

        Lack of access to treatment is not the only reason that incarceration fails to deter people who use drugs. These policies fail because they do not address the root causes of addiction, including a lack of access to educational opportunities, mental health treatment, or gainful economic opportunity. At its worst, incarceration can make these conditions worse. Individuals who have been convicted of a felony often find difficulty obtaining housing and employment upon release. Because of these hardships, they often return to the same social networks that they were in before arrest. If these are the same groups of people who were also using drugs, there may be little opportunity for individuals to seek help.[29] Criminalizing addiction thus helps to reinforce harmful negative stereotypes of poor, Appalachian addicts and contributes to a frustrating cycle of incarceration, relapse, and recidivism.

        Beyond failing to curb individual drug use, strict drug laws may exacerbate the risk of overdose death. An example of this phenomenon has occurred in West Virginia. West Virginia has what are known as Good Samaritan laws, which protect individuals from being charged with a crime if they voluntarily help individuals during emergency situations. In theory, these laws would protect someone who was experiencing overdose. However, West Virginia is also one of 25 states which have drug-induced homicide laws.[30] Under these laws, sharing drugs with someone who dies of an accidental overdose can result in murder charges. These two seemingly contradictory laws place people who use drugs in a difficult position: if individuals are using together, and one person overdoses, others may avoid calling emergency services out of fear of being charged with a crime.[31]

        A final consequence of retributive approaches to OUD is that they foster a culture of blame. Especially when addiction is viewed as a choice, individuals are blamed for their drug use. Blame can then be used to justify attitudes that people with substance use disorders deserve the consequences of addiction, including incarceration, barriers to secure housing and employment, poverty, or even overdose.[32] [33] To be sure, individuals have a degree of personal agency when it comes to drug use, but a culture of blame further stigmatizes drug use in ways that can prevent people who use drugs from seeking help.[34] However, throughout Appalachia, some groups are challenging the stigma surrounding drug use in an effort to move away from blame and to help people who use drugs connect to vital resources and services. A second philosophy of justice, restorative justice, can help to construct strategies for responding to the opioid crisis.

Restorative Responses to the Opioid Crisis in Appalachia

        The philosophy of restorative justice began as a critique to retributive approaches to punishment. Rather than focusing on lawbreaking, restorative justice attempts to respond to harm by restoring what has been lost (e.g., money, property, trust) following a harmful action. This perspective acknowledges that not all behaviors which have been criminalized are harmful, just as not all harmful behaviors are criminalized. Restorative approaches ask who or what has been harmed by a given act, what is needed to repair the harm, and who should be responsible for offering the repair. Restorative approaches often bring the experience of both victims of harm and the community into the center of discussions on how to move forward after harm has taken place.[35]

        Appalachian cultural values of kinship, independence and pride, community, and love of place[36] contribute to a culture where restorative approaches to harm can thrive. Indeed, the region is home to a deep history of community organizing and mutual aid as a response to various local social problems, including drug use and abuse. Relying on local networks of family, both blood kinship and chosen family, is sometimes a preferred response due to distrust of outsiders. For example, people who use drugs in Appalachia may avoid calling law enforcement or seeking help from outside medical services because they do not trust that these groups can adequately help them.[37] [38] Local groups, staffed by volunteers and members who come from the same community, on the other hand, may have a greater understanding of the issues faced by people who use drugs in Appalachia. When it comes to responses of opioid use, staff and volunteers may be former substance users themselves, further increasing connections with people who use drugs. Many of these groups reject traditional understandings of addiction as being a choice or a personal moral failure best handled by the justice system. Instead, they seek to understand the root causes of addiction within their community and work to restore harm caused by substance misuse.

A key principle that many local groups responding to the opioid crisis in Appalachia embrace is the philosophy of harm reduction. Harm reduction, in contrast, begins from a place of empathy and respect for people who use drugs. It is a nonjudgmental perspective which acknowledges that drug use is a reality of human life, and it emphasizes that ignoring or condemning the behavior only increases the stigmatization of people who use drugs. Given that it is a reality that some people will use drugs, proponents of harm reduction seek to help make drug use safer, and to make sure that people who use drugs are aware of options for treatment if or when they are ready to seek help. Programs that focus on harm reduction do not ignore the problems that accompany substance use or abuse; on the contrary, given that stigmatizing drug use has such a high potential to exacerbate these harms, harm reduction seeks nonjudgmental responses which can make use safer.[39] Three restorative strategies being implemented right now in Appalachia include mobile distribution sites, needle exchange programs, and medication assisted treatment.

The Steady Collective’s mobile resource unit is just one of many groups operating mobile units throughout Appalachia. Sometimes, mobile distribution units operate through health departments, such as the Mobile Harm Reduction Unit in Kentucky, which provides services for Clay, Knox, Laurel, Jackson, and Whitley counties. Each unit is different, but they provide a variety of services: distribution of health information, fentanyl testing, screening for diseases such as hepatitis-C and HIV, basic wound care, and a list of local healthcare and service providers. Importantly, mobile resource units often offer training to instruct community members how to recognize and respond to an overdose. Such training is often accompanied by the distribution of naloxone, a drug used to reverse opioid overdose. Naloxone distribution is sometimes a controversial issue, but it is essential for reducing opioid overdose deaths.[40] Sometimes, mobile resource distribution takes the form of setting up a table at a community event. For example, the Travelin’ Appalachians Revue (TRA), based in West Virginia, is an arts show that features poetry, music, and art at various festivals and productions throughout the region. In addition to celebrating Appalachian art, TRA regularly sets up information tables to provide harm reduction information. Mobile resource units such as these help build trust between providers and community members, and they also reach community members who may have limited ability to travel. Ultimately, the goal of many units is to provide healthcare to community members and to reduce the harms associated with substance abuse through education and community building.

        Sometimes, mobile resource units will also offer syringe exchange programs (SEPs). SEPs may  be offered at standing locations, such as at the offices of Choice Health Network in Tennessee or at certain public health departments. For people who inject drugs, using a clean syringe each time they use is essential for stopping the spread of infectious diseases like HIV or hepatitis-C, and SEPs provide a safe way for people to dispose of used syringes and to obtain new supplies. These sites are often accompanied by information distribution, fentanyl testing, HIV and hepatitis screening, and more resources. However, people who inject drugs often face barriers to obtaining clean syringes, and some areas within Appalachia prohibit the possession of syringes without a prescription. Even in areas without these laws, people who inject drugs may face stigma when purchasing new syringes, which can deter them from doing so.[41] 

        As with the distribution of naloxone, SEPs are controversial. Some people are hesitant to support SEPs, believing that they may encourage drug use and consequently increase used syringes in community neighborhoods. However, evidence has shown that SEPs are more likely to reduce syringe litter because they provide places for people who inject drugs to safely dispose of used syringes. There has been no evidence demonstrating a relationship between syringe exchange programs and an increase in illegal drug use, or even first drug use, meaning SEPs have not been found to encourage drug use. What’s more, individuals who use SEPs are five times as likely to seek treatment for OUD than those who do not.[42] Researchers often point out that more education is needed regarding opioid addiction and syringe exchanges, as education can lead to increased support for comprehensive drug treatment, including SEPs.[43] 

        A final example of effective OUD intervention is medication assisted treatment (MAT), which refers to the use of prescription drugs, such as methadone, to help reduce cravings for opioids so that users can quit. Often, MAT is combined with therapy or other treatment options. People who participate in MAT are often stigmatized as trading one drug for another by both community members and criminal justice professionals alike.[44] Educating the public about the realities of the disease that is addiction can help demystify medication-assisted treatment, especially education offered at community events.[45] Local organizations often carry information regarding MAT, as well as referrals to service providers to help users connect with treatment. Additionally, some mutual aid groups provide community members with microgrants, small amounts of cash assistance to cover healthcare copays or prescription costs.

Effective intervention for OUD includes public health knowledge, implementation of evidence-based strategies, and information that is sensitive to the region.[46] Treatment has been shown to decrease the odds of long-term nonmedical prescription opioid use, so long as that treatment goes beyond detoxification alone. High quality, evidence-based treatments show the biggest impact.[47] Three responses beyond incarceration for responding to OUD in Appalachia are mobile resource distribution, syringe exchange programs, and medication-assisted treatment. These approaches are sometimes criticized as not being tough on crime, or as inviting more drug use to take place. Research has not shown support for these claims. Rather, they have been proven to be effective strategies for reducing stigma surrounding drug use and abuse, as well as rates of opioid overdose death. These approaches are more restorative than incarceration, as they seek to respond to harm and restore what has been lost.

Conclusion

Much like prescription painkillers promised an easy solution to chronic pain, retributive responses offer a seemingly easy solution to addiction. Opioid addiction is a complicated problem, and there are no easy solutions. Retributive responses to the opioid crisis often neglect the root causes of addiction. Because meaningful pathways to recovery are not often accessible through the prison system, these responses serve to reinforce stereotypes regarding addiction and exacerbate the social conditions which make certain groups vulnerable to addiction in the first place. Restorative justice, in contrast, seeks to reframe the social response to opioid addiction by addressing what can be done to restore the harms that result from addiction. When people who use drugs in Appalachia are asked what they need in order to get help, they often emphasize more comprehensive substance use treatment such as inpatient treatment, community outreach, mental health services, and certified drug and alcohol abuse counselors.[48] Rarely is there a need for more prisons, law enforcement, or harsh drug laws. Instead, restorative justice depends on community-led organizations in Appalachia with the hope to destigmatize drug use and address addiction at the root as opposed to punishing individual people who use drugs.

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[1] NIHCM, “Synthetic Opioids.”

[2] Tunnell, “Cultural Constructions.”

[3] CDC, “Commonly Used Terms.”

[4] NIHCM, “Synthetic Opioids.”

[5] Buer, Rx Appalachia.

[6] Miet et al., “Investigating the Impact of Diseases.”

[7] CDC, “Understanding the Epidemic.”

[8] NIHCM, “Synthetic Opioids.”

[9] Schalkoff et al., “The Opioid and Related Drug Epidemics.”

[10] Ibid.

[11] Moody et al., “Substance Use in Rural Central Appalachia,” 123-35.

[12] Beatty, “Health Disparities Related to Opioid Misuse.”

[13] Miet et al., “Investigating the Impact of Diseases.”

[14] Moody et al., “Substance Use in Rural Central Appalachia,” 123-35.

[15] Beatty, “Health Disparities Related to Opioid Misuse.”

[16] Buer, Rx Appalachia.

[17] Havens et al., “Longitudinal Trends in Nonmedical Prescription Opioid Use.”

[18] Ibid.

[19] Bunting et al., “Clinician Identified Barriers.”

[20] Faulkner, “Substance Abuse in Rural Appalachia,” 65-73.

[21] Bunting et al., “Clinician Identified Barriers.”

[22] Wilson et al., “A Primary Care Response.”

[23] Boyes-Watson et al., “Understanding Victims in the Criminal Justice System.”

[24] Loughran, Paternoster, and Weiss, “Deterrence.”

[25] Gelb, “More Imprisonment.”

[26] Zhang et al., “An Analysis of Mental Health.”

[27] Havens et al., “Longitudinal Trends in Nonmedical Prescription Opioid Use.”

[28] Binswanger et al., “Release from Prison.”

[29] Bunting et al., “Clinician Identified Barriers.”

[30] PDAPS, “Drug Induced Homicide Laws.”

[31] Ondoscin et al., “Hostility, Compassion, and Role Reversal,” 74-85.

[32] Richard et al., “You are Not Clean Until You're Not on Anything,” 1-7.

[33] Buer, Rx Kentucky.

[34] Baker et al., “Community Perception of Comprehensive Harm Reduction,” 239-44.

[35] Boyes-Watson et al., “Understanding Victims in the Criminal Justice System.”

[36] Helton et al., “Appalachian Women,” 151-61.

[37] Buer et al., “I'm Stuck,” 70-84.

[38] Morgan et al., “Trauma-Informed Care,” 156-69.

[39] National Harm Reduction Coalition, “Principles of Harm Reduction.”

[40] Beachler et al., “Community Attitudes Toward Opioid Use,” 29-34.

[41] Davis et al., “Barriers to Using New Needles,” 1-8.

[42] Hagan et al., “Reduced injection frequency,” 247-52.

[43] Beachler et al., “Community Attitudes Toward Opioid Use,” 29-34.

[44] Bunting et al., “Clinician Identified Barriers to Treatment.”

[45] Richard et al., “You are Not Clean Until You're Not on Anything,” 1-7.

[46] Moody et al., “Substance Use in Rural Central Appalachia,” 123-35.

[47] Havens et al., “Longitudinal Trends in Nonmedical Prescription Opioid Use.”

[48] Faulkner, “Substance Abuse in Rural Appalachia,” 65-73.

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