Lesly-Marie Buer was living and working Colorado when she became interested in substance abuse treatment and harm reduction programs.

Buer grew up in East Tennessee, in the Knoxville area, but moved west and attended the University of Colorado where she got a master’s in public health.

“But then I was talking to friends who were going through treatment programs in East Tennessee, and they were telling me about them. Most of these were guys and most of the research I had seen [on recovery] was on guys,” Buer recalled. “I was looking for what was going on with women trying to make it through treatment programs in Appalachia and I just couldn’t find anything. So I decided that’s what I really wanted to look at for my dissertation.”

Buer moved back east to attend the University of Kentucky and soon began living alongside women in recovery in rural Kentucky communities, interviewing them in detail and trying to understand their struggles. Those interviews and her research resulted in “Rx Appalachia: Stories of Treatment and Survival in Rural Kentucky,” being released Tuesday, May 12. Buer spoke about the book and her research with 100 Days in Appalachia’s Taylor Sisk before its release.

This interview has been edited for length and clarity.


Taylor Sisk: You open your book with a quote from a book by Anne Pancake called Strange as this Weather Has Been. Could you read that quote for us and then tell us why you chose to open your book with it.

Lesly-Marie Buer: “I’ve learned something about times like these. And times like these you have to grow big enough inside to hold both the loss and the hope.”

I think that I’ve seen this with my generation growing up in Appalachia, but also in my research as well. Most friend groups have lost some friends to overdose death or to suicide, sometimes it’s hard to tell the difference which, and that takes a toll. You know, you start getting scared when you get phone calls from friends late at night thinking that it’s another death.

But at the same time, there’s so much beauty and activism here. And you see that with the youth and all the youth groups that are happening in Appalachia. They have these beautiful radical ways of conceptualizing what Appalachia is going to look like, and I saw a lot of that with the women I spoke to who are going through substance use treatment. They had all these imaginings of what life could be like and there was so much hope in those imaginings, yet there was so much hurt as well.

TS: The subtitle of your book is stories of treatment and survival and rural Kentucky. Why did you choose that title?

So, most the people I worked with and spoke with, they had really been placed in situations that were very risky. And so, so much of their life was focused on surviving, not really necessarily on thriving or moving past that, but just getting through the everyday and I was just catching them at a certain point with one of a big thing in their life was trying to survive treatment. And that was the one of the biggest hurdles.

So as they were trying to work through treatment, they were also trying to survive in their family and in their communities, which was no small feat for a lot of them as they were trying to deal with issues of child custody, not having jobs, you know, maybe not getting the child support they rode and just placed in these situations where it just seemed like not much was going right.

TS: You spent a lot of time in these rural Kentucky communities. Tell us about the course of your research.

LB: One of my biggest focuses was just trying to be there. I have family in rural East Tennessee, I’m from East Tennessee, but that doesn’t mean I know what it means to be in rural Kentucky.

And so I got a studio apartment there. I lived there, tried to go to community events. I went through a round of festivals for every vegetable and fruit you can think of. But when you start talking to people and saying what you’re doing, then you get all sorts of stories.

I would talk to treatment providers and walk through what treatment looked like for them, and if I was allowed in, go to some group sessions for treatment. I went to a lot of court sessions, just anything I could get my hands on that I thought would relate to this, church services, city council meetings, anything I could go to, to just try to feel what it was to be in that place.

And then I talked to a lot of women. I talked to 40 women at least once, most of those conversations were about an hour, hour and a half. Some went to three or four hours and those are the most the women I ended up going back to talk to  a few times to try to really get their story, see where they were at in treatment and sort of followed them through.

TS: You chose not to use the real names of these women or the agencies they were seeking help from in the book so, in general terms, tell us who these women are.

LB: Almost every one I talked to were mothers. And there was a lot of hurt in people’s lives. So about half the women had been sexually assaulted at some point, about half the women had experienced domestic violence. So just being placed in very at risk situations, where oftentimes the options were either a bad option or a terrible option. And sometimes you just got to go with bad over terrible.

Most had a hard time providing economically for themselves and their families, and that’s not because of some lack of will or anything like that, but because there was just a lack of access to jobs, especially if they had gotten any sort of record either a criminal felony record or a record through Child Protective Services, it was really impossible for them to enter the workforce in those counties where the biggest sources of employment are oftentimes through some sort of health care or through the school system. And then they were regulated, they could not participate in that economy.

TS: You close the book with some recommendations on how to change the health care system. What are those?

LB: Medicaid expansion has been very successful in addressing some issues in Kentucky and so I would love to see more support for Medicaid expansion in other Appalachian states. I’ve also seen a lot of success around harm reduction programs and I would like to see broader community support for those. When I talk about harm reduction, I’m thinking about programs that really meet people where they’re at and try to provide services that people who use drugs say they want, not just services that other folks think they need.

And then the last one is really stigma reduction. I would love to see less judgment on people just because of one behavior that’s in their lives, because people are a lot more things than just one behavior.

TS: So many of the women in your book are were facing drug offenses and you use the term a just alternative to incarceration. What would that look like?

LB: I think in critiques of how the response to opioid use versus crack use and heroin use in the past there’s been this idea that some people– especially in rural areas– are seeing a just alternative to incarceration, but what I saw in eastern Kentucky was in no way just.

A lot of the women there were not being incarcerated, or at least being incarcerated for long periods of time, but they were being processed through state systems that were very punitive, whether that was punitive social services or punitive Child Protective Services, and so while we’re looking at trying to decriminalize drug use or at least not incarcerate as many people [for it], I hope we don’t fall into the pit of just sending people through underfunded state programs that still marginalize people even though it may not be incarceration.

I think a just alternative is really meeting people where they’re at, seeing what they need, what they say they need and trying to supplement people’s resources, especially when they don’t have access to an economy or a social situation where they can provide for themselves and their family. The last thing we want to do is forcing people through programs that just further hurt them. So we really need to be about reducing harms and not increasing harms.

Lesly-Marie Buer is a harm reductionist and medical anthropologist living in East Tennessee. She has a PhD in anthropology and a graduate certificate in gender and women’s studies from the University of Kentucky and a master’s in anthropology and master’s in public health from the University of Colorado.