Not long after a large steel mill closed in the small town of Portsmouth, Ohio in the mid-1980s, the first pill mill appeared. With a handful of cash at an unscrupulous pain clinic, anyone could get a prescription for Oxycontin or other painkillers. By 2009, there were 10 pill mills in the area. Addiction was so common that pills became local currency: You could use them to buy a refrigerator or pay the dentist.

This culture of free-flowing opiates has been driven by aggressive marketing from pharmaceutical companies. And when insurance money or prescriptions run out, the patients still need a fix—which often takes the form of cheap heroin from Mexico. It’s a cycle that’s being repeated all across America, and small towns like Portsmouth, with collapsed economies, have been hit hardest.

Michelle Frankfurter is a documentary photographer, currently living in Takoma Park, Maryland.

Co-published with Fast Company Co.EXIST.