Deindustrialization in Central Appalachia

Deindustrialization in Central Appalachia is the slow dismantling of a work-based economy whose mines and factories had supported household income, routine, and local services. In the book, that decline is not a backdrop separable from the opioid crisis: it helps explain why communities already facing shrinking opportunity were especially exposed to expanding opioid supply, rising disability, and inadequate treatment. The account links these forces without reducing addiction to unemployment or individual character.

A Work-Based Economy Unravels

The region’s coalfields had been losing mining jobs for decades when Lieutenant Richard Stallard encountered a new, powerful painkiller in 1997. The coal-mining workforce would be cut in half between 1983 and 2012. Pollution regulations, competition from natural gas and cheaper low-sulfur coal mined farther west, automation, and the closure of factories that burned coal all contributed. The persistence of the name coalfields thus obscured a basic change: coal remained a marker of regional identity even as the work that had sustained it contracted.

Manufacturing had offered a modest but important alternative. Sue Cantrell recalled taking a mobile clinic to the Buster Brown apparel factory in the early 1990s, where women were paid by the number of pieces they sewed and had no sick leave. Such jobs did not make families prosperous, but they could help keep households from the edge of being unable to pay for food or utilities. They also gave a shape to daily life: people rose and went to work, including many who had not finished high school. As production work disappeared, there were few replacement jobs.

The contraction was tied to changes in the wider economy as well as to local industrial decline. After the North American Free Trade Agreement took effect in 1994 and China entered the World Trade Organization in 2001, apparel and furniture production increasingly moved to lower-wage countries in Latin America and Asia. In Galax, Virginia, two major employers, Hanesbrands clothing and Webb Furniture, closed, while other plants continued to reduce their workforces. The losses deprived workers not only of wages but also of the stable employment that had helped organize family and community life.

Household Insecurity and the Opioid Supply

The consequences became visible in measures of economic distress. In Martinsville, Virginia, and surrounding Henry County in Virginia, unemployment rose above 20 percent, food-stamp claims more than tripled, and disability rates increased by 60.4 percent. The book sets those figures beside scenes of people arriving at food pantries well before opening and the remains of a closed furniture factory after an unemployed man’s attempt to remove copper wire for resale accidentally started a fire. These details show economic decline entering ordinary life as lost income, reliance on emergency support, and the repurposing of abandoned industrial spaces.

In the coalfields, opioids did not arrive into a vacuum. The book describes a region where poverty and a dwindling supply of work predated the pill epidemic; by the time Stallard first encountered the new painkiller, the area had also become associated with high disability and prescription diversion. In Galax, patients seen by Steve Huff had received large amounts of OxyContin, sometimes alongside benzodiazepines, despite medical records that did not explain the scale of their prescriptions. The drug also became a resource that could be resold: a large bottle of eighty-milligram tablets could, in Huff’s account, provide a month’s income when sold on the street.

The later spread of heroin makes clear that industrial decline alone cannot explain the crisis. In 2006, Clifton “Lite” Lee brought heroin into Roanoke’s market, recruiting suburban teenagers to sell to friends and use some themselves. Police found evidence implicating dozens of other young people, including students from Hidden Valley High School, in Roanoke County. In the northern Shenandoah Valley, the book describes a related cycle in which some people began with prescriptions, turned to heroin, and resold portions of what they bought to finance further purchases. New customers could in turn recruit others. Economic insecurity formed part of the terrain on which this supply network grew; it was not the only force shaping who used drugs or how the market expanded.

The Structural Causes of Unequal Risk

Shannon Monnat frames the crisis as the convergence of collapsing work, growing disability, and the flood of painkillers promoted by pharmaceutical companies and approved by regulators. Her analysis gives economic decline a specific place in the causal chain: reduced work and rising disability were followed by an expanding supply of opioids. The book’s wildfire comparison distinguishes kindling from spark. The loss of work made communities more vulnerable, while the availability of powerful drugs helped ignite and spread the epidemic. This interpretation shifts attention from a simple account of individual choices to the conditions that shaped exposure, income, and prospects for recovery.

Those conditions also intersected with race and drug enforcement in unequal ways. Don Wolthuis recalled that heroin in Roanoke had once been viewed as an inner-city drug and associated with a small, largely Black group whose use was comparatively invisible to the public. By 2014, federal data showed that doctors prescribed painkillers to people of color at much lower rates than to white patients, reflecting physicians’ greater suspicion that patients of color would misuse them. Meanwhile, Black and Hispanic people made up a disproportionate share of those imprisoned for drug offenses. The book therefore resists treating opioid exposure and punishment as evenly distributed effects of economic hardship: medical trust, prescribing, and policing also shaped who encountered risk and who faced incarceration.

Care, Coverage, and Community Resources

Economic decline also narrowed the practical routes to medical care. Virginia repeatedly rejected Medicaid expansion after passage of the Affordable Care Act, forgoing federal funds and coverage for hundreds of thousands of low-income residents. By contrast, states that expanded Medicaid could use it to pay for addiction treatment, counseling, and medication, and to cover people who were too poor to afford private insurance but did not otherwise qualify for Medicaid. In 2014, Virginia’s proposed expansion was defeated after state senator Phillip P. Puckett resigned, giving Republicans the votes to block it.

The consequences of limited coverage are represented through the circumstances of a fifty-four-year-old teacher whose husband, a former Walmart worker disabled by strokes, received Medicare. She had gone decades without insurance and pieced together free care at Remote Area Medical events and visits to the Health Wagon, a mobile medical unit. She delayed seeing her family doctor, who offered a discounted cash visit, until she was nearly dying. The episode shows how the absence of insurance did not simply leave treatment unavailable in theory; it made timely care depend on charity, mobility, and a person’s ability to pay.

The book’s proposed alternative to a purely punitive response is to rebuild practical supports as well as treatment access. Bryan Stevenson describes a model in which people leaving prison are connected with housing, employment assistance, and harm-reduction services, while low-level drug offenders can be diverted from prosecution. These supports could help former dealers find legitimate work and reduce the economic pressure that sustains drug dealing. Nancy D. Campbell likewise argues that recovery depends on rewarding alternatives to drug use: work, recreation, relationships, and activities around which people can build lives. In this account, deindustrialization matters not only because jobs vanished, but because rebuilding community resources and meaningful opportunities is part of what any durable response to addiction would require.