Drug addiction, alcoholism, and suicide are all diseases of “despair”; people in communities without adequate opportunities for employment and people who have low social status frequently suffer from diseases of “despair.” The rural communities Macy describes are riddled with diseases of “despair,” particularly opioid addiction, because global trade has removed many of the jobs residents in Appalachia depend on for survival and identity.

Drug diversion occurs when legally prescribed drugs end up in the hands of anyone other than the person for whom they were prescribed. Young people’s diversion of prescription drugs from each other or family members fueled the opioid epidemic in affluent Roanoke, Virginia, homes. Macy blames Purdue Pharma for the heroin epidemic in these communities because Purdue Pharma’s prescription drugs led to heroin use once young people with substance use disorders were addicted and could no longer divert legally prescribed OxyContin.

Harm reduction is an effort to minimize the social, legal, and health costs of addiction. Proponents of harm reduction support programs such as providing clean needles to prevent the spread of hepatitis, creating sites where those with substance use disorders can inject themselves without fear of arrest, and providing testing strips to detect drugs laced with fentanyl.