On a Monday night in the town next to mine, about 100 people—a big turnout for Greene County, whose population is only 47,000—crowded into a movie theater to watch a documentary called Smacked! It’s about opioid addiction in rural areas, focusing in particular on two counties west of here.

Most of the attendees, it was clear from the discussion after the film, knew someone—often a family member—who was addicted or who had died of an overdose. They were angry, bewildered, and at a loss as to what to do. When a mother who had featured in the film said during the discussion that she blamed herself for her son’s overdose death, I felt the sense of shared heartbreak throughout the hall.

One former addict, offering his thoughts on how to help people kick their habit, said, “We have to just love each other.” But somehow, that didn’t seem like an adequate solution.

The spotlight has moved on from opioid addiction in the last couple of years as the national death rate has started to come down, in parallel with more addiction programs and tighter restrictions on opioid prescriptions. But where I live, and in a lot of other rural areas, things may have stopped getting worse—but they aren’t getting noticeably better. Despite growing attention to the problem, Greene County has one of the highest per capita death rates from overdoses in the state.

Moreover, the outbreak of the coronavirus has led to a spike that experts attribute to factors including increased stress and the cancellation of face-to-face addiction support group meetings. Over the last couple of months, there have been 25 overdoses and three deaths in the county, compared with 10 overdoses and two deaths in the same period last year, according to Greener Pathways, a local addiction assistance organization. (At present the death toll in the county from Covid-19 is 18.)

And grim as the figures are, they don’t represent the full extent of the problem. Narcan—the most common brand of the medication naloxone, which reverses the effects of the opioid—is so widely available these days that many overdoses (including from heroin, an increasingly popular opioid that is cheaper and easier to obtain than pills) are never reported.

There doesn’t seem to be any single answer to why rural counties like mine are hurting so badly. People working in the field cite reasons ranging from the inadequacy of treatment to the isolation of rural life. “There’s nothing else to do” for many young people who stay in the area, says Aidan O’Connor, a friend of mine who works as a trained paramedic. “It’s also an area of high binge drinking and high suicide rates.” And even if someone wants to seek treatment in one of the few locations where it’s offered, he says, “How do you get the gas money to go there?”

One big reason for the opioid problems now is the fact that for many years, rural residents were given opioid prescriptions at nearly double the rate of patients in large urban areas, only partially explainable by the presence of more older people with chronic pain. More than 18 million prescription pain pills were distributed in Greene County between 2006 and 2014—enough to provide over 40 pills a year for every resident.

I got more than my share: When I had a bad case of shingles a few years ago, a doctor at our nearest hospital gave me a prescription for 120 Oxycontin pills but provided no warning about their addictive potential. Fortunately, I had the good sense to be nervous and took only a dozen.

As for why rural residents don’t seek help for addiction, the most plausible explanation seems to me to be the fear of social shaming. In an area where everyone knows everyone, and everyone is expected to stand on their own two feet, drug use is often perceived as a sign of weak character. “The stigma is a really big thing,” says Danielle Hotaling, who describes herself as having abused both alcohol and drugs as a teenager. Hotaling, who lives in my village and is now the coordinator of the Columbia-Greene Addiction Coalition, says people view drug use as “a moral issue.” She adds, “Many are not yet seeing it for what it is: It’s a disease.” Katie Oldakowski, who works for a local mental health organization, says the lack of sympathy extends even to substance abusers who die of overdoses. “They call it ‘thinning the herd,’” she says.

I haven’t heard that phrase myself, but I’ve heard similarly dismissive ones such as “frequent flyers,” used to describe addicts who regularly overdose and then are brought back by Narcan. Explaining why this is so common, Aidan O’Connor says that addicts are in such mental or physical distress that they aren’t thinking rationally. “The drugs take away the pain,” he says. “If you give them Narcan you’re taking away the euphoria or bringing back the pain.”

Then what’s the solution? I was surprised during the discussion after the movie to hear one former addict say that what had prompted him to seek help was the fear of prison or death. That certainly accords with what I’ve heard from “lock ’em up” law enforcement officials. But even the recently elected county sheriff, who also spoke, said he favors more treatment rather than more jail time.

“Scare tactics work for some people,” Oldakowski says, but everyone has to find their own path out.

Looking at the broader picture, says O’Connor, who served a term as our town’s representative on the county legislature, elected officials need to come up with ways to improve schools, housing, and the economy. Rural America as a whole needs fixing, he says. “We’ve taken care of the health emergency; we’ve stopped the numbers growing with needle exchanges and other programs,” he says. “But we still have the same problems we did before.”