A record number of people died of a drug overdose in the US last year, according to government estimates.
The death toll of 93,000 is a big increase from the 72,000 estimate in the previous year, and it means there were more than 250 deaths each day, roughly 11 every hour.
Only two states – New Hampshire and South Dakota – did not see an increase in drug overdose deaths.
Kentucky saw a 54% increase to more than 2,100 and Vermont was up 58% – from 118 to 186, with large increases also seen in South Carolina, West Virginia, and California.
There is no evidence that more Americans started using drugs last year but the deaths were more likely to be among those who were already struggling with their addiction, according to Shannon Monnat, an associate professor of sociology at Syracuse University.
Prof Monnat, who researches geographic patterns in overdoses, said some addicts also told her that, when benefits were extended and evictions were paused as part of government pandemic measures, they had more money to feed their addiction.
Lockdowns and other pandemic-related restrictions left addicts isolated and made it more difficult for them to get treatment.
Needle exchange programmes, opioid substitution therapy, safe injection sites, support groups, and therapy sessions were all curtailed by social distancing and stay-at-home orders.
Jordan McGlashen died after overdosing on heroin and fentanyl in his Michigan apartment in May last year, a day before his 39th birthday.
The musician had seen his father die of cancer a few months earlier and had also lost his job in the early days of the pandemic.
His brother Collin said: “He was alone, and suffering emotionally and felt like he had to use again.”
“Someone can be doing really well for so long and then, in a flash, deteriorate.
“It was really difficult for me to think about the way in which Jordan died.”
Decades ago, overdoses were driven by prescription painkillers but they were overtaken by heroin, with around 7,200 deaths in 1970.
By 1988, crack cocaine was the drug of choice and there were about 9,000 overdose deaths.
Then fentanyl took over and it is thought to have been involved in more than 60% of overdose deaths last year, with opioids overall blamed for 74.7%.
Fentanyl, which is 80-100 times stronger than morphine, was made to treat pain from illnesses such as cancer but it is now mixed with other drugs and sold illicitly.
It is too soon for national figures covering 2021 but state data so far indicates that fentanyl is continuing to push up the number of drug overdose deaths.
Rhode Island reported 34 in January and 37 in February – the most for those months in at least five years.
Prof Monnat said: “What’s really driving the surge in overdoses is this increasingly poisoned drug supply.
“Nearly all of this increase is fentanyl contamination in some way. Heroin is contaminated. Cocaine is contaminated. Methamphetamine is contaminated.”