Chapter 33 Exercises: The Opioid Crisis

Exercise 1: Mapping the Vulnerability

Chapter 33 identifies four layers of vulnerability that made Appalachia specifically susceptible to the opioid crisis: the history of industrial injury, economic despair, inadequate healthcare infrastructure, and geographic isolation.

a) For each layer, provide a specific example from the chapter that illustrates the vulnerability. Use concrete details — names, places, numbers — not generalizations.

b) The chapter argues that these layers are interconnected: each one reinforced and compounded the others. Draw a diagram showing how the four layers connect to and reinforce each other. For example, how does geographic isolation worsen the healthcare gap? How does economic despair increase vulnerability to pharmaceutical marketing?

c) Could the opioid crisis have occurred in Appalachia if only ONE of these four layers had been present? Why or why not? What combination of factors was necessary — and does the relative importance of each factor matter for designing a response?

d) Identify a non-Appalachian community that experienced a severe opioid crisis. What vulnerability factors were present in that community? How do they compare to the Appalachian factors described in this chapter?

Exercise 2: Analyzing the Three Waves

The chapter describes the opioid crisis as occurring in three overlapping waves: prescription opioids (1996-2010), heroin (2010-2015), and fentanyl (2015-present).

a) Create a timeline showing the key events of each wave. Include at least three specific events or data points per wave.

b) How did the transition from Wave One to Wave Two occur? Why did reducing the supply of prescription opioids lead to an increase in heroin use rather than a decrease in opioid use overall?

c) What made the fentanyl wave (Wave Three) deadlier than the first two waves? Be specific about the pharmacological, economic, and distribution factors that made fentanyl more dangerous.

d) Some analysts have argued that the policy response to Wave One (restricting prescription opioids) directly caused Wave Two (the heroin surge). Evaluate this argument. Did the well-intentioned effort to reduce prescription opioid abuse make the overall crisis worse? If so, what alternative approach might have been more effective?

Exercise 3: The Purdue Pharma Case

Read Case Study 1 alongside this chapter's discussion of Purdue Pharma's marketing strategy.

a) List the specific marketing tactics Purdue Pharma used to promote OxyContin in the coalfields. For each tactic, explain why it was effective in the specific context of Appalachian communities.

b) Purdue Pharma's marketing of OxyContin was, at the time, largely legal. The company employed licensed sales representatives, distributed FDA-approved materials, and promoted a legally manufactured drug. At what point, if any, did legal marketing become something else? Where would you draw the line?

c) In 2007, Purdue Pharma paid $634 million in fines for misbranding OxyContin. In 2020, the company pleaded guilty to additional charges and agreed to an $8.3 billion settlement. Are these penalties proportionate to the harm caused? How should corporate accountability be measured when the harm includes hundreds of thousands of deaths?

d) The chapter draws a parallel between the coal industry extracting mineral wealth and the pharmaceutical industry extracting profit from pain. Write a one-page analysis evaluating the strength of this parallel. Where does the comparison hold up? Where does it break down?

Exercise 4: Evaluating Response Strategies

The chapter evaluates several response strategies: criminalization, naloxone distribution, syringe service programs, Medication-Assisted Treatment, and drug courts.

a) For each strategy, create a brief evaluation that includes: (1) what the strategy aims to do, (2) the evidence for its effectiveness, (3) the barriers to implementation in rural Appalachia, and (4) the moral or political controversies surrounding it.

b) The chapter argues that criminalization "failed" as a response to the opioid crisis. Present the strongest possible argument in FAVOR of a law enforcement approach to drug policy. Then present the strongest possible argument AGAINST it. Which argument do you find more persuasive, and why?

c) The cost of incarcerating a person for a drug offense is estimated at $30,000-40,000 per year. The cost of outpatient MAT is a fraction of that amount. If the evidence consistently shows that treatment is both more effective and less expensive than incarceration, why has the United States historically relied more heavily on criminalization? What forces sustain a policy approach that is less effective and more costly?

d) Design a comprehensive response plan for an Appalachian county experiencing a severe opioid crisis. Your plan should address immediate harm reduction, treatment access, community engagement, law enforcement, prevention, and long-term economic recovery. Be specific about who does what, who pays for it, and how success would be measured.

Exercise 5: The Settlement Question

Opioid litigation has produced billions of dollars in settlements from pharmaceutical companies, distributors, and pharmacy chains.

a) Research the opioid settlement distribution formula for your state (or a state of your choice). How is the money allocated between state government, counties, and cities? What restrictions exist on how the money can be spent?

b) The chapter raises the concern that settlement money may not reach the communities that suffered most — the small, rural, impoverished counties of the coalfields. Based on your research, is this concern justified? What mechanisms exist (or should exist) to ensure equitable distribution?

c) Compare the opioid settlements to the 1998 tobacco Master Settlement Agreement. How was tobacco settlement money supposed to be spent? How was it actually spent? What lessons does the tobacco settlement offer for the opioid settlements?

d) If you were responsible for distributing $100 million in opioid settlement funds across your state's Appalachian counties, how would you allocate the money? What programs would you fund? How would you ensure accountability?

Exercise 6: Primary Source Analysis

Read the three primary source excerpts in Chapter 33 (the physician's account, the mother's account, and the community elder's statement).

a) Each excerpt represents a different perspective on the opioid crisis. Identify the perspective of each speaker and explain what their account reveals that the other accounts do not.

b) The physician describes believing Purdue Pharma's claims "because we needed to believe her, because we had waiting rooms full of people in agony." What does this statement reveal about the conditions under which misinformation is most likely to be accepted?

c) The mother distinguishes between her son's character ("a good boy") and his behavior under the influence of addiction ("the lying, the stealing, the jail"). This distinction between person and disease is central to how addiction is understood. How does the framing of addiction as a disease differ from the framing of addiction as a moral failure? What practical consequences follow from each framing?

d) Write a fourth primary source excerpt from one of the following perspectives: (1) a pharmacist who filled suspicious prescription volumes, (2) a child raised by grandparents because their parent was addicted, (3) a Purdue Pharma sales representative who worked in the coalfields, or (4) an EMT who administers naloxone routinely.

Exercise 7: Neonatal Abstinence Syndrome

a) In your own words, explain what neonatal abstinence syndrome (NAS) is and why the opioid crisis caused a sharp increase in NAS cases in Appalachian hospitals.

b) The chapter describes mothers of babies with NAS as "not criminals or bad mothers" but "persons failed by multiple systems." Identify at least three systems that failed and explain how each failure contributed to NAS.

c) Research the current treatment protocols for NAS. What does treatment involve? How long does it take? What is the estimated cost per case?

d) A mother who is addicted to opioids during pregnancy faces a painful dilemma: continuing to use exposes the fetus to opioids, but abrupt withdrawal can also harm the fetus. Research the medical recommendation for managing opioid use disorder during pregnancy. Why is MAT considered the standard of care for pregnant women with opioid use disorder?

Exercise 8: Connecting to the Larger History

Chapter 33 argues that the opioid crisis was "the latest chapter in a centuries-long history of Appalachian health disparities."

a) Trace the health history thread through at least four previous chapters of this textbook, identifying specific health challenges that predated and laid the groundwork for the opioid crisis.

b) The chapter states that "the pharmaceutical companies that profited from Appalachian pain were the successors of the coal companies that created the pain." Evaluate this claim. In what specific ways is the pharmaceutical industry's relationship with Appalachia similar to the coal industry's? In what ways is it different?

c) If the opioid crisis is understood as part of a longer pattern — not an isolated event but a continuation of structural neglect — how does that understanding change what an adequate response would look like? What would it mean to address the crisis at the level of root causes rather than symptoms?

d) Write a 500-word essay connecting any TWO of the following: (1) black lung disease and OxyContin marketing, (2) company towns and pill mills, (3) the Great Migration and the fentanyl wave, (4) the "War on Poverty" and the opioid settlements. Your essay should identify specific parallels and differences between the two phenomena.