UC Berkeley

Drug-related deaths, most of which involve opioids, have skyrocketed in the United States to over 107,000 in 2021 and more than one million in the 21st century. In contrast to previous drug crises, the overdose crisis has severely affected nonurban areas. In 2017 I entered California’s mountainous backcountry with several questions: how had opioids spread in regions where they seemingly had not previously? How were drugs obtained in places that lacked organized drug markets? How did isolation and scarcity affect the health consequences of opioid use? And how were drugs policed in towns where authorities lived alongside their targets?

To answer these questions, I conducted in-depth interviews and over two years of ethnographic fieldwork across a dozen counties, almost all remote and nonurban. I interviewed 69 people who used drugs, mostly heroin and other opioids, spending time with many as they bought, sold, and used drugs. I also interviewed 176 local officials and service providers, including practitioners in health care, public health, substance use treatment, harm reduction, and social services, as well as law enforcement officers, judges, attorneys, and probation officers. In this dissertation I report in-depth on two counties that I call Oak and Sage.

In the first two chapters, I discuss the history of the overdose crisis in the United States and California and highlight changing inequalities in its impact over time, by place, and by race and ethnicity. In Chapter 3, I construct several concepts to account for distinctive features of nonurban social structure, subjectivity, and local government. In particular, I argue that geographic isolation and dense, multiplex social ties generate “acquainted marginality,” exposing people who use drugs to formal and informal surveillance, durably spoiling their reputations, and discouraging them from seeking health care and other services.

Chapter 4 recounts how opioids were used in the backcountry to compensate for weak local health systems and to soothe untreated anguish, and how residents sought out heroin as pharmaceuticals became scarce. In Chapter 5 I describe a small-town heroin scene and catalogue the extensive planning, coordination, time, and money necessary to consistently obtain the drug from urban markets. The sixth chapter illustrates how geography and social structure jointly affect the health consequences of opioid use, including pain and withdrawal, infection and injury, and natural hazards. In Chapter 7, I examine how people who use drugs are tracked through gossip, by neighbors, and in public space, how social ties are appropriated by law enforcement, and how stigma and drug criminalization reinforce each other.

In the Conclusion I outline a sociological model of drug use and addiction as an effect of institutional and organizational relations that selectively expose people to hardship, sources of meaning and inclusion, and experiences with drugs. This approach implies that drug use is a normal element of human social life and that negative consequences from drugs are not inevitable but shaped by policy choices. Since efforts to eliminate drugs have caused significant harm, I argue for accommodating drug use and recommend policy changes to achieve that goal.