The U.S. has experienced a massive surge in drug addiction, and consequently fatal overdoses, in recent years. In 1999, the National Institute on Drug Abuse reported an age-adjusted rate of 6.1 fatal overdoses per 100,000 Americans. By 2019, that figure had more than tripled to 21.6 fatal drug overdoses per 100,000 people.

While this problem has affected every part of the country, certain areas struggle with an outsized share of drug overdose deaths. There are dozens of counties and county equivalents in which drug overdose deaths are more than twice as common as they are nationwide. Each state has one place where the drug overdose problem stands out as especially severe.

To determine the county with the worst drug problem in every state, 24/7 Tempo reviewed the annual average number of drug-related deaths per 100,000 residents in all U.S. counties and county equivalents from 2015 to 2019, using data from the Centers for Disease Control and Prevention.

Addiction and drug use are complicated and multifaceted issues that touch Americans nationwide and at all socioeconomic levels. Still, the counties that have the worst drug problems tend to have certain characteristics in common, including relatively lower income, higher unemployment, and higher poverty. This is the poorest county in every state.

Rural areas like those in the Rust Belt and the Appalachian region have become the face of the opioid epidemic — but this was not always the case. Until recently, drug problems were largely seen as a problem plaguing cities. Only in 2015 did drug overdose deaths become more common in rural areas than in cities.

As Americans have looked for answers as to how the drug problem in the country has gotten so severe, much of the blame has been placed on large pharmaceutical companies — particularly Purdue Pharma. The company began selling the painkiller OxyContin in 1996. Since then, the company has paid over $10 billion to settle a litany of lawsuits that claimed Purdue deceived patients and doctors about the risks of becoming addicted to the drug when advertising it. These are America’s most hated companies.

Click here to see the counties with the worst drug problem in every state.

To determine the counties with the worst drug problem in every state, 24/7 Tempo reviewed the average number of drug-related deaths per 100,000 residents in all U.S. counties and county equivalents each year for the 2015 to 2019 period with data from the Centers for Disease Control and Prevention’s WONDER web application. The causes of drug-induced deaths include unintentional overdoses, suicide, homicide, and undetermined causes. Figures on poverty and population came from the U.S. Census Bureau’s American Community Survey and are five-year averages for the period of 2015 to 2019. All data is for the most recent period available.