Theodore Dalrymple has made an inestimable contribution toward productive discourse on western social ills by insisting first on clarity of language beginning with the critical distinction between `the poor' and `the underclass', a distinction that will ultimately improve our efforts to help both groups. Thus, I recommend reading his prior books `Life at the Bottom' and `Our Culture' first, unless you have a special interest in the subject of opiate addiction, which I do. Like Dalrymple, I am a physician. My experience is also with an almost exclusively white, Anglo-Saxon population; his reference group being British, and mine being a decade spent working in a rural section of the southern Appalachian mountains. The similar ethnic factor we share in patient demographics is helpful in demonstrating how substance abuse, like other underclass behaviors, is a cultural rather than a racial issue - important in that race issue mischaracterization has been a smokescreen often blown over reality by both white and minority activists for reasons other than a desire to help the needy. Here again I thank Dalrymple for bringing the core issue into focus, as we are unlikely to solve any problem we do not correctly understand.
In rural Appalachia intravenous heroin use is relatively rare. But the past decade has seen an explosion in the abuse of what is sometimes termed `hillbilly heroin', which is prescription diversion of oral synthetic opiates such as hydrocodone, oxycodone, and morphine. Of seven national hotspots of per capita hydrocodone use, four are in eastern Kentucky, and between 1998 and 2001 annual grams of hydrocodone consumed per capita increased in some Appalachian counties more than five fold. These drugs get to the streets and hollows and into the high schools not by way of international crime cartels, but straight from the signatures on physician's prescription pads.
I was there, as a primary care doctor to the poor and underclass, and I can say that every conceptual and practical mistake made in American and British attempts to address heroin abuse in the urban environment are mirrored in drug saturated rural communities in the USA. I can also attest that the big city drug seeker's country cousins are every bit as flagrantly dishonest, manipulative, self-centered, and lazy at any enterprise other than acquiring their drugs as are their urban counterparts.
It is intentional that I use the words 'abuser' and 'seeker', rather than 'addict' in regards to the misuse epidemic of synthetic opiates in rural America. The term 'addict' incorrectly conjures up images of someone with a hellish physiological dependancy upon opiates who could not possibly face more than a few hours without their drugs before decending into horrific and life threatening withdrawl. This is pure nonsense. What one typically sees instead is the sporadic though habitual turning back to opiates as life's preferred alternative, involvment in the underground pill trade as supplemental income, or both.
One important factor overlooked in Dalrymple's analysis is that of the vulnerabilities often inherent to the physician personality, vulnerabilities heightened by the commission of the medical enterprise to be empathetic and to help, and the training process to listen and to believe what the patient tells you - all good things, to be sure. Yes, I'm now jaded, but these factors, positive as they are, set us up as suckers for the historical myths about opiates, the drug seeker's mastery of the victim role and of manipulation, and the more recent general myths about contemporary underclass American. This book should be required reading for all fourth year medical students. Read it if you interface with opiate abuse in any way. Read Dalrymple's other books as well if you want the full picture.
