Inside Look:

The States Hit Hardest by the Opioid Epidemic

In the early 2000s, Appalachia was ground zero for the opioid epidemic. Today, states from New England to New Mexico are among those most impacted by these addictive painkillers. Six states have declared public health emergencies, and communities across the country are scrambling to develop strategies to prevent people from dying from overdoses.


The public health crisis of opioid addiction and abuse has continued to worsen since the Centers for Disease Control and Prevention announced that prescription painkiller overdoses reached epidemic levels in 2011.

Few states have made progress against the rising death tolls.

“When areas see a reduction of prescription opioid use, they’re also seeing increases in heroin and fentanyl.”

Janice Pringle, Ph.D., University of Pittsburgh School of Pharmacy

“It’s continuing to rise in a way that we hadn’t expected,” Dr. Janice Pringle, a professor at the University of Pittsburgh School of Pharmacy, told “It’s starting to have a drag on resources in emergency departments, emergency medical services, police, coroners, medical examiners and substance use disorder treatment providers.”

Nineteen states experienced significant increases in overdose death rates between 2014 and 2015, according to the CDC’s most recent data. California, Ohio, Pennsylvania, Florida and New York had the most overdose deaths in 2015. West Virginia, New Hampshire, Kentucky, Rhode Island and New Mexico had some of the highest drug death rates in the nation that year.

Percent Change in Drug Overdose Deaths Rates by State, 2014 – 2015

Centers for Disease Control and Prevention

The rise in overdoses is fueled by prescription opioids, such as oxycodone and hydrocodone, and illicit opioids, such as heroin and black-market fentanyl.

Some areas of the country have reduced prescription drug abuse by educating prescribers and consumers, but increases in heroin and fentanyl use have overshadowed that progress.

“The prescription opioids are not the sole underlying cause of this,” Pringle said. “They exacerbated the issue. When areas see a reduction of prescription opioid use, they’re also seeing increases in heroin and fentanyl.”

In recent years, a movement to treat pain was blamed as the underlying cause of the opioid epidemic. In Rural America, economic recession and limited social mobility were thought to have contributed to the crisis.

Close up of author Sam Quinones

Sam Quinones, author of “Dreamland: The True Tale of America’s Opiate Epidemic”

“It did start in Appalachia, but the places that it’s now affecting are Salt Lake City, Indianapolis and Charlotte, North Carolina,” Sam Quinones, author of “Dreamland: The True Tale of America’s Opiate Epidemic,” told “A lot of these places are doing very well economically, so I don’t think economics fully explains it.”

Geography doesn’t explain it either.

A New York Times analysis of preliminary numbers concluded that Pennsylvania, Ohio, Maine and Maryland were among the states with the highest increases in overdose deaths in 2016. But Florida was also in the top five, and western states such as Utah and New Mexico have ranked in the top 10 in highest drug death rates for years.

The one common factor across the country seems to be isolation. In his book, Quinones wrote that heroin thrives in isolation. Addiction experts point to isolation as a primary cause of relapse. People in recovery say loneliness and boredom fed their addiction.

Across the country, more Americans seem to be disconnecting from society and living in loneliness and despair.

River in Appalachia

Appalachia: Ground Zero for the Opioid Epidemic

When the opioid epidemic began in the early 2000s, small towns in Appalachia were among the first to experience widespread addiction. West Virginia was the first state to file a lawsuit against Purdue Pharma, the maker of OxyContin, for misrepresenting the safety of its painkiller. Just to the west, Kentucky was one of the last states to settle a lawsuit with Purdue.

More than 15 years after the first lawsuit, West Virginia had the highest overdose death rate in the country, and Kentucky had the fourth highest rate. To the north, Ohio had the third highest death rate from drug overdoses.

“It’s a grim reality that all too many Ohioans feel too keenly,” Marcie Seidel, executive director of the Prevention Action Alliance, told in a statement. “Preventing substance misuse, treating those who have become addicted and supporting those living in recovery so they can continue to live in recovery are among the pressing public health issues in our state.”

In 2016, the region made national headlines after several overdose outbreaks:

Downtown Cincinnati, OH

174 People Overdosed in Cincinnati during a six-day period.

Downtown Louisville, KY

31 People Overdosed in Louisville during a 24-hour period.

Downtown Clevland, OH

52 People Died in Cleveland from overdoses in a single month.

The availability of fentanyl and its derivatives fluorofentanyl and carfentanil — an elephant tranquilizer — have been involved in the majority of overdose outbreaks. Many dealers unknowingly sell tainted heroin to others. In April 2017, an Ohio man traveled to Huntington, West Virginia, to sell heroin that he didn’t know was laced with fentanyl and carfentanil. At least 26 people overdosed in a matter of hours.

But the availability of heroin and fentanyl isn’t the main reason people are turning to drugs. Cory Murphy, a University of Cincinnati graduate who is in recovery from opioid addiction, told that people in Cincinnati were turning to drugs for the same reasons that people in his hometown of Butler, Pennsylvania, were using heroin.

“A lot of people in poverty feel defeated,” Murphy said. “They feel like they have no purpose in life, and they’re not wrong. They think, ‘what can I do?’ Well, here’s a drug that makes me happy.”

Before enrolling at Cincinnati, Murphy worked at a ministry for people trying to recover from addiction in Covington, Kentucky. He said people in northern Kentucky would drive across the bridge to Cincinnati to buy drugs, just as he used to drive to Pittsburgh to buy heroin as a teen.

Roberto Clemente Bridge in Pittsburgh, PA

Pennsylvania: A Desperate Situation Getting Worse

In 2015, Pennsylvania had the sixth-highest drug-related death rate and ranked third for drug overdose deaths in the United States. The situation worsened in 2016, according to new numbers recently released by the Drug Enforcement Administration.

An estimated 4,642 people died from drug overdoses in Pennsylvania in 2016, more than the total of any state in 2015.

Dr. Pringle and her team at Pittsburgh’s Program Evaluation and Research Unit have created a clearinghouse of information that community coalitions can use to combat the epidemic. OverdoseFreePA provides training programs and technical assistance to community groups striving to prevent opioid abuse in cities and towns across the state.

She said some good has come from the destruction. People who don’t normally work together have collaborated on a variety of unique efforts. But the problems aren’t easy to solve, and they require multiple approaches.

“This is a cultural issue,” Pringle said. “We delude ourselves if we think that by reducing prescribing of opioids that it’s going to go away. People for some reason have a tremendous need for drugs.”

Cory Murphy in his car

Cory Murphy in Butler, Pennsylvania, about one month after attending rehab for the first time in 2004.

Murphy knew what it was like to think he needed drugs. He grew up in a town of 13,000 people in rural Pennsylvania during the early 2000s. Murphy’s life changed when he received morphine after shoulder surgery. The opioid gave him a buzz that he enjoyed, and all of the cool kids at his high school were popping pills or shooting heroin, he said.

“It’s small-town culture,” Murphy said. “People feel like they aren’t really relevant in the world. They try to find an identity. Kids don’t have exposure to the real world, so they go off what they hear in hip hop music or see on TV. And people get bored. There’s nothing to do.”

After the surgery, Murphy asked friends whom he smoked marijuana with if they had opioids. The drugs were easy to find at his high school, which he says was nicknamed “Heroin High.”

He didn’t know much about the dangers of opioids. The few presentations from police officers at his school made the drugs sound more appealing than dangerous. Kids with parents who openly smoked marijuana decided heroin couldn’t be that bad.

“There was no one to guide me and say, ‘Hey, you’ve made a big mistake, but I’m going to help you not ruin the rest of your life.’”

Cory Murphy, in recovery from opioid addiction

Murphy first started misusing opioids to feel the euphoria he had felt in the hospital. But he soon realized the drugs relieved the tension and stress he felt from being bullied in school. The emotional escape fueled his desire to keep using. He eventually got caught, and, because his school had a zero-tolerance policy, he was expelled.

“I lost everyone I’d ever known, who I went from kindergarten through 11th grade with,” Murphy said. “They didn’t offer counseling or rehab. There was no one to guide me and say, ‘Hey, you’ve made a big mistake, but I’m going to help you not ruin the rest of your life.’ At the time, I thought I had no chance of going to college. I thought the only thing I could do was work fast food and get high. That was going to be the rest of my life.”

Murphy went on to attend multiple rehabs before entering long-term recovery. He helped others in recovery in Kentucky before enrolling at the University of Cincinnati. In December 2014, with 10 years of sobriety under his belt, Murphy graduated from college.

An estimated 4,642 people died from drug overdose in Pennsylvania in 2016. dead body at the morgue

Source: Drug Enforcement Administration

“What this country needs is a culture change,” Murphy said. He believes high school should be about getting people into the workforce. But his small-town school was more focused on socializing, proms and sports, he said. As someone who wasn’t popular, he felt he had no purpose in life.

“Some states, like Ohio or West Virginia, are in the trafficking lanes where the drugs come in, so there’s availability,” Pringle said. “There’s also socioeconomic depression and feeling like you don’t have a way to find a future. We don’t look at people as being human beings. We look at them as objects or being a trouble on our lives. That creates a culture of people not knowing where they belong.”

University of New Mexico

New Mexico: Where Progress Is Met with Cautious Optimism

For nearly 15 years, New Mexico was among the country’s leaders in overdose death rates. The impact of opioid painkillers forced the state to become one of the first to mandate participation in a prescription drug monitoring program. The program keeps track of how many prescriptions doctors write for controlled substances and how many prescriptions individual patients receive.

The program helped reduce the number of opioid deaths in 2012 and 2013 before heroin caused an increase in 2014. The small successes have helped the state’s drug death rate fall out of the top five.

“Our ranking has improved a little bit with the worsening of the situation in the northeast with fentanyl, which we’ve been relatively spared from,” Dr. Bill Wiese, co-chair of the Bernalillo County Opioid Accountability Initiative, told “But our averages have consistently been twice the national average for the past 15 years, and Bernalillo County is above average for the state.”

Dr. Bill Wiese, co-chair of the Bernalillo County Opioid Accountability Initiative

Dr. Bill Wiese, co-chair of the Bernalillo County Opioid Accountability Initiative

Wiese retired from his medical career at the University of New Mexico School of Medicine in the late 1990s, when primary care physicians weren’t trained to screen for substance abuse. He went on to run the public health division for the state’s department of health.

In 2010, Wiese worked on opioid policy for a state task force charged with developing recommendations to reduce opioid use and addiction.

“Those recommendations were developed around the four pillars: prevention, harm reduction, treatment and criminal justice,” Wiese said. “We used that format for our [local] accountability initiative in 2013. We developed task forces in each of those four areas.”

The Bernalillo County Opioid Accountability Initiative has helped coordinate hundreds of people and dozens of organizations in the Albuquerque area since its first major meeting in 2013. The group helped create the statewide drug monitoring program, and it spurred efforts to develop childhood intervention programs and naloxone distribution sites.

“This progress can blow away in a flash.”

Dr. Bill Wiese, co-chair of the Bernalillo County Opioid Accountability Initiative

The initiative also launched efforts to increase methadone access in the county’s jail and to provide naloxone to those at risk for relapse upon their release.

“We’ve been plateaued in terms of prescription opioid deaths for the past five years or so,” Wiese said. “Heroin has gone up. I think some of the things that we’re doing are having an effect. We aren’t seeing any reversals in the data.”

He’s cautiously optimistic about the limited progress the state and county have had. New Mexico is one of the few states that have made any type of progress against opioid abuse.

“This (progress) can blow away in a flash,” Wiese said. “The southwest has been spared from the white heroin with its adulterants and the huge problems that they’re having in the northeast.”

Black tar heroin is the most commonly available form of heroin in New Mexico. It’s easy for drug dealers to mix fentanyl, which is white, and other chemicals in the white heroin that is commonly available in Appalachia and other parts of the country. It’s difficult to conceal those drugs in black tar heroin. Wiese knows that if white heroin becomes available in New Mexico, the numbers can worsen.

For now, any type of progress in a fight that has been drastically one-sided and misunderstood is reassuring.

“The national publicity has greatly escalated,” Wiese said. “This is now front and center of political policy at the national level. None of that existed three years ago. But basic stigma is still out there, and it’s still a major, major problem.”

South Florida beach

Florida: Why Reducing Opioid Prescribing Isn’t Enough

No other state in the country had a pill mill problem that compared to the Sunshine State’s. More than 1,500 pain clinics opened in Florida between 2003 and 2009, and the state became a hotbed for prescription drug trafficking.

A crackdown in 2010 contributed to lower rates of drug overdose deaths in the state from 2010 to 2013, but the death rate began growing again in 2014 and 2015. The New York Times reported that Florida experienced one of the biggest death rate increases between 2015 and 2016, but official data isn’t available.

“No one cares what’s in the bag. Dealers don’t care. They’re selling death.”

Cory Murphy, in recovery from opioid addiction

In an email, Florida’s Chief Medical Examiner Stephen Nelson told that data for the second half of 2016 was not available. However, an interim report from the Florida Medical Examiners Commission indicated that drug-related deaths for the first half of 2016 increased by 15 percent as compared with the first half of 2015.

Deaths caused by heroin increased by 25 percent during that time frame, and deaths caused by fentanyl grew by 140 percent.

“Consistently for the last year or so, we respond two or three times a day to some type of drug overdose,” Orange County Sheriff Jerry Demings said at a 2017 opioid workshop in Orlando. “In the first three months of this year, we had 23 people who died, compared to 26 in 2016.”

Those numbers may be misleading. Increased access to naloxone may have reduced the number of people dying from overdoses. First responders in Orlando and Orange County began carrying the overdose reversal drug in 2015 and 2016. But the overdose rates are still climbing.

“In 2017, during the first three months, we have responded to 160 heroin overdose cases compared to 69 during the same period of time in 2016,” Demings said. “We’re up 132 percent in 2017 compared to 2016. When we look at the number of individuals who have died as a result of a heroin overdose, which is sometimes heroin and fentanyl, in 2017 we’ve had a 113 percent increase in the number of heroin-related deaths.”

“We respond two or three times a day to some type of drug overdose.”

Orange County Sheriff Jerry Demings

The May workshop at which Demings spoke was held one day before Florida Governor Rick Scott declared the opioid epidemic a public health emergency in the state. Florida became the fifth state to declare such an emergency. Arizona became the sixth state in June. The declaration makes states eligible for federal funds to pay for increased prevention, treatment and recovery efforts.

Several counties in Florida have created innovative programs to combat the drug epidemic:

At the May opioid workshop, Orange County Mayor Teresa Jacobs said county police officers had saved 80 lives with naloxone since they began carrying the drug in 2016. Officers in other counties across the state have reported similar successes.

“I believe the key to winning the fight against such a deadly and addictive drug is an effective campaign of awareness and prevention,” Jacobs said. “Through awareness and education, we’ve got to get ahead of this epidemic.”

map of the united states

More than Economics or Geography

From coast to coast, states with few similarities are in crisis. New Mexico, West Virginia and Massachusetts had death rates well above the national average in 2015. But their neighboring states — Texas, Virginia and New York — had overdose rates below the national average.

While he was writing Dreamland, Sam Quinones said he understood how the problem developed in Portsmouth, Ohio. He didn’t understand why it was devastating Charlotte, North Carolina.

Cory Murphy presenting at Ohio State University

Cory Murphy representing the University of Cincinnati’s International Business Club at a summit at Ohio State University in 2013.

“What is the similarity between Utah, New Hampshire and West Virginia?” Quinones asked. “I’m not sure economics explains it. They’re very different parts of the country, and yet they all have this problem in very serious degrees. I think every state has a different story while every state also shares the same story.”

In his book, he wrote that communal ties became a part of the country’s past. Helicopter parents emerged, and children stopped spending time outside interacting with the world.

“Whether in poverty or wealth, we are horribly isolated from each other,” Quinones told “It’s true in suburbia. It’s true in rural America. It’s true in wealthy areas and Rust Belt areas. People are isolated from each other in ways that are debilitating.

“We began to believe that free trade and economic liberalization were good. They are good, but we neglected to stop and say, there will be losers, too. We need to do something to help people and towns that lose out in this process.”

The communities that lost are littered across rural America, but they’re also found in inner cities overcome with poverty.

“A lot of these places are doing very well economically, so I don’t think economics fully explains it.”

Sam Quinones, author of “Dreamland: The True Tale of America’s Opiate Epidemic”

Murphy used to drive from Butler to Pittsburgh’s inner city. He had one thing in common with the people who would sell him drugs on the street: he believed drugs were the only thing good in his life. But that was his only connection to those people.

Even though they had similar life circumstances, there was no bond between them.

“No one cares what’s in the bag,” Murphy said. “The addict doesn’t care what’s in there as long they get the experience they’re paying for. The runners keep half the profit or something, so they don’t care. And dealers don’t care. They’re selling death.”

The lack of empathy and compassion for one another has made the opioid epidemic increasingly difficult to fight. As sheriffs in some communities offer naloxone and aid to people who overdose, others demonize people with addiction.

In July, Sheriff Rick Jones of Butler County Ohio, which neighbors Cincinnati’s Hamilton County, told The Enquirer that his deputies would not carry Narcan because he worried about his officer’s safety. People who are revived by Narcan are often confused and can be hostile.

In Orlando, Sheriff Demings has humanized people with substance use disorders. He said his officers aren’t interested in charging people who overdose.

Dr. Janice Pringle of the University of Pittsburgh

Dr. Janice Pringle, director of the Program Evaluation and Research Unit at the University of Pittsburgh

“These are human beings, loved ones,” Demings said.

The lack of awareness that addiction is a disease prevents many people from caring. It prevents elected officials from acting until a community has become so devastated that their hand is forced. And it prevents those who need help from getting the care they need.

“If we really wanted to spend the money to treat this problem, we could treat it,” Pringle said. “Treatment for a substance use disorder is actually more effective than treatment for hypertension or diabetes. Patients are more compliant than patients for hypertension or diabetes.”

But insurance regulations prevent people who require months of care from getting more than a few weeks, she said.

“Like a tea bag, we dip their toes in and pull them out again,” Pringle said. “And we ask why it isn’t working.”

Across the country, millions of people from different backgrounds and life circumstances feel driven to use opioids in isolation. Ironically, the best solutions seem to emerge from coming together. As coalitions and task forces form, and people from diverse backgrounds begin connecting, innovative solutions are being created to help those who feel like no one cares.

Trey Dyer contributed to this report.

Medical Disclaimer: aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.

Chris Elkins, MA
Senior Content Writer,
Chris Elkins worked as a journalist for three years and was published by multiple newspapers and online publications. Since 2015, he’s written about health-related topics, interviewed addiction experts and authored stories of recovery. Chris has a master’s degree in strategic communication and a graduate certificate in health communication.

Last updated on: November 16, 2022

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