In recent years, drug abuse has fueled a surge in overdose deaths and created an emergent public health crisis in the United States. According to estimates from the Centers for Disease Control and Prevention, fatal drug overdoses surged by over 60% between 2018 and 2022 — from about 68,600 to nearly 111,000. These overdose deaths were linked to a wide range of both illicit and prescription drugs, including cocaine, methamphetamine, benzodiazepines, and antidepressants. But the vast majority — over 75% — were caused by opioids.
Opioids are a class of drugs that can be derived from the opium poppy plant or created synthetically in a lab. In a medical context, prescription opioids can be an effective pain management tool. Opioids have a high potential for abuse, and even with medical supervision, they can be extremely dangerous. While thousands of fatal overdoses in the U.S. are linked to opioids like heroin and prescription painkillers each year, powerful synthetic opioids, such as fentanyl, account for the bulk of opioid overdose deaths.
Encouragingly, since peaking in 2022, overdose deaths have been declining in the United States. In 2024, the most recent year of complete data, there were about 81,000 fatal overdoses nationwide, a 25% decline from the previous year. Data for the early months of 2025 suggest the improvement accelerated that year. Over the 12 month period ending in April of last year, there were an estimated 76,500 overdose deaths, down about 25% from the same period one year earlier.
Still, the opioid epidemic remains a national health emergency. Despite recent improvements, there were tens of thousands more fatal overdoses in the last 12 months than there were a decade ago. Local overdose data shows that some American communities have been hit especially hard by the opioid crisis.
Using data from County Health Rankings and Roadmaps, a program of the University of Wisconsin Population Health Institute, 24/7 Wall St. identified the counties bearing the brunt of the national opioid epidemic. We reviewed fatal overdose data in over 2,000 U.S. counties and county equivalents and ranked them by the local overdose rate — or the number of deadly overdoses for every 100,000 people. Rates were calculated based on the number of fatal overdoses reported between 2020 and 2022. Supplemental data on additional health outcomes, household income, and population are also from CHR.
Among the 35 counties and independent cities on this list, fatal overdose rates range from 91.2 to 180.7 per 100,000 people. The places on this list are concentrated in the South, including 14 in West Virginia alone, and most are home to predominantly rural populations.
The nation-leading rates of overdose fatalities in these places are linked to other indicators of poor public health outcomes. For example, in nearly every city and county on this list, adults are more likely to report feeling lonely as well as frequent mental and physical distress than is typical across the state as a whole. Additionally, deaths linked to drug overdoses are premature and preventable, and in each community on this list, average life expectancy at birth is lower than it is statewide, often by five years or more.
These are the U.S. counties that have been hit hardest by the opioid epidemic.
Why It Matters
The number of fatal drug overdoses in the United States has more than doubled since 2015. Over the decade ending in 2024, more than 830,000 Americans died of a drug overdose — and nearly half of those deaths were reported in 2021 or later. In 2023, one of the peak years for overdose fatalities, drug overdoses ranked among the leading causes of death nationwide — trailing only heart disease, cancer, stroke, chronic respiratory conditions, and Alzheimer’s. While the overdose epidemic has impacted every corner of the United States, cutting across socioeconomic and demographic lines, certain parts of the country have been hit especially hard.
35. Gallatin County, Kentucky
- Drug overdose deaths, 2020-2022: 91.2 per 100,000 people (24 total)
- Avg. life expectancy at birth: 71.6 years (73.3 years in Kentucky)
- Share of adults reporting frequent mental distress: 19.1% (16.4% in Kentucky)
- Share of adults reporting frequent physical distress: 15.1% (14.3% in Kentucky)
- Share of adults who report feeling lonely: 34.7% (29.8% in Kentucky)
- Median household income: $66,789 ($61,099 in Kentucky)
- Local population: 8,792 (100% rural)
34. Roanoke City, Virginia
- Drug overdose deaths, 2020-2022: 91.3 per 100,000 people (270 total)
- Avg. life expectancy at birth: 70.2 years (77.6 years in Virginia)
- Share of adults reporting frequent mental distress: 20.4% (17.1% in Virginia)
- Share of adults reporting frequent physical distress: 14.8% (11.8% in Virginia)
- Share of adults who report feeling lonely: N/A
- Median household income: $51,782 ($89,864 in Virginia)
- Local population: 97,171 (100% urban)
33. Magoffin County, Kentucky
- Drug overdose deaths, 2020-2022: 91.8 per 100,000 people (32 total)
- Avg. life expectancy at birth: 68.1 years (73.3 years in Kentucky)
- Share of adults reporting frequent mental distress: 21.7% (16.4% in Kentucky)
- Share of adults reporting frequent physical distress: 20.2% (14.3% in Kentucky)
- Share of adults who report feeling lonely: 36.6% (29.8% in Kentucky)
- Median household income: $40,162 ($61,099 in Kentucky)
- Local population: 11,228 (100% rural)
32. Cheatham County, Tennessee
- Drug overdose deaths, 2020-2022: 92.4 per 100,000 people (115 total)
- Avg. life expectancy at birth: 72.3 years (73.5 years in Tennessee)
- Share of adults reporting frequent mental distress: 19.5% (21.3% in Tennessee)
- Share of adults reporting frequent physical distress: 12.8% (14.6% in Tennessee)
- Share of adults who report feeling lonely: 34.0% (34.3% in Tennessee)
- Median household income: $82,030 ($67,651 in Tennessee)
- Local population: 42,254 (100% rural)
31. Perry County, Kentucky
- Drug overdose deaths, 2020-2022: 94.1 per 100,000 people (76 total)
- Avg. life expectancy at birth: 65.7 years (73.3 years in Kentucky)
- Share of adults reporting frequent mental distress: 20.6% (16.4% in Kentucky)
- Share of adults reporting frequent physical distress: 17.1% (14.3% in Kentucky)
- Share of adults who report feeling lonely: 34.7% (29.8% in Kentucky)
- Median household income: $42,519 ($61,099 in Kentucky)
- Local population: 27,133 (72.6% rural, 27.4% urban)
30. Mason County, West Virginia
- Drug overdose deaths, 2020-2022: 94.1 per 100,000 people (72 total)
- Avg. life expectancy at birth: 71.1 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 23.9% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 16.8% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 34.3% (31.1% in West Virginia)
- Median household income: $52,054 ($55,875 in West Virginia)
- Local population: 24,765 (68.7% rural, 31.3% urban)
29. Boyd County, Kentucky
- Drug overdose deaths, 2020-2022: 95.4 per 100,000 people (136 total)
- Avg. life expectancy at birth: 71.6 years (73.3 years in Kentucky)
- Share of adults reporting frequent mental distress: 18.8% (16.4% in Kentucky)
- Share of adults reporting frequent physical distress: 14.6% (14.3% in Kentucky)
- Share of adults who report feeling lonely: 32.7% (29.8% in Kentucky)
- Median household income: $57,112 ($61,099 in Kentucky)
- Local population: 47,826 (23.8% rural, 76.2% urban)
28. Anderson County, Tennessee
- Drug overdose deaths, 2020-2022: 96.6 per 100,000 people (226 total)
- Avg. life expectancy at birth: 72.6 years (73.5 years in Tennessee)
- Share of adults reporting frequent mental distress: 19.3% (21.3% in Tennessee)
- Share of adults reporting frequent physical distress: 13.7% (14.6% in Tennessee)
- Share of adults who report feeling lonely: 37.3% (34.3% in Tennessee)
- Median household income: $61,009 ($67,651 in Tennessee)
- Local population: 80,234 (36.5% rural, 63.5% urban)
27. Lincoln County, West Virginia
- Drug overdose deaths, 2020-2022: 98.2 per 100,000 people (59 total)
- Avg. life expectancy at birth: 68.7 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 24.7% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 19.7% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 34.6% (31.1% in West Virginia)
- Median household income: $47,435 ($55,875 in West Virginia)
- Local population: 19,701 (100% rural)
26. Hopewell City, Virginia
- Drug overdose deaths, 2020-2022: 99.3 per 100,000 people (68 total)
- Avg. life expectancy at birth: 67.3 years (77.6 years in Virginia)
- Share of adults reporting frequent mental distress: 22.6% (17.1% in Virginia)
- Share of adults reporting frequent physical distress: 17.4% (11.8% in Virginia)
- Share of adults who report feeling lonely: N/A
- Median household income: $49,111 ($89,864 in Virginia)
- Local population: 22,752 (100% urban)
25. Fayette County, West Virginia
- Drug overdose deaths, 2020-2022: 99.6 per 100,000 people (121 total)
- Avg. life expectancy at birth: 69.8 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 24.5% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 18.4% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 34.6% (31.1% in West Virginia)
- Median household income: $49,739 ($55,875 in West Virginia)
- Local population: 39,072 (63.0% rural, 37.0% urban)
24. Wolfe County, Kentucky
- Drug overdose deaths, 2020-2022: 99.9 per 100,000 people (20 total)
- Avg. life expectancy at birth: 65.5 years (73.3 years in Kentucky)
- Share of adults reporting frequent mental distress: 24.1% (16.4% in Kentucky)
- Share of adults reporting frequent physical distress: 22.4% (14.3% in Kentucky)
- Share of adults who report feeling lonely: 36.9% (29.8% in Kentucky)
- Median household income: $40,949 ($61,099 in Kentucky)
- Local population: 6,282 (100% rural)
23. St. Louis City, Missouri
- Drug overdose deaths, 2020-2022: 101.8 per 100,000 people (893 total)
- Avg. life expectancy at birth: 71.5 years (75.2 years in Missouri)
- Share of adults reporting frequent mental distress: 18.5% (18.1% in Missouri)
- Share of adults reporting frequent physical distress: 14.5% (13.4% in Missouri)
- Share of adults who report feeling lonely: 36.5% (31.9% in Missouri)
- Median household income: $55,231 ($68,484 in Missouri)
- Local population: 281,754 (100% urban)
22. Kanawha County, West Virginia
- Drug overdose deaths, 2020-2022: 104.4 per 100,000 people (553 total)
- Avg. life expectancy at birth: 71.0 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 21.9% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 15.2% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 33.2% (31.1% in West Virginia)
- Median household income: $56,633 ($55,875 in West Virginia)
- Local population: 174,805 (29.4% rural, 70.6% urban)
21. Lee County, Kentucky
- Drug overdose deaths, 2020-2022: 104.6 per 100,000 people (23 total)
- Avg. life expectancy at birth: 68.3 years (73.3 years in Kentucky)
- Share of adults reporting frequent mental distress: 22.0% (16.4% in Kentucky)
- Share of adults reporting frequent physical distress: 20.6% (14.3% in Kentucky)
- Share of adults who report feeling lonely: 35.5% (29.8% in Kentucky)
- Median household income: $37,939 ($61,099 in Kentucky)
- Local population: 7,293 (100% rural)
20. Bath County, Kentucky
- Drug overdose deaths, 2020-2022: 105.0 per 100,000 people (40 total)
- Avg. life expectancy at birth: 68.8 years (73.3 years in Kentucky)
- Share of adults reporting frequent mental distress: 19.1% (16.4% in Kentucky)
- Share of adults reporting frequent physical distress: 14.9% (14.3% in Kentucky)
- Share of adults who report feeling lonely: 33.5% (29.8% in Kentucky)
- Median household income: $54,247 ($61,099 in Kentucky)
- Local population: 12,975 (100% rural)
19. Boone County, West Virginia
- Drug overdose deaths, 2020-2022: 108.9 per 100,000 people (69 total)
- Avg. life expectancy at birth: 68.9 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 23.9% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 17.9% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 34.7% (31.1% in West Virginia)
- Median household income: $48,034 ($55,875 in West Virginia)
- Local population: 20,576 (100% rural)
18. Mahnomen County, Minnesota
- Drug overdose deaths, 2020-2022: 111.0 per 100,000 people (18 total)
- Avg. life expectancy at birth: 68.5 years (79.3 years in Minnesota)
- Share of adults reporting frequent mental distress: 22.4% (15.6% in Minnesota)
- Share of adults reporting frequent physical distress: 17.2% (10.2% in Minnesota)
- Share of adults who report feeling lonely: 34.5% (31.0% in Minnesota)
- Median household income: $54,177 ($85,070 in Minnesota)
- Local population: 5,280 (100% rural)
17. Rio Arriba County, New Mexico
- Drug overdose deaths, 2020-2022: 111.2 per 100,000 people (132 total)
- Avg. life expectancy at birth: 69.3 years (74.4 years in New Mexico)
- Share of adults reporting frequent mental distress: 18.4% (16.7% in New Mexico)
- Share of adults reporting frequent physical distress: 16.4% (13.4% in New Mexico)
- Share of adults who report feeling lonely: 41.5% (36.3% in New Mexico)
- Median household income: $51,703 ($62,286 in New Mexico)
- Local population: 39,876 (56.4% rural, 43.6% urban)
16. Petersburg City, Virginia
- Drug overdose deaths, 2020-2022: 112.1 per 100,000 people (109 total)
- Avg. life expectancy at birth: 64.3 years (77.6 years in Virginia)
- Share of adults reporting frequent mental distress: 19.7% (17.1% in Virginia)
- Share of adults reporting frequent physical distress: 15.2% (11.8% in Virginia)
- Share of adults who report feeling lonely: N/A
- Median household income: $46,216 ($89,864 in Virginia)
- Local population: 33,309 (2.7% rural, 97.3% urban)
15. Summers County, West Virginia
- Drug overdose deaths, 2020-2022: 113.5 per 100,000 people (41 total)
- Avg. life expectancy at birth: 69.4 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 24.0% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 17.9% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 34.9% (31.1% in West Virginia)
- Median household income: $44,218 ($55,875 in West Virginia)
- Local population: 11,581 (100% rural)
14. Wayne County, West Virginia
- Drug overdose deaths, 2020-2022: 114.2 per 100,000 people (132 total)
- Avg. life expectancy at birth: 70.4 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 25.2% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 18.1% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 31.8% (31.1% in West Virginia)
- Median household income: $51,532 ($55,875 in West Virginia)
- Local population: 37,686 (59.8% rural, 40.2% urban)
13. Vinton County, Ohio
- Drug overdose deaths, 2020-2022: 115.1 per 100,000 people (44 total)
- Avg. life expectancy at birth: 67.6 years (75.2 years in Ohio)
- Share of adults reporting frequent mental distress: 24.0% (19.4% in Ohio)
- Share of adults reporting frequent physical distress: 17.3% (13.4% in Ohio)
- Share of adults who report feeling lonely: 34.9% (34.4% in Ohio)
- Median household income: $52,999 ($67,873 in Ohio)
- Local population: 12,474 (94.3% rural, 5.7% urban)
12. Knott County, Kentucky
- Drug overdose deaths, 2020-2022: 117.8 per 100,000 people (50 total)
- Avg. life expectancy at birth: 67.1 years (73.3 years in Kentucky)
- Share of adults reporting frequent mental distress: 22.1% (16.4% in Kentucky)
- Share of adults reporting frequent physical distress: 19.6% (14.3% in Kentucky)
- Share of adults who report feeling lonely: 35.4% (29.8% in Kentucky)
- Median household income: $42,345 ($61,099 in Kentucky)
- Local population: 13,659 (100% rural)
11. Mercer County, West Virginia
- Drug overdose deaths, 2020-2022: 118.1 per 100,000 people (208 total)
- Avg. life expectancy at birth: 68.7 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 23.0% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 15.6% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 32.8% (31.1% in West Virginia)
- Median household income: $47,084 ($55,875 in West Virginia)
- Local population: 58,057 (41.8% rural, 58.2% urban)
10. Mingo County, West Virginia
- Drug overdose deaths, 2020-2022: 119.7 per 100,000 people (82 total)
- Avg. life expectancy at birth: 65.8 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 25.4% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 19.7% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 37.9% (31.1% in West Virginia)
- Median household income: $38,358 ($55,875 in West Virginia)
- Local population: 22,023 (100% rural)
9. Wyoming County, West Virginia
- Drug overdose deaths, 2020-2022: 119.9 per 100,000 people (74 total)
- Avg. life expectancy at birth: 68.7 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 25.8% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 20.1% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 34.8% (31.1% in West Virginia)
- Median household income: $47,212 ($55,875 in West Virginia)
- Local population: 20,277 (100% rural)
8. Menominee County, Wisconsin
- Drug overdose deaths, 2020-2022: 122.8 per 100,000 people (16 total)
- Avg. life expectancy at birth: 63.0 years (77.8 years in Wisconsin)
- Share of adults reporting frequent mental distress: 22.2% (17.0% in Wisconsin)
- Share of adults reporting frequent physical distress: 17.5% (11.6% in Wisconsin)
- Share of adults who report feeling lonely: 37.1% (32.1% in Wisconsin)
- Median household income: $49,791 ($74,671 in Wisconsin)
- Local population: 4,226 (100% rural)
7. Estill County, Kentucky
- Drug overdose deaths, 2020-2022: 123.1 per 100,000 people (52 total)
- Avg. life expectancy at birth: 69.5 years (73.3 years in Kentucky)
- Share of adults reporting frequent mental distress: 20.8% (16.4% in Kentucky)
- Share of adults reporting frequent physical distress: 17.7% (14.3% in Kentucky)
- Share of adults who report feeling lonely: 35.3% (29.8% in Kentucky)
- Median household income: $45,129 ($61,099 in Kentucky)
- Local population: 13,936 (71.6% rural, 28.4% urban)
6. Scioto County, Ohio
- Drug overdose deaths, 2020-2022: 126.0 per 100,000 people (277 total)
- Avg. life expectancy at birth: 69.2 years (75.2 years in Ohio)
- Share of adults reporting frequent mental distress: 23.2% (19.4% in Ohio)
- Share of adults reporting frequent physical distress: 16.5% (13.4% in Ohio)
- Share of adults who report feeling lonely: 36.0% (34.4% in Ohio)
- Median household income: $52,447 ($67,873 in Ohio)
- Local population: 71,969 (55.3% rural, 44.7% urban)
5. Cabell County, West Virginia
- Drug overdose deaths, 2020-2022: 131.8 per 100,000 people (366 total)
- Avg. life expectancy at birth: 69.5 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 24.1% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 17.4% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 32.6% (31.1% in West Virginia)
- Median household income: $55,031 ($55,875 in West Virginia)
- Local population: 92,082 (22.0% rural, 78.0% urban)
4. Raleigh County, West Virginia
- Drug overdose deaths, 2020-2022: 138.0 per 100,000 people (303 total)
- Avg. life expectancy at birth: 69.5 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 22.3% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 17.4% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 32.8% (31.1% in West Virginia)
- Median household income: $53,456 ($55,875 in West Virginia)
- Local population: 72,356 (43.1% rural, 56.9% urban)
3. Baltimore City, Maryland
- Drug overdose deaths, 2020-2022: 144.1 per 100,000 people (2,496 total)
- Avg. life expectancy at birth: 70.6 years (77.8 years in Maryland)
- Share of adults reporting frequent mental distress: 19.8% (15.2% in Maryland)
- Share of adults reporting frequent physical distress: 13.3% (9.8% in Maryland)
- Share of adults who report feeling lonely: 38.0% (35.9% in Maryland)
- Median household income: $58,616 ($98,568 in Maryland)
- Local population: 565,239 (100% urban)
2. Logan County, West Virginia
- Drug overdose deaths, 2020-2022: 164.4 per 100,000 people (156 total)
- Avg. life expectancy at birth: 66.2 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 25.6% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 19.7% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 36.0% (31.1% in West Virginia)
- Median household income: $48,745 ($55,875 in West Virginia)
- Local population: 30,827 (72.9% rural, 27.1% urban)
1. McDowell County, West Virginia
- Drug overdose deaths, 2020-2022: 180.7 per 100,000 people (96 total)
- Avg. life expectancy at birth: 65.1 years (72.1 years in West Virginia)
- Share of adults reporting frequent mental distress: 26.0% (22.5% in West Virginia)
- Share of adults reporting frequent physical distress: 21.3% (16.6% in West Virginia)
- Share of adults who report feeling lonely: 35.0% (31.1% in West Virginia)
- Median household income: $35,161 ($55,875 in West Virginia)
- Local population: 17,439 (100% rural)
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