My grandmother is a drug addict.

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She still refuses to admit it even though most everyone around her knows that her dependence on opioid painkillers drives nearly every part of her life. At first glance, she might look like a typical little gray-haired lady, but she lies, she cons, and she uses others in ways most of us couldn’t fathom just to get the money to buy more Vicodin.

At this point, most all her family is estranged, and I am not certain she really cares. For her, the only priority is the pills. It has been this way for at least twenty years, and I'm not sure if the drug abuse made her selfish and hateful, or if she was that way before the drugs. I suspect the former. I want to believe the former. I probably need to believe the former.

As much as I would like to help her, the hard truth is that it has proven nearly impossible for any of us who are related to her to try to help her without being pulled into miserable situations ourselves. I don't know what the answer is because I know that even as hateful and selfish as she is, she didn't choose to be a drug addict. Circumstances beyond her control dealt her a life so terrible that she came to think of drugs as the only solution. As much as I want to be angry at her, I know in my heart that she is suffering in ways I cannot begin to understand. And frankly, I consider myself blessed, lucky, whatever you want to call it, that I cannot understand myself what she is going through.

While it might seem rare, or even a bit of a novelty, for an elderly lady to be a drug addict, it really isn't that unusual in Appalachia. Addicts come in all ages here in the mountains. They come from rich families and from poor families. Addiction in Appalachia is not limited by race or by education level. It afflicts the Baptists and the Methodists and the Pentecostals and the agnostics. If you live in Appalachia, you almost certainly know someone who is, or was, an addict. In fact, you most likely know someone who died as a result of their addiction.

While addiction reaches both the rich and the poor in Appalachia, the stark reality is that addiction thrives in these mountains in large part because of poverty. The poverty came first. The drug addiction came later, often as a desperate response. The poor are disproportionally destroyed by addiction. They have the least access to treatment options, and they are more likely to escape addiction through death than through recovery. Most remain addicted all their lives, and their lives are usually cut tragically short.

Over the past few years, the opioid epidemic that is plaguing rural America has finally begun to get a bit of national attention. The evening news shows have run a few specials, and some documentary filmmakers have made important films about the crisis.

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Today, prescription opioids have largely taken the place of heroin, methamphetamine, and crack cocaine in bringing heartache and desperation to Appalachia. These opioids don’t come across the southern border or from a clandestine lab or even from a trailer park chemist. They come from multi-national corporations. They are prescribed by physicians, and purchased and dispensed, at least initially, from licensed pharmacies. The most popular form is called Oxycodone. You might know it by one of its brand names: OxyContin, Roxycodone, or Percocet. A closely-related drug, hydrocodone, is sold under brand names including Vicodin, Lorcet, and Norco. In much of Appalachia, these drugs, all of which are opioids, are household names.

While many Americans encounter these drugs only while recovering from a surgical procedure, OxyContin and other prescription opioids are responsible for thousands of deaths per year in Appalachia. According for the Centers for Disease Control, more than a thousand people per day seek treatment in US emergency rooms because they have misused prescription opioids. In 2014, the most recent year for which statistics are available, over 2,000,000 people in the United States either abused or were dependent on prescription opioids.

It all sounds so clinical and official, really, when we talk about "prescription opioids" and data compiled by the CDC. The reality, however, is that many people who abuse opioids in Appalachia buy them illegally, and getting a fix isn't cheap. In many parts of Appalachia, especially in eastern Kentucky and in West Virginia, a sort of illicit economy has developed around the widespread abuse of opioids. While the pills are manufactured by multi-national companies, prescribed by health practitioners, and dispensed by pharmacies, those to whom they are prescribed often sell them illegally. In most parts of Appalachia, street-level dealers, some of whom are addicts themselves and sell pills to support their habits, are able to get more than a dollar per milligram for the pills. A thirty milligram OxyContin, for example, will usually fetch $30. For addicts in advanced stages of addiction, a single 30 mg pill is barely enough to stave off withdrawal symptoms. It takes substantially more than that for them to get high.

Those who buy these prescription opioids illegally rarely take them in the ways intended by the manufacturers. While some addicts simply take the pills orally, many eventually end up crushing the pills and snorting them or, worse, shooting them up intravenously. It is a mind-boggling journey, really, from the tightly controlled manufacturing laboratory of a major pharmaceutical manufacturer to the vein of an addict in central Appalachia, via what might be a secondhand needle. No matter how the OxyContin gets to its final destination, however, its initial sale is still added into the black side of the manufacturer's balance sheet. As Appalachia is slowly rotted from the inside by this dangerous poison, drug company executives and shareholders are making billions.

I have always wondered: do they know? Do they care? When Mark Timney, CEO of Purdue Pharma, the maker of OxyContin, sees his direct payroll deposit hit his bank account, does he think about the hundreds of people who die every year because of his product? Does Timney think about the moral implications of running a company that makes a product that has destroyed lives and homes and towns? I suspect that Timney doesn't think about the unfortunate and hopelessly addicted end-users of his products any more than the CEO of Raytheon thinks about the collateral damage on the receiving end of the Tomahawk Missiles his company manufactures. Perhaps the world would be a better place if these aloof and isolated executives were forced to step outside their bubbles and see the gut-wrenching destruction their products cause.

If Timney had to walk through the alley behind Cumberland Avenue in Middlesboro, Kentucky and see the dirty needles lining the gutter, he might be forced to consider his moral obligations to folks other than his board or Purdue’s stockholders. If he had to ride along with police officers who have to remove malnourished babies from the homes of parents who have died from OxyContin overdoses, perhaps he would understand the full implications of what he willfully does for a living. He has a choice. Those who become addicted to his product are deprived of choices by the chemistry Purdue Pharma has worked so hard to perfect.

My grandmother is a drug addict.

She still refuses to admit it even though most everyone around her knows that her dependence on opioid painkillers drives nearly every part of her life. At first glance, she might look like a typical little gray-haired lady, but she lies, she cons, and she uses others in ways most of us couldn’t fathom just to get the money to buy more Vicodin.

At this point, most all her family is estranged, and I am not certain she really cares. For her, the only priority is the pills. It has been this way for at least twenty years, and I'm not sure if the drug abuse made her selfish and hateful, or if she was that way before the drugs. I suspect the former. I want to believe the former. I probably need to believe the former.

As much as I would like to help her, the hard truth is that it has proven nearly impossible for any of us who are related to her to try to help her without being pulled into miserable situations ourselves. I don't know what the answer is because I know that even as hateful and selfish as she is, she didn't choose to be a drug addict. Circumstances beyond her control dealt her a life so terrible that she came to think of drugs as the only solution. As much as I want to be angry at her, I know in my heart that she is suffering in ways I cannot begin to understand. And frankly, I consider myself blessed, lucky, whatever you want to call it, that I cannot understand myself what she is going through.

While it might seem rare, or even a bit of a novelty, for an elderly lady to be a drug addict, it really isn't that unusual in Appalachia. Addicts come in all ages here in the mountains. They come from rich families and from poor families. Addiction in Appalachia is not limited by race or by education level. It afflicts the Baptists and the Methodists and the Pentecostals and the agnostics. If you live in Appalachia, you almost certainly know someone who is, or was, an addict. In fact, you most likely know someone who died as a result of their addiction.

While addiction reaches both the rich and the poor in Appalachia, the stark reality is that addiction thrives in these mountains in large part because of poverty. The poverty came first. The drug addiction came later, often as a desperate response. The poor are disproportionally destroyed by addiction. They have the least access to treatment options, and they are more likely to escape addiction through death than through recovery. Most remain addicted all their lives, and their lives are usually cut tragically short.

Over the past few years, the opioid epidemic that is plaguing rural America has finally begun to get a bit of national attention. The evening news shows have run a few specials, and some documentary filmmakers have made important films about the crisis.

Today, prescription opioids have largely taken the place of heroin, methamphetamine, and crack cocaine in bringing heartache and desperation to Appalachia. These opioids don’t come across the southern border or from a clandestine lab or even from a trailer park chemist. They come from multi-national corporations. They are prescribed by physicians, and purchased and dispensed, at least initially, from licensed pharmacies. The most popular form is called Oxycodone. You might know it by one of its brand names: OxyContin, Roxycodone, or Percocet. A closely-related drug, hydrocodone, is sold under brand names including Vicodin, Lorcet, and Norco. In much of Appalachia, these drugs, all of which are opioids, are household names.

While many Americans encounter these drugs only while recovering from a surgical procedure, OxyContin and other prescription opioids are responsible for thousands of deaths per year in Appalachia. According for the Centers for Disease Control, more than a thousand people per day seek treatment in US emergency rooms because they have misused prescription opioids. In 2014, the most recent year for which statistics are available, over 2,000,000 people in the United States either abused or were dependent on prescription opioids.

It all sounds so clinical and official, really, when we talk about "prescription opioids" and data compiled by the CDC. The reality, however, is that many people who abuse opioids in Appalachia buy them illegally, and getting a fix isn't cheap. In many parts of Appalachia, especially in eastern Kentucky and in West Virginia, a sort of illicit economy has developed around the widespread abuse of opioids. While the pills are manufactured by multi-national companies, prescribed by health practitioners, and dispensed by pharmacies, those to whom they are prescribed often sell them illegally. In most parts of Appalachia, street-level dealers, some of whom are addicts themselves and sell pills to support their habits, are able to get more than a dollar per milligram for the pills. A thirty milligram OxyContin, for example, will usually fetch $30. For addicts in advanced stages of addiction, a single 30 mg pill is barely enough to stave off withdrawal symptoms. It takes substantially more than that for them to get high.

Those who buy these prescription opioids illegally rarely take them in the ways intended by the manufacturers. While some addicts simply take the pills orally, many eventually end up crushing the pills and snorting them or, worse, shooting them up intravenously. It is a mind-boggling journey, really, from the tightly controlled manufacturing laboratory of a major pharmaceutical manufacturer to the vein of an addict in central Appalachia, via what might be a secondhand needle. No matter how the OxyContin gets to its final destination, however, its initial sale is still added into the black side of the manufacturer's balance sheet. As Appalachia is slowly rotted from the inside by this dangerous poison, drug company executives and shareholders are making billions.

I have always wondered: do they know? Do they care? When Mark Timney, CEO of Purdue Pharma, the maker of OxyContin, sees his direct payroll deposit hit his bank account, does he think about the hundreds of people who die every year because of his product? Does Timney think about the moral implications of running a company that makes a product that has destroyed lives and homes and towns? I suspect that Timney doesn't think about the unfortunate and hopelessly addicted end-users of his products any more than the CEO of Raytheon thinks about the collateral damage on the receiving end of the Tomahawk Missiles his company manufactures. Perhaps the world would be a better place if these aloof and isolated executives were forced to step outside their bubbles and see the gut-wrenching destruction their products cause.

If Timney had to walk through the alley behind Cumberland Avenue in Middlesboro, Kentucky and see the dirty needles lining the gutter, he might be forced to consider his moral obligations to folks other than his board or Purdue’s stockholders. If he had to ride along with police officers who have to remove malnourished babies from the homes of parents who have died from OxyContin overdoses, perhaps he would understand the full implications of what he willfully does for a living. He has a choice. Those who become addicted to his product are deprived of choices by the chemistry Purdue Pharma has worked so hard to perfect.