Nobody could say precisely where or how it started, but the first hints of it cropped up in rural Maine, in the rust belt of western Pennsylvania and eastern Ohio, in the Appalachian areas of Virginia, West Virginia, and Kentucky. The abuse spread, quickly, like some airborne virus, from one small community to the next. The regions where the problem began often had large numbers of people who were out of work, or who worked hard, manual-labor jobs, people who were disabled or chronically ill, people who were suffering from pain. As it happened, these were also precisely the kinds of regions
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