Episode Summary:

Podcast: New Books Network – New Books in Medicine
Title: Lesly-Marie Buer, "RX Appalachia: Stories of Treatment and Survival in Rural Kentucky" (Haymarket, 2020)
Date: January 26, 2026
Host: Claire Clark
Guest: Lesly-Marie Buer

Main Theme

This episode centers on RX Appalachia, a book by Lesly-Marie Buer, which explores women’s experiences with addiction, treatment, and survival in rural Kentucky. The conversation delves into the unique structural challenges in Appalachia’s response to substance use—particularly as they relate to gender, broken treatment systems, and resilience among women. Buer discusses her ethnographic fieldwork, critiques of prevailing treatment approaches, the pervasive role of structural violence, and the promise of harm reduction and mutual aid in Appalachian communities.

Key Discussion Points & Insights

1. Author’s Background and Motivation

• Strong Ties to Appalachia: Buer grew up in East Tennessee and, after learning about harm reduction in Denver, felt compelled to bring this perspective back home ([01:30]).

• Dissertation to Book: Her research began as a dissertation at University of Kentucky, but she wanted to make her findings accessible to broader audiences, avoiding academic jargon ([02:59]).

  “... I felt like what I had produced via dissertation was not really consumable by the general public as much... I really wanted to translate my dissertation into a book that sort of anybody could pick up and read.”
  (Lesly-Marie Buer, 03:40)

2. Fieldwork Surprises in Rural Kentucky

• Extreme Rurality: Buer was struck by how small and interconnected these communities were, noting both supportive and stigmatizing effects ([04:50]).

• Unexpected Findings: She anticipated more stories about policing but found that encounters with child protective services (DCBS) dominated women’s narratives ([05:39]).

  “...how much my interviews centered on DCBS...was really surprising to me.”
  (Lesly-Marie Buer, 06:13)

3. Gendered Analysis and Social Dynamics

• Focus on Women: Buer deliberately foregrounded women’s narratives, given the male-dominated nature of prior research ([07:06]).

• Intersections with Race: Most participants were white, meaning different social outcomes than in urban Black communities—more treatment funding and less overt criminalization ([08:15]).

• Violence and Caretaking: High prevalence of domestic/sexual violence and the distinct burdens of caretaking shaped women’s experiences with treatment and social services ([09:50]).

  “...about half the women I spoke to had experienced sexual assault of some degree, and over half had experienced domestic violence.”
  (Lesly-Marie Buer, 10:21)

4. Addiction Treatment Modalities

• Three Main Channels:

  1. Drug Court (punitive; tied to incarceration if goals unmet)
  2. Community Mental Health Center/DDCS Programs (punitive via threat of losing child custody/visitation)
  3. Buprenorphine Clinics (medication-assisted treatment; more therapeutic, enabled by Medicaid expansion)
     ([11:16])

  “...counseling services that were not tied to something punitive...they could open up...and not be worried that what they were telling their counselor...was going to go back to hurt them in terms of being incarcerated or losing custody of their children.”
  (Lesly-Marie Buer, 12:45)

5. Barriers and Stigma in Treatment

• Accessibility Challenges: Distance, daily travel for methadone, and stigma from pharmacists made access hard.

• Community Stigma: Even effective treatments like buprenorphine faced local skepticism and discrimination ([13:58], [14:40]).

  "...pharmacists can deny that they even have buprenorphine and not fill it. So that becomes pretty problematic...there’s a lot of stigma against buprenorphine in the community."
  (Lesly-Marie Buer, 14:34)

6. Structural Violence, Resilience, and Mutual Aid

• “Broken Systems:” The book utilizes the concept of structural violence to show how systemic failings harm individuals ([16:03]).

• Resourcefulness: Families pooled resources (gardens, land, disability checks), traded childcare, and cared for each other. Heritage and attachment to the land provided a source of sustenance and solace ([16:53]).

  “...mutual aid has a pretty longstanding history in Appalachia. And I think the women I spoke to really showed that history.”
  (Lesly-Marie Buer, 17:11)

7. The Emerging Promise and Limits of Harm Reduction

• Harm Reduction Movement: Kentucky rapidly implemented syringe service programs in response to HIV outbreaks—positive but inconsistent depending on attitudes of health department staff ([22:36]).
• Gaps in Services: When Buer conducted research, harm reduction was non-existent; today, it is expanding with both benefits and some challenges ([24:19]).

8. Longitudinal Outcomes for Participants

• Divergent Paths: Those with family resources experienced better outcomes; those without fared worse, some ending up incarcerated. Buer emphasizes that structural factors weigh heavily against individual efforts ([24:52], [25:20]).

  “...some of the people who maybe we would consider have not been successful also worked really hard. And it’s not only about what the individual is doing, but it also is about what’s happening around them.”
  (Lesly-Marie Buer, 26:44)

9. Advocacy, Policy, and Action

• Why List Advocacy Groups? The book’s appendix lists organizations for readers who want to help; pseudonyms were used in the book to avoid harming overburdened staff and maintain participant confidentiality ([28:23]).

• Structural Change & Policy Recommendations: Buer advocates for:

  • Community acceptance of harm reduction programs
  • Reducing stigma
  • Redirecting funding from police to mental health and harm reduction
  • Ensuring these social services remain non-punitive ([34:46], [36:30], [37:30])

  “...before we start, you know, funding these other programs, we have to make sure that they are no longer criminalized, that they are trying to take a harm reduction approach and not just becoming pseudo police...”
  (Lesly-Marie Buer, 37:23)

10. Recent Positive Developments & Future Directions

• Legalization and Expansion: Harm reduction services legalized in both Kentucky and Tennessee.
• Community Shifts: Increasing openness to harm reduction, recognition that punitive models are failing ([38:38], [40:56]).
• Current Work: Buer now directs harm reduction research, focusing on destigmatization and expanding services, particularly for rural and marginalized communities ([41:04]).

Notable Quotes & Memorable Moments

• On Structural Violence and Individual Blame:

  “Our models of treatment in the US are...based on personal responsibility...[but] it’s not only about what the individual is doing, but...what’s happening around them.”
  (Lesly-Marie Buer, 26:49)

• On Harm Reduction as Social Justice:

  “Harm reduction for me is really a broader social justice movement...if you’re also not thinking about reproductive justice and racial justice, LGBTQ issues, then you’re not really taking a harm reduction approach.”
  (Lesly-Marie Buer, 30:40)

• On Reproductive Justice and Criminalization:

  “Women are having their children removed for doing what they should be doing...doctor prescribed buprenorphine...they lost custody...because they were doing what their doctor told them to do.”
  (Lesly-Marie Buer, 31:39)

• On Community Transformation:

  “...if you went into those communities five years ago and told people what you were doing, they would literally yell at you...over the past year, we’ve actually found many communities who are very willing to engage...”
  (Lesly-Marie Buer, 40:33)

Timestamps for Key Segments

| Timestamp | Topic | |-----------|-------------------------------------------------------------| | 01:26 | Lesly-Marie Buer introduces her background and research path | | 02:59 | Transition from dissertation to accessible book | | 04:50 | Fieldwork surprises: deep rurality and community dynamics | | 07:06 | Why focus on gender—unique challenges for women | | 11:16 | Types of treatment available and their punitive aspects | | 13:58 | Barriers and stigma in accessing medication-assisted treatment | | 16:03 | The concept of structural violence and women’s resilience | | 20:46 | Buer’s current work in harm reduction research | | 22:39 | The rollout and challenges of harm reduction in Kentucky | | 24:52 | Long-term outcomes for women studied | | 28:23 | Rationale for advocacy appendix and pseudonyms | | 30:40 | Harm reduction and reproductive justice integration | | 34:46 | Needed policy and structural changes | | 38:38 | Most significant shifts since book research | | 41:04 | Buer’s ongoing projects and future focus |

Conclusion & Takeaway

This episode offers an essential, accessible primer on the intersection of drug policy, gender, and rurality in Appalachia. Lesly-Marie Buer provides a deeply humane perspective, advocating for solutions rooted not in punishment, but in harm reduction, mutual aid, and structural change. Her research captures both the failures and the quiet strengths of rural Kentucky communities coping with the opioid crisis, especially the overlooked struggles and resourcefulness of women.

For listeners seeking resources or action steps, consult the advocacy appendix in Buer’s book and consider supporting local harm reduction and reproductive justice organizations—just as the author recommends.