In the Epicenter: Surveilling, Supporting, and Punishing Families amid the Rural Opioid Crisis and Beyond

Abstract

While the opioid crisis has impacted communities across the United States, it has left a particularly indelible mark on Central Appalachia—an area widely regarded as the “epicenter” of the crisis. One consequence has been a fundamental shift in the structure of local families: rural Appalachian communities have witnessed rapid growth in the prevalence of kinship care, or children living with relatives, due to parental substance use disorder. While scholars across disciplines have documented outcomes for relatives and children in these arrangements, research on families’ experiences entering and navigating kinship care—particularly amid parental substance use—is lacking. In this dissertation, I draw on four years of ethnographic fieldwork in Appalachian Kentucky, including over 2,000 exposure hours of participant observation and observant participation and 164 in-depth interviews with relative caregivers, parents who use(d) drugs, and representatives of the local institutions which surveil, support, and punish these families. I examine how kinship care arrangements come to be, how kinship care impacts family relations, and how local communities and institutions support, surveil, and punish these families. Part I sets the stage by illustrating the progression of the opioid crisis within rural Appalachian communities. I consider how people in rural Appalachia have come to understand the opioid crisis, and how local communities have sought to mitigate its impacts. I argue that Appalachia’s long history of corporate exploitation primed local people to embrace the narrative that Big Pharma’s greed and deceit had created the destruction of the opioid crisis. While this has decreased the stigma associated with legal prescription opioid use, communities have instead vilified people who use other drugs, like heroin and meth. The distrust of outsiders evolving from such exploitation has also made communities resistant to substance use services started by non-residents, like medical innovations. While local people have come together to design their own solutions, they may lose some of the benefits which these outsiders could bring to their communities. When recovery resources do successfully come to the region, these resources tend to locate in larger hubs, enhancing place-based inequalities within the region and leaving smaller and more remote communities further behind. In Part II, I turn to the experiences of families navigating parental substance use disorder within these communities. I first consider how local institutional responses to substance use have led to relatives taking children into care. I argue that the criminal justice and child welfare systems subject parents who use drugs to an additional level of derision and stigma precisely because they are parents. While these systems have increasingly utilized addiction treatment, this medicalized approach has not brought additional sympathy. Rather, the combined use of both therapeutic (i.e. rehabilitation) and punitive (i.e. incarceration) responses to substance use actually contributes to the derision and stigma wielded at parents who use drugs, who go through a “revolving door” of alternating treatment and punishment. The entanglement of these therapeutic and punitive responses also deters parents from seeking help, furthering the damage incurred by their substance use disorder. Given that a child is being taken in by a relative, I then consider the legal process by which such a caregiving shift happens. When relatives step in to raise these parents’ children, either on their own accord or due to state intervention, they must choose one of a number of different legal arrangements that define their caregiving role. I find that caregivers’ ability to choose the arrangement best suited to their family’s needs depends on their legal capital—a form of social capital derived from connections to key players in one’s local legal system. While those who are well-connected may be able to maximize their stability and minimize the level of surveillance they must endure, caregivers who are poorly connected lack the power to do so for their own families. Finally, I consider how these kinship care arrangements fundamentally shape the relationships between parents and relative caregivers. I find that while the child welfare system leans on families’ natural support systems when placing children with relatives, it simultaneously breaks those support systems by removing relatives’ abilities to assist the children’s parents. By forcing relatives to essentially choose between the parents and children, the child welfare and social welfare systems actually encourage families to avoid state intervention at all costs. However, this assumes parent-relative relationships were positive to begin with; relatives and parents may also possess negative or difficult social ties to one another. In this case, both relatives and parents may exploit the child welfare and social welfare systems in order to punish the other person. Alternatively, the cumbersome and adversarial nature of child custody shifts can create such negative or difficult ties between relatives and parents. In either case, families’ abilities to support their children in the best way possible suffer. This dissertation offers a rare glimpse into the rather remote and isolated communities of rural Appalachia, often regarded as ground zero for many of the issues which plague the wider nation, like poverty and addiction. To conclude, I offer suggestions for how to encourage community healing amid the opioid crisis, and I envision more flexible treatment options and legal arrangements which empower families to navigate parental substance use disorder collectively, rather than stripping them of control and inflicting further trauma.