28-minute listen | 17-minute read
Substance use is similar to extreme weather due to climate change in multiple ways. Both have had impacts in rural towns and big cities. Both can impact any socio-economic class. Both are here to stay for the foreseeable future, and both can damage lives. Another connection is the impact of one on the other, specifically, how extreme weather, like flooding, can impact a community's ability to support those afflicted with substance use disorder. Through their project, titled Exploring the Impacts of Flooding Events on Substance Use in Rural Appalachia, Kristina Brant, Zhen Lei, and Sarah Kawasaki are using weather and overdose data combined with the stories from people impacted by these hazards to show the importance of this need in Appalachia.
INTRO: People believe that these floods are not going to go away. This is something because of changing weather patterns that's going to continue. What could be the long-term impacts of this on people's lives, especially people who use drugs?
HOST: Welcome to Growing Impact, A podcast by the Institutes of Energy and the Environment at Penn State. Growing Impact explores cutting-edge projects of researchers and scientists who are solving some of the world's most challenging energy and environmental issues. Each project has been funded through an impactful seed grant program that's facilitated through IEE. I'm your host, Kevin Sliman.
HOST: Substance use and the opioid crisis continue to affect people in every community. Additionally, environmental impacts such as climate change and extreme weather compound the already-difficult lives of those struggling with addiction. This can be especially true in some rural areas where there can be additional barriers related to the lack of substance abuse services and support and a stigma of addiction and treatment. Kristina Brant and her research team are working on a project that looks to bring data to community leaders and decision makers to show why this is a need in rural communities and to inform what adaptations could be made to help save lives.
HOST: Welcome, Kristina, to Growing Impact. Thank you so much for being here. I really appreciate you coming and speaking about your research and discussing your seed grant project.
Kristina Brant (KB): Thank you so much for having me. I'm excited to be able to share.
HOST: Could you introduce yourself and provide a brief background of your research?
KB: I am an assistant professor of rural sociology at Penn State. That means I'm housed in the College of Ag Sciences, which is a bit unusual for a social scientist. But those of us who are in Ag Sciences who are social scientists are usually focused on either one, social issues just in rural communities at large, or specifically social issues around agriculture and food systems. I am someone who primarily studies rural communities. If we think that place matters for people's outcomes, if place matters for people's experiences, I'm someone who thinks specifically about how the rural context shapes people's lives. Within Penn State, I also have a unique position in that I am not someone with a research and teaching split, which is what many faculty members are. I have a split between research and Extension. In addition to doing research, which is how we primarily think—come up with a research question, carve out a project, write scholarly articles. Extension’s purpose is to take research and boil it down in a way that can be used for community education purposes. To tell you the types of topics I focus on within research and Extension, I primarily think about the experience of substance use in rural places. I think about how the opioid crisis has impacted rural communities. How has it shaped the landscape of rural places? But also how living in a rural place shapes the way that people who use drugs experience substance use, experience the policies and programs that we have created around substance use.
HOST: How did you become interested in substance abuse? How did this become a passion of yours?
KB: When I started graduate school in 2014, my hope was to take the method of ethnography, which is true qualitative work within sociology. Ethnography involves participant observation, spending very long periods of time watching the dynamics you're studying. I wanted to take that from urban contexts, where it's typically done, to rural contexts. Universities are often based in cities, so it's easy for researchers who live at universities to do this deep embedded work in cities. It's much less common for people to do that in places that are remote because it's harder to access. You don't live there. You don't know people there necessarily. Ethnography within sociology has long been a central way of studying the phenomenon of urban poverty. And I wanted to do that in rural spaces. So I wanted to be an ethnographer who studied rural poverty. When I was in graduate school, I moved very early on to eastern Kentucky, which is part of what we often call central Appalachia—an area that has long had really entrenched and concentrated poverty in large part because of these cycles of exploitation from the coal industry. These cycles of busts and booms that have dominated local labor markets, that have decimated environmental landscapes, have created this long term very deep rural poverty. I think this was 2015 when I started fieldwork for my dissertation. I moved to eastern Kentucky from grad school. This was the height of the opioid crisis. So I moved, looking to study rural poverty and to think about how social policies that focus on poverty reduction should be tailored to rural places, but you couldn't think about poverty at this time without thinking about substance use. Yes, the opioid crisis had been boiling since the early 2000s. 2015 is 15 years later. But this is the time where the opioid crisis started to get more deadly. This is the time where substances started getting more potent. This undercurrent was coming to a head. When I was doing exploratory work, just talking with people, getting to know what people thought was important, what people wanted research to be done on in their communities, it kept coming back to substance use. I also have a history of addiction within my family. I've had loved ones who have suffered with substance use issues. And so it's something that I cared about personally too. And I felt like I could talk to people about in a non-judgmental way and allow for them to share stories that often they tried to hide because of how stigmatized the issue was. I got into the space because of, one, the need, and two, because I felt like I was uniquely positioned to be able to do deep work on the topic.
HOST: Can you provide some background and history on substance abuse and the opioid crisis in rural areas, but really across the United States?
KB: Yeah, most everyone in America, you can't pick up a newspaper, you can't watch documentaries without at some point hearing about the impact of the opioid crisis on the United States within the 2000s. This is not a uniquely rural issue. In many ways, the opioid crisis began in rural places, specifically in rural Appalachia. And that's for a few reasons. I'll give a brief background. As I mentioned, central Appalachia, especially eastern Kentucky, southern West Virginia, these areas had been dominated by the coal industry for a very long time. Coal didn't just disappear overnight. The industry slowly started to hemorrhage jobs throughout the '80s, '90s, 2000s. So slowly different communities are starting to lose their biggest job opportunities. Coal also wasn't just like a means to an income. It also, for many people, was this source of pride, this source of identity. This is what our communities do. Our communities keep the lights on for the country. As jobs were hemorrhaging, one, people are losing a source of income, but, two, often people are losing pride, this identity that's not just at the individual level but at the community level. In the early 2000s, this was a period where we're losing these coal jobs. People themselves who are losing coal jobs are often individuals who have developed these long-term illnesses, chronic pain. For a long time, rural places, especially in rural Appalachia, lacked access to primary health care. A lot of times like these chronic illnesses, people have been forced to leave them to fester, to not address them, which allows them to get more severe. This is the background. In the early 2000s, we see for the first time this proliferation of prescription opioids that are being used by doctors’ offices to address this problem. As prescription opioids proliferate across communities, that means there's more on the streets for people to use without a prescription. It's both people who have a prescription and people who don't, who are starting to rely on opioids to deal with some of those like chronic pain issues like I mentioned, or even just feelings of despair that come from communities that are falling apart. Things started to change in the 2010s. A big part of this was because the country started to realize, look, maybe passing out pills left and right isn't the answer. The number of prescriptions per capita in these communities was astronomical, and so doctors feel the need to start reining in prescriptions. Pharmaceutical companies reformulate some of these prescriptions, so they become less addictive. Essentially, we start to get prescription opioids off the street. Without prescription opioids on the street, this pushes people to start to look to alternative options that are easier or cheaper to get. An important point is cheaper. Often higher-income people could still access things like oxy on the street. But if you don't have access to a higher income, you have to take what you can get. This is the time where we saw huge increases in rates of heroin use, more recently the introduction of fentanyl into the heroin supply. Fentanyl is even more potent. In a paradoxical way, getting pills off the street made people turn to substances that were more dangerous, which is what started to make the overdose rate skyrocket. The thing that makes rural communities unique is that—I'd say it's twofold. You can look at the structure of rural places and you can look at the culture of rural places. What do people need to address this? We have harm reduction services. Harm reduction services exist in order to make sure that people who use drugs don't die. Substance use is a given. People will always use drugs. There will always be a reason to use drugs. It doesn't matter if the state provides them or not. They're going to be there. People will use them. So how do we make sure people don't die? We make sure that people have access to things like naloxone. Naloxone, often called NARCAN, is something that people can use to reverse the impact of an overdose. But in rural places, structure and culture, one, there's less organizational infrastructure. You don't necessarily have the same number of organizations who are able to provide services like this to people, right? You need to have access to a local health group who's passing this out on the street to make sure that everyone has access to it and everyone can use it when they need. Two, culture. Unfortunately, it is the case that substance use and substance use services are both still more stigmatized in rural communities than not. That's certainly changing. I have seen it change over time while I've been doing research. However, there's still a lot of work to go.
HOST: Okay. Can we now pull in the environmental component? Can you explain how substance abuse and say an environmental impact like flooding, how they're related, and how they impact one another?
KB: I was still living in Eastern Kentucky in 2021 before I moved here in the fall. And in that spring, there was an extreme flooding event where many—I mean it was in New York Times—many communities were suddenly underwater. This in large part stems from one, the fact that often communities and especially houses are in hollers, placed along creek beds. You know, you can't build on top of the mountain necessarily, so communities exist in between the mountains. Also, the coal industry has created lasting environmental damage in a lot of these places too. So, mountaintop removal has changed the landscape of how places naturally deal with things like absorbing rain. This first extreme flooding event that happened in 2021. Just high levels of rain. Creeks rose. Low land near creeks flooded. While I was doing my research, all of a sudden, I was trying to contact some of my respondents to do work. I was contacting some of the organizations that I was working with who helped me connect with respondents. And people aren't thinking about substance use in a moment where houses are underwater. Suddenly it became harder for me to contact organizations. But also organizations were not focused on things like providing a support group for families of people who use drugs, right? They're just trying to get people water and electricity. They're trying to make sure people aren't living in tents. Fast forward to 2022. At this point, I have moved to State College. I'm living in Penn State. On my birthday of 2022, that's how I remember, July 28, there was another, even more extreme flooding event that hit many of the same communities in eastern Kentucky and West Virginia that the one in 2021 hit. I remember seeing on Facebook, a lot of my contacts, like friends that I had made when I lived in eastern Kentucky posting: “SOS the waters rising. It's waist high in my house.” This is before it hits the news. I'm just seeing all of these frantic posts, people wondering, have you heard from my grandma? Have you heard from this person? Have you heard from this person? One of my contacts was pregnant at the time. She's saying like, “My husband's carrying me out of the water. Our house is floating down the creek.” These places are not prepared for these new weather events that are happening. This second flood was even more extreme than the first. People had just started to rebuild from the first when the second happened. Again, I saw a similar thing. I'm on these email listservs of organizations that do substance use work in the area and people are saying, look, we need to cancel these meetings. Let's stop this service. We need to pivot and focus on triaging the flood. All of a sudden, one, you already have communities that are hurting, you already have people that are hurting, and you've created this whole new level of disadvantage and despair. And then two, the limited number of organizations that do all of the social services work in these communities are the ones that have to respond in the moment. Those other services that are important to make sure people have access to harm reduction services, people have access to treatment—those disappear. In seeing those two events, I had this inkling in the back of my mind of, okay, what is this doing in real time to people who use drugs? How is access to harm reduction services changing, treatment changing? How can I actually look at this in a systematic way? People believe that these floods are not going to go away. This is something because of changing weather patterns that's going to continue. What could be the long-term impacts of this on people's lives, especially people who use drugs? Those observations are how this project was born, and I'm really excited for the chance to actually be able to delve into this beyond those early observations I had.
HOST: With the same areas that are predicted to get hit again and again with flooding due to climate change—can you talk about the physical layouts of these communities in Appalachia and how that reflects financial realities for certain communities?
KB: This is a microcosm of when we think about the impact of climate change and rising sea levels, for example, more broadly, right? Because of the history of who owns land in Appalachia. It stems back to, again, coal industry. Higher lands are usually owned by wealthier people or by companies. Usually, the lowest income people live on the lowest land in Appalachia. Like I explained, people live in hollers, often next to creeks. And it would be quite common for some of the more economically disadvantaged folks to live in, for example, a trailer next to a creek in a holler. When that creek rises, the people that are going to be most impacted often are those with the least economic resources in the first place. What's more, usually the places they live aren't at all capable of withstanding an event like this. Truly, these modular homes just float down the creek that has expanded. People lose literally everything they have. These floods have certainly impacted people across economic status, kind of like how the opioid crisis has impacted people across economic classes—the people that are most impacted tend to be the most disadvantaged. That's the same with the opioid crisis, right? Although it impacts people across classes, those who are most harmed by it are typically those with the least resources.
HOST: What does your project look to do?
KB: This is a mixed methods pilot project. We have two sides. On the one hand, my colleagues in the College of Earth and Mineral Sciences are going to be looking at the quantitative side of how flooding events have impacted substance use outcomes. So they're going to use weather databases to pinpoint when flooding events occurred and where, specifically what counties those flooding events occurred in. And then we can leverage overdose death data, as well as overdose admittances into emergency rooms to be able to see in counties where there were floods at these specific times, was there an impact on overdoses? So that you can specifically pinpoint in these counties at this time, were overdoses different than this neighboring county where there was no flood or in that county right before the flood? And you can pinpoint in that way whether the floods had an impact on overdoses. What I see is the beauty of mixed method studies is that this quantitative angle can prove to us a trend. It can prove to us an association. Qualitative work is impactful in that it can point to mechanisms. It can start to say why. Okay, quantitative work, you've showed us a trend. Well, why? This is where my components of the research project—I will then turn to reach out to many of those organizations that I've done work with in the past. Sit down and have interviews where we specifically look back and think about when the floods happened, what was going through your head? How did you guys adapt? Who was most impacted? When were you able to go back to normal and start to talk through this? You do this with many organizations. You continue to talk to different people until you've reached what we call redundancy—meaning you're starting to hear the same things over and over again. And analyzing that, you can start to piece through, okay. Can we explain the why? So say flooding, increased overdoses, or say it decreased them—now we can start to use people's perspectives to figure out why that was. Another piece of the project will entail going back to those communities and literally going to look at some of those places that were most impacted by flooding to see the remaining damage that has left, to see how rebuilding has occurred. Often going to places with people, helps people tell stories better. Physically being in a place can allow you to think back, to reproduce memories and talk through the qualitative component will be very place based and draw on physical settings as well as people's recollections.
HOST: How do you plan to work with communities?
KB: One, I'm going to draw on connections I've already made through past research to know, okay, what are the key organizations in these communities that I'm going to turn to and talk to first? How can I use those connections to help introduce me to other people? Maybe folks who experienced some of the more extreme flooding in their homes. Talk with them and snowball to meet more and more people, to hear other perspectives, to add into your collection of data that you're assembling. The other thing I think is really important in doing this work is to talk with organizations about how your work can aid theirs. Are there questions I can ask in my interviews that you all would like to know the answers to? What can I give back to you? This is like a community engaged piece. Are there things that we can do in, in the short term that can also be given back to help communities during the rebuilding process? That I think is just a really important piece to include in research, especially that works with more vulnerable populations or communities. Communities I've found are so willing to open themselves up to hope that something bigger will come from them sharing their stories. That's the goal of research, that's what we hope to do. But that's a really long time horizon and a big time horizon. I think it's important to think, okay, in the immediate as well, how can we use this to give back?
HOST: What could be some results from this project, some impacts, and what do you hope that it could do in the future?
KB: The consensus is that these extreme flooding events are going to continue in rural Appalachia, especially eastern Kentucky, southern West Virginia. That this is not the end. Communities and state governments and federal governments to an extent too, are needing to think about how to help communities become more resilient to these environmental hazards. My hope is that I can help show the connection between these events and substance use so that in thinking about helping communities become more resilient, we can also think about, okay, how can we maintain local risk environments that save lives when it comes to substance use in the face of flooding events in the future? Not just the flooding event itself, those five days where towns were underwater, but also the aftermath of them. How can we make sure that people continue to have access to what they need in those months and years of rebuilding? My hope is that this project can help provide some of that data to show why this is an important thing to be thinking about and to help craft what those adaptations could be. In the longer run, I have another hypothesis that this isn't just confined necessarily to floods, and this isn't confined to Appalachia. We know that it's not just rural places that are having to deal with this deadly wave of the opioid crisis. Cities are too. And both rural places and cities elsewhere experience these same kind of random and extreme weather events that can impact every facet of life. So that could include like hurricanes in the Gulf, that can include wildfires in California. It could include extreme cold events in the Northeast. It could include extreme heat events in the Summers. How are these extreme weather events impacting substance use and access to substance use services and elsewhere when those things happen? My hunch is that there are similar consequences elsewhere as well. My hope is to expand this pilot study, to be able to do a similar mixed methods exploration of a few other types of weather events and a few other regions. So I'd have to choose which places we want to focus on or what types of weather events we'd want to focus on. But then we could expand and use the same design to see if what we're finding in Appalachia around flooding holds elsewhere.
HOST Kristina, thank you so much for being on Growing Impact. This conversation was enlightening. I really appreciate you taking time to be here.
KB: It was great to be here. Thanks so much for allowing me to share some of my past research, some of these burgeoning ideas. And I'll be excited to hopefully share findings with you guys within a year or two. If anyone wants to contact me to discuss any of this further, I have an open door. Just send me an email. My email is firstname.lastname@example.org. I’d love to chat.
HOST: This has been season three, episode 11 of Growing Impact. To read the transcript from this episode and to learn more about Kristina and her research team, find previous podcast episodes, see related graphics and so much more, visit iee.psu.edu/podcast. Thanks for listening.