Every day more than a million packages enter the US from abroad through the postal service. As state and federal governments crack down on legally prescribed opioid medication,
addicts and dealers are looking to the dark web and the US mail as a new way to acquire increasingly potent - and deadly - drugs.
Van Ingram's voice cracks as he describes the toll opioid drug abuse has exacted on his home state of Kentucky. "I go to bed thinking about those 1,400 people we lost in 2016 every night," he says. "Thinking about it every day when I get up. It's somebody's son, somebody's daughter, somebody's mother, somebody's father, somebody's sister, somebody's friend. The human toll is just unimaginable."
Ingram, who was speaking to the BBC for a World Service documentary on Donald Trump's healthcare record, has served as the executive director for the Kentucky Office of Drug Control Policy since 2004. Before that, he spent more than two decades as a police officer. He's witnessed first-hand the rise of the opioid drug problem in his state - considered "ground zero" for the epidemic.
It started with doctors - some well-meaning, others operating "pill-mills" looking to turn a quick profit - prescribing opioid painkillers to their patients. Medication was offered a month's supply at a time for one-time injuries and chronic pain, often to treat years of working in physically arduous jobs - like those in manufacturing and the coal mines of the eastern part of the state. The kind of jobs that have been disappearing across the US in recent years.
"If you overexpose a society or culture to cheap, plentiful food, you'll have an obesity epidemic," Ingram says. "If you overexpose a culture to opioids, you're going to have an opioid epidemic. And it wasn't just Kentucky that got overexposed. We just got overexposed first."
An addiction crisis shifts
Kentucky, and other states, eventually enacted legislation to address the problem. The pill mills were shut down. Doctors, who had been told by pharmaceutical companies that the medication they were offering was not addictive, began to realise the consequences of their actions and prescribe less often and for shorter periods.
At that point, however, the damage was done. A population, sometimes whole communities, had become hooked and were now searching for a new way to get their fix.
The good news is we're prescribing fewer opioids in this state and in this country," Ingram says. "The bad news is there's always something to take its place."
What came next was a stream of increasingly more potent drugs, causing overdose fatality numbers to spike in Kentucky and across the US. By last year, more Americans had died from opioids than in the Vietnam, Iraq and Afghanistan wars combined. More Americans die annually from the drugs than are killed in car accidents or firearm incidents. Of the 63,630 recorded drug overdose deaths in the US in 2016, 42,249 were from opioids.
Increasingly, the agent of death is a drug called fentanyl - 50 to 100 times more powerful than doctor-prescribed morphine - which is manufactured predominantly in China and frequently enters in the US in small packages shipped through the postal system.
Nationally, from 2014 15, the number of fentanyl-related overdose deaths increased by 72%, to nearly 10,000. In 2016, that number had doubled, to 20,100.
The 'iron law'
"Emerging year-over-year figures and episodic outbreaks of fentanyl-related deaths paint a grim picture of an uncontained, plague-like contagion," write Professors Leo Beletsky and Corey Davis in a paper on the fentanyl crisis published last year in the International Journal of Drug Policy.
In their report, they said that the transition to increasingly potent drugs from illicit - often foreign - sources was as inevitable as it was shocking. A similar pattern emerged when the US tried to ban the sale of alcohol during the Prohibition era of the 1920s.