Young Americans are dying from despair. After the Great Recession, people aged between 25 and 44 started to overdose on opioids at an alarming pace. Overall, death rates for this age group rose an astounding 8% between 2010 and 2015.

Younger people in central Appalachia are not surprised by these statistics. Our friends and family members have been dying from these drugs for the past two decades. The region was the epicenter of the opioid epidemic that is now ravaging the entire country.

Q&A Why is there an opioid crisis in America? Show Hide Almost 100 people are dying every day across America from opioid overdoses – more than car crashes and shootings combined. The majority of these fatalities reveal widespread addiction to powerful prescription painkillers. The crisis unfolded in the mid-90s when the US pharmaceutical industry began marketing legal narcotics, particularly OxyContin, to treat everyday pain. This slow-release opioid was vigorously promoted to doctors and, amid lax regulation and slick sales tactics, people were assured it was safe. But the drug was akin to luxury morphine, doled out like super aspirin, and highly addictive. What resulted was a commercial triumph and a public health tragedy. Belated efforts to rein in distribution fueled a resurgence of heroin and the emergence of a deadly, black market version of the synthetic opioid fentanyl. The crisis is so deep because it affects all races, regions and incomes

In the beginning, doctors needed a way to treat coal miners here for their debilitating pain, so they could go back to work underground. The synthetic opiate OxyContin was new and heavily marketed as a solution. Soon afterwards OxyContin started to be used for other chronic pain conditions like arthritis, migraines and injuries from automobile accidents.

Stacked on to medical pain are the economic and social problems that people in the region face, primarily underemployment. Doctors prescribed opioids and Appalachians in poverty found relief. And in the exam rooms, doctors told their patients that a drug potent enough to relieve cancer pain did not create dependency. In reception areas of rural clinics across Appalachia, a television played the video I Got My Life Back, promoting OxyContin.

Many teenagers in the region in the late 1990s had a family member or a neighbor with a bottle of OxyContin. Not understanding how addictive it was, students in my high school bought or stole pills and started to pop them in between classes at school and at parties. In 1999 my “holler” saw its first overdose from the drug. Josie was a cheerleader with natural pale blonde hair who had picked out her wedding dress that day for fun with her cousin. That night her life was over.

A significant number of young people were already dependent on opioids by the time the overdoses began. Still others started to illegally take the pills despite the risks. Many switched to abusing heroin once officials cracked down on painkiller prescriptions 10 years later.

A nurse at the local hospital told me that heroin is so powerful that patients “wake up resentful that the hospital staff revived them from an overdose.” “They don’t want to die”, she said, but “to stay blanked out of this world.”

Many young people in rural Appalachia struggle with a profound loss of purpose, especially if they do not go to college. They want to live in rural Appalachia or cannot afford to leave but face very few job prospects. The girl with the highest SAT score in my graduating class works at a Wendy’s in town.

Her purpose is to support her extended family with her meager wages. But tight-knit families and towns have broken up as many rural Appalachians do move away for work. Life loses deeper meaning for younger people who stay behind without their moms or nieces or lifetime playmates. As opioids spread like a social contagion throughout the remaining community, a family member or friend who does not take painkillers can feel like an outcast.

Loneliness and hardship compound as rural Appalachians live geographically isolated without a car or the internet. Access to food is a persistent problem. Marriages fail. Young adults become depressed but don’t know to name it as such. My town does not have a mental health clinic. Faced with hopelessness and flooded with pills, people self-medicate.

Countless patients prescribed OxyContin did not “get their life back” either. In fact, the pills made their pain worse as their tolerance increased. The captain of a neighboring county’s basketball team suffered a back injury in high school, and 10 years later his pain was so severe that in a desperate moment he ate his morphine patches and overdosed.

Half of my schoolmates are dead, in jail or battling addiction. It is often repeated in the holler as a solemn warning that your school years are the best years of your life. They may also be the last years of your life for an increased number of all young Americans, not just young Appalachians, for the first time in a century.

Opioid addiction has spread to the cities and the suburbs. But addiction is a symptom for many young adults, not the root problem. The only group of 25 to 44 year olds that did not see their death rate go up was those with four-year college degrees.

It is critical that young Americans without college degrees also find employment that provides them with a decent income and a bit of the American dream. People without college degrees are 370% more likely to experience severe pain. But opioids and the medicalization of poverty cannot replace a job with a decent wage and benefits. Appalachians will tell you that jobs are the key.