Over the Great Recession, an estimated 7 million Americans lost their homes, 7.6 million lost their jobs, and nearly every American experienced lower economic security. Along with economic hardship and insecurity, Americans’ drug use also increased.

While 18.9% of Americans use mood-altering drugs or medications to help them relax almost every day, a nation-leading 28.2% of West Virginians report near-daily drug use.

9. Indiana

> Near-daily drug use: 21.9%
> Median household income: $50,532 (16th lowest)
> Avg. poor mental health days per month: 4.3 (6th highest)
> 2016 unemployment rate: 4.4% (21st lowest)

Survey participants were not told specific drugs to consider in their answers, so substances used by daily drug users could include anything from tobacco to prescription medications. Prescription drug use in Indiana, at 13.4 prescriptions filled per resident annually, while higher than the national average of 12.7 per capita, is lower compared with other states on this list. On the other hand, Indiana is similar to most states on this list in its high adult smoking rate of 23.4%, which is one of the highest in the nation.

The Gallup-Healthways Well-Being Index, which measures a range of metrics to compare the well-being of Americans across the United States, includes a measure of near-daily drug use. Residents of each state were asked how frequently they use drugs that affect their mood or help them relax. Respondents were told to consider prescription medications. Otherwise, mood-altering drug use could be interpreted to include alcohol or nicotine consumption.

In an interview with 24/7 Wall St., Dan Witters, research director of the Gallup-Healthways Well-Being Index, highlighted clinical diagnosis of depression and daily physical pain as two of the factors most closely related to regular drug use. Both conditions, while often cited as motivations for substance use, can also be the result of daily drug consumption.

American workers are more likely to experience physical pain or stress in lower-paying jobs, which tend to involve more manual labor or longer working hours. In nine of the 10 states with the largest shares of regular drug users, the median income is less than the national median income of $55,775 a year. Witters claimed that individuals living in poverty were as much as three times as likely to use drugs than those with incomes above the poverty level. In eight of the 10 states with the highest shares of regular drug users, the poverty rate is higher than the 14.7% national rate.

According to Witters, while regular drug use is “for the most part going to be detrimental to your long-term well-being,” the opposite is also true. Nine of the 10 states with the largest shares of drug users, consumption of illegal drugs such as marijuana, heroin, or cocaine is below the national average. On the other hand, faithful adherence to legally prescribed medications alleviates pain and enhances quality of life for thousands of Americans. Such drugs “help manage certain forms of disease burden.”

Nationwide, 12.7 prescriptions are filled for every American each year. In all of the 10 states reporting the highest near-daily drug use, the number of prescriptions filled per capita is above the national average.

To determine the states using the most mind-altering drugs, 24/7 Wall St. reviewed the percentage of state residents reporting near-daily drug use to relax based on interviews conducted between January and December 2015 for the latest Gallup-Healthways Well-Being Index.

We also considered data from the U.S. Census Bureau’s 2015 American Community Survey, including median household income, poverty rate, uninsured rate, and adult educational attainment rates. The 2016 annual state unemployment rate came from the Bureau of Labor Statistics. The 2015 obesity and teen pregnancy rates, as well as the 2014 smoking, inactivity, and diabetes rates, came from the Centers for Disease Control and Prevention. Death rates from heart disease for 2014 and deaths from cancer for 2013 were also from the CDC. The number of annual retail prescription drugs filled per capita are for 2015 and came from the Kaiser Family Foundation. Data on recreational drug consumption and mental illness in the past year came from the Substance Abuse and Mental Health Services Administration’s National Survey on Drug Use and Health, are an average of 2014 and 2015 figures and adjusted for population using data from the ACS. Lastly, the premature mortality rate is from the County Health Rankings & Roadmaps program, a collaboration between the Robert Wood Johnson Foundation and the University of Wisconsin Population Health Institute and is for 2014.

Click here to see the states using the most mood-altering drugs.