The triplicate paper, in essence, makes it look like the opioid epidemic was mostly the fault of Big Pharma’s marketing, not the result of an economic shock. But David Powell, a senior economist at Rand and an author of the triplicate paper, thinks both could be true. To get the worst drug overdose epidemic in U.S. history, he says, “you need a huge rise in opioid access, in a way that misuse is easy, but you also need demand to misuse the product.”

The next step will be for researchers to see how the marketing of opioids interacted with economic conditions to increase the likelihood that a given place would succumb to addiction. In the meantime, researchers working on the ground say opioid addiction looks like the result of a perfect storm of poverty, trauma, availability, and pain.

When Silva, the Bucknell sociologist, asked her subjects about their painkiller addictions, they would often link their problems back to the decline of coal. When the coal jobs went away, they said, families fell apart. Some people started drinking heavily and abusing their children—who then went on to be traumatized themselves and sought the relief of OxyContin. Some grew bored and aimless without a job, and they started abusing drugs to fill the time or to ease their sense of purposelessness. Some had to switch to other manual jobs, and days of heavy lifting eventually took their painful toll. OxyContin was just a short doctor’s visit away—in one case, a doctor would simply refill opioid prescriptions by phone. “The men and women in this book suffer from physical pain—muscles torn and backs worn out by heavy lifting and repetitive tasks,” Silva writes. But they also “turn to food and Percocet, heroin and cigarettes, to manage the feelings of anxiety, disappointment, and trauma from their pasts.”

Her interviewees had easy access to opioids, yes, but they also felt betrayed by the world. When Silva presented her work recently, an economist told her, “This is, like, an everything problem.”

“I thought that was a really smart way of putting it,” she told me. Indeed, in one of their studies, the Princeton economists Anne Case and Angus Deaton, who coined the “deaths of despair” hypothesis, noted that opioid overdoses, suicides, and alcohol abuse are the results of “cumulative distress,” or the overall “failure of life to turn out as expected.”

The solutions to this “everything problem” are not clear. Silva told me that the opioid epidemic had made some of her interviewees even more resentful, because they saw their neighbors as too weak to pull themselves out of addiction. At times, they seemed to almost celebrate the pain of withdrawal from opioids, as a necessary way of toughening up. “They actually end up supporting programs that would give people less help or less aid, because they feel like it’s enabling to keep giving help to people who refuse to get better,” she told me.

One of Silva’s interviewees tried to convince her that stress is how people grow. But stress can also make people hurt.