A car is parked outside of the "Hard Times Tavern" in Fort Gay, West Virginia May 19, 2014. REUTERS/Robert Galbraith The current opioid epidemic has plagued the entire US. But it has hit one state harder than the rest — West Virginia.

West Virginia had the highest drug-overdose death rate in the US in 2014, according to a recent CDC report.

The state also has one of the highest prescription rates of opioids in the US, trailing only Alabama and Tennessee. And it ranks in the top 10 for the highest rate of prescriptions given out for high-dose opioids and extended-release opioids — both of which are targets for abusers.

The roots of the opioid crisis in West Virginia mirror the rest of the US. But there are a couple of crucial differences.

As in the rest of the US, opioid prescriptions started skyrocketing in the mid-1990s as pharmaceutical companies introduced powerful new painkillers such as MS Contin and Oxycontin to the public. And medical groups began calling pain the "fifth vital sign" that doctors should attend to, according to Dr. Ted Cicero, a professor of psychiatry at Washington University in St. Louis and an opioid-use researcher.

"There was a big push saying we had a big problem with the under-treatment of pain," Cicero told Business Insider. "Opioid prescriptions skyrocketed from the early '90s until about 2010."

The same phenomenon applied in West Virginia — but, in Appalachia, these liberal prescribing practices collided with two other factors:

1. A disproportionate number of jobs involving manual labor like coal mining, timbering, and manufacturing; and

2. High rates of joblessness.

Nick Browning enters a coal mine prior to the start of the afternoon shift at a coal mine near Gilbert, West Virginia May 22, 2014. REUTERS/Robert Galbraith

West Virginia has long been known as “coal country.” Mining, timbering, and manufacturing play a huge role in West Virginia’s economy. They are all jobs that require heavy manual labor and leave workers prone to injury.

Coal mining accounts for more than 18,000 jobs in West Virginia, nearly doubling the next state on the list, according to the US Department of Energy.

And though the state's coal mines have lost more than 7,000 jobs since 2011, the mining industry as a whole has continued to grow in the state, thanks to strong growth in the natural gas and oil industries. According to the US Bureau of Economic Analysis, mining accounted for 18% of the state’s overall GDP in 2014.

Mining operations proved to be flash points for opioid abuse when prescription practices liberalized, as workers tried to stave off injuries. John Temple, a professor at West Virginia University and the author of the 2015 book "American Pain," described the scene that arose at mining camps to the Charleston Gazette-Mail last year.

“In a mining camp, there aren't a lot of doctors,” he said. “That doctor is going to be more likely to opt for the quick fix and give people pills to fix their pain and get them back into the mine, rather than give them rest or therapy or those things that can actually cure pain."

Dr. Carl "Rolly" Sullivan, who has run the addiction program at West Virginia University Hospitals since 1985, has noted the link between opioid abuse and the West Virginian economy.

“West Virginia was ripe for the picking,” Sullivan told the Charleston Gazette-Mail. “We had a lot of blue-collar workers who were in farming and timbering and coal mining and things that were likely to produce injuries.”

Cicero found a similar link in his research.

“There are a lot of dangerous occupations" in Appalachia, he said. "People get prescribed opioids far more frequently" for the injuries associated with them.

A heroin addict smokes heroin in Lamu Thomson Reuters

Opioid abuse was further exacerbated by a declining economy and heavy job loss in the state over the last 20 years.

As of March 2016, West Virginia has the second-highest unemployment rate in the US, at 6.5%. It trails only Alaska. According to a Bureau of Labor Statistics report last August, West Virginia was the only state to experience a statistically significant decrease in employment over the previous year, losing 19,100 jobs from 2014 to 2015.

Though the coal-mining industry has been hit hard — jobs in the sector have decreased from 41,000 in 1983 to approximately 18,000 in 2016, according to the Mine Safety and Health Administration — other industries were struck as bad or worse. According to The Wall Street Journal, jobs in construction and manufacturing have fallen by 23% and 16%, respectively, since the recession.

With a population primed by prescriptions from work-related injuries, job loss was the gasoline on the fire.

Dr. Richard Vaglienti, the director of the Pain Management Center at West Virginia University and a co-chair of West Virginia’s Expert Pain Management panel, explained the problem.

“The parts of the state that were worst hit were the areas in the southern coal fields that had just collapsed. It became a problem there and it spread throughout the state until it was everywhere," Vaglienti told Business Insider. "If you look at the areas that are hardest hit, they are usually the areas that have nothing going on economically.”

According to Dr. Matt Cupp, a primary-care doctor in Elkins, West Virginia, substance abuse in the state becomes more common as joblessness increases.

“I grew up in this area. … When there is work, [West Virginians] can bear down. They put up a house in no time at all, “ Cupp told Business Insider. “But when times get slow … a lot of them will turn to alcohol, tobacco, illegal drugs and get high for recreation until the next job comes along.”

A 2009 report from the Appalachian Regional Commission put it even more bluntly.

“Low education levels, high rates of unemployment and job-related injuries are closely linked to abuse of alcohol, illicit drugs and prescription medications,” the report read, according to the Charleston Gazette-Mail.

The problem is that as opioid prescribing rose across the country, prescription opioids became the recreational drug of choice. "Pill mills" like the Sav-Rite Pharmacy in Kermit, West Virginia — which reportedly doled out 3.2 million dosage units of hydrocodone in 2006, according to Salon — thrived in the state, dispensing the drugs to anyone savvy enough to complain of pain to a doctor.

According to Sullivan, the composition of the patients at his WVU addiction program switched from 90% alcoholism in the 1990s to between 90% and 95% prescription painkiller addiction by 2002.



Not long after, the state began cracking down on the "pill mills," tightening prescription rules, and launching a prescription drug monitoring program, leading to the arrests of many physicians and pharmacists. But at that point, the epidemic was in full swing.

Joe Ciccarelli, a FBI supervisory senior resident agent in Charleston, told the Charleston Gazette in 2011 that even as law enforcement cracked down on "pill mills," drug dealers moved in and "flooded the market" with pills from outside the state.

When pill supplies did finally subside, prices on the pills rose, and drug dealers moved in with cheap heroin to capitalize on the large base of users already addicted to prescription drugs.

By 2010, the vast majority of Sullivan's patients in the addiction program were being treated for heroin addiction.

That's still the case in 2016.