In the summer of 1976, as cyclists rode through the city of Radford, they passed within a few blocks of the community hospital, established in the second world war, and a pillar of the community’s downtown. At the present time, cyclists along this route will see a new facility, built in the late 1990s, from route 76 just southeast of Radford, where Mud Pike Road parallels Interstate 81. This hospital is an example of how Radford, like other cities in predominantly rural parts of Virginia, has become a hub for medical care. The shift from a downtown hospital serving the immediate community to a regional health center on a highway interchange is reflective of broader patterns in small town America as well as the reconfiguration of health services into managed networks. This structural shift also provides a unique perspective to explore the impact on rural and small town America of a major health crisis of the twenty-first century: the costs of opioid addiction. In this case, underlying social, economic, and regional dynamics created vulnerabilities among marginal populations that brought long-term losses to individuals, families, and communities. Understanding southwest Virginia in the present is impossible without an appreciation for the causes and consequences of this devastating health crisis, in Appalachia specifically and more broadly in rural America. This episode is connected to the city of Radford, located just under 400 miles from Yorktown, the starting point for the westbound route, and about 150 miles from the Kentucky border, where eastbound riders enter Virginia.