In 2014, Anthony Bourdain’s CNN show, Parts Unknown, travelled to Massachusetts. He visited his old haunts from 1972, when he had spent a high school summer working in a Provincetown restaurant, the now-shuttered Flagship on the tip of Cape Cod. “This is where I started washing dishes …where I started having pretensions of culinary grandeur,” Bourdain said in a wistful voiceover. For the swarthy, rail-thin dishwash-er-turned-cook, Provincetown was a “wonderland” bursting with sexual freedom, drugs, music, and “a joy that only came from an absolute certainty that you were invincible.” Forty years later, he was visiting the old Lobster Pot restaurant, cameras in tow, to share Portuguese kale soup with the man who still ran the place. Bourdain enjoyed a lot of drugs in the summer of 1972. He had already acquired a “taste for chemicals,” as he put it. The menu included marijuana, Quaaludes, cocaine, LSD, psilocybin mushrooms, Seconal, Tuinal, speed, and codeine. When he moved to the Lower East Side of New York to cook profession-ally in 1980, the young chef, then 24, bought his first bag of heroin on the corner of Bowery and Rivington. Seven years later he managed to quit the drug cold turkey, but he spent several more years chasing crack cocaine. “I should have died in my twenties,” Bourdain told a journalist for Biography. By the time of his visit to Provincetown in 2014, a wave of painkillers had already washed over parts of Massachusetts and a new tide of heroin was rolling in. Bourdain wanted to see it for himself and traveled northwest to Greenfield, a gutted mill town that was a hub of opioid addiction. In a barebones meeting room, he joined a weekly recovery support group. Everyone sat in a circle sharing war stories, and when Bourdain’s turn came he searched for words to describe his attraction to heroin. “It’s like something was missing in me,” he said, “whether it was a self-image situation, whether it was a character flaw. There was some dark genie inside me that I very much hesitate to call a disease that led me to dope.” A dark genie: I liked the metaphor. I am a physician, yet I, too, am hesitant to call addiction a disease. While I am not the only skeptic in my field, I am certainly outnumbered by doctors, addiction professionals, treatment advocates, and researchers who do consider addiction a disease. Some go an extra step, calling addiction a brain disease. In my view, that is a step too far, confining addiction to the biological realm when we know how sprawling a phenomenon it truly is. I was reminded of the shortcomings of medicalizing addiction soon after I arrived in Ironton, Ohio where, as the only psychiatrist in town, I was asked whether I thought addiction was “really a disease. 
In September 2018, I set out for Rust Belt Appalachia from Washington, D.C., where I am a scholar at a think tank and was, at the time, a part-time psychiatrist at a local methadone clinic. My plan was to spend a year as a doctor-within-borders in Ironton, Ohio, a town of almost eleven thousand people in an area hit hard by the opioid crisis. Ironton sits at the southernmost tip of the state, where the Ohio River forks to create a tri-state hub that includes Ashland, Kentucky and Huntington, West Virginia. Huntington drew national attention in August 2016, when twenty-eight people overdosed on opioids within four hours, two of them fatally. I landed in Ironton, the seat of Lawrence County, by luck. For some time I had hoped to work in a medically underserved area in Appalachia. Although I felt I had a grasp on urban opioid addiction from my many years of work in methadone clinics in Washington DC, I was less informed about the rural areas. So I asked a colleague with extensive Ohio connections to present my offer of clinical assistance to local leaders. The first taker was the director of the Ironton-Lawrence County Community Action Organization, or CAO, an agency whose roots extend to President Johnson’s War on Poverty. The CAO operated several health clinics. Ironton has a glorious past. Every grandparent in town remembers hearing first-person accounts of a period, stretching from before the Civil War to the early turn of the century, when Ironton was one of the nation’s largest producers of pig iron. “For more than a century, the sun over Ironton warred for its place in the sky with ashy charcoal smoke,” according to the Ironton Tribune. “In its heyday in the mid-nineteenth century there were forty-five [iron] furnaces belching out heat, filth, and prosperity for Lawrence County.” After World War II, Ironton was a thriving producer of iron castings, molds used mainly by automakers. Other plants pumped out aluminum, chemicals, and fertilizer. The river front was a forest of smokestacks. High school graduates were assured good paying if labor-intensive jobs, and most mothers stayed home with the kids. The middle class was vibrant. But then the economy began to realign. Two major Ironton employers, Allied Signal and Alpha Portland Cement, closed facilities in the late 1960s, beginning a wave of lay-offs and plant closings. The 1970s were a time of oil shocks emanating from turmoil in the Middle East. Inflation was high and Japanese and German car makers waged fierce competition with American manufacturers. As more Ironton companies downsized and then disappeared, the pool of living wage jobs contracted, and skilled workers moved out to seek work elsewhere. At the same time, the social fabric began to unravel. Domestic order broke down, welfare and disability rolls grew, substance use escalated. Most high school kids with a shot at a future pursued it elsewhere, and the place was left with a population dominated by older folks and younger addicts. Ironton continues to struggle. Drug use, now virtually normalized, is in its third, sometimes fourth, generation. Almost everyone is at least one degree of separation away from someone who has overdosed. Although precise
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