See a county-by-county map of overdose deaths in West Virginia here. 

See a related story, "Preventing prescription drug overdoses: Where West Virginia stands," here.

This is the first in a four-part series examining prescription drug abuse in West Virginia.

ST. MARYS, W.Va. -- By the time he was in his 20s, Nick Bills had gone through so many medical procedures, he swore he could do brain surgery.

When he started abusing prescription drugs, he thought he could handle it.

On a July night in 2009, the 26-year-old pulled his pickup into the parking lot of a St. Marys bar. There, he squeezed the clear gel out of a fentanyl patch, mixed it with water, and injected it into his 6'2" frame.

He died there that night.

In a sense, he didn't die alone. Prescription drug overdoses now kill hundreds of West Virginians every year:

Many people still don't realize how dangerous it is to abuse prescription drugs, said the state's chief medical examiner, Dr. James Kaplan.

"They need to know that it is like playing Russian roulette," he said.

'I didn't expect this'

"This is Nick in a nutshell," said his mother, Vivian, picking up a photo of a family reunion. "Nick and the old men telling stories at the Bills reunion. He was so interested in all their stories."

She always worried about her son. He had abused alcohol for years.

"Every night, I expected a call of some kind, that he was in trouble," she said. "I didn't expect this."

A week before he died, Nick told his mother he wanted to go to rehab. She assumed he wanted help for his alcohol problem. She wishes she had taken him right away.

His problems had started early. When he was about 9, he found a gas can his brother had for the lawn mower. He found a lighter, too. The fire burned 20 percent of his body.

"His personality changed with that extreme pain," his mother said.

She remembers Nick wrapped in gauze at the hospital. He looked like a little mummy.

After the fire, his happy-go-lucky demeanor disappeared. He struggled in school.

Doctors ordered Nick to wear pressure garments - tight, uncomfortable things to stop his scar tissue from puffing up. As a child, he peeled them from his limbs and threw them in the weeds on the way to school. His parents never found them.

He had nightmares of being burned, his mother later learned. Something else haunted him, too: A deep sense of inadequacy.

"Stupid, fat and ugly." That's how he thought of himself.

She was relieved when he found a career he loved after high school. He became a union ironworker.

Around age 20, Nick suffered another accident. One night, as he rode as a passenger with his arm hanging out of the window, the driver whipped past a pole that was close to the roadway. Nick shattered his elbow.

His career as an ironworker ended. He could only lift a few pounds, a gallon of milk at the most. He had to sleep in a recliner. He wore special Velcro shirts to accommodate the metal rods inserted into his injured arm.

Although in great pain, he didn't need all of the drugs doctors prescribed him, said Logan Bloomer, Nick's ex-girlfriend and the mother of his 3-year-old daughter, Addison. He amassed a collection of pain pills that covered the top of the refrigerator at his sister's house, where he was staying.

"[Doctors] just kept giving him more when, to begin with, he wasn't taking a lot," Bloomer said, "so it just kind of backed up."

Friends wanted the pills. He was happy to share. "It made him feel important," said Bloomer, who was no longer dating Nick when he died. "It made him feel needed."

Research shows that nearly two-thirds of West Virginians who misuse pain relievers get them from friends or relatives for free.

As time went on, Nick developed a taste for them himself. He didn't want to give them away.

'A sense of urgency'

Last year, National Drug Control Policy Director Gil Kerlikowske called prescription abuse "our nation's fastest-growing drug problem."

Nationwide, deaths from drug overdoses more than doubled between 1999 and 2007, according to the federal Centers for Disease Control and Prevention, with opiate painkillers fueling the increase. These drugs, which include fentanyl and oxycodone, act on the central nervous system.

The problem hit West Virginia hard and early, said Dr. Rolly Sullivan, a psychiatry professor and director of addiction services at the West Virginia University School of Medicine.

In the 1990s, "I was so completely overwhelmed with patients hooked on prescription drugs that I thought it was just a completely hopeless case," he said.

During that period, there was a movement to treat pain more aggressively.

OxyContin became available in 1996. The drug was heavily marketed to doctors who were "underprepared to judge the risk of addiction," Sullivan said.

Today, he sees all kinds of people struggling with painkiller addictions. His patients include a lawyer and a woman living in a homeless shelter.

Experts don't know exactly why the problem is so bad here, but they point to several factors.

Prescription drugs are abundant in West Virginia medicine cabinets. Residents of the state filled nearly 19 prescriptions per capita in 2009, the most in the nation, according to the Kaiser Family Foundation. The national average was 12.

Many West Virginians work in industries where they get hurt, like coal mining.

Help for addiction is hard to find, Sullivan said. "There's been pathetically inadequate treatment options," he said. "The state has been really slow to finance any."

Then, there is the lasting misperception that prescription drugs are safer than illegal drugs.

"There's a huge level of ignorance behind this because [people] don't know about the drugs," said Mike O'Neil, pharmacy professor at the University of Charleston and an expert on drug diversion.

People abuse many types of prescription drugs: Painkillers, tranquilizers, stimulants and sedatives.

Opiate painkillers cause so many overdose deaths because of the way the body develops tolerance to them, O'Neil said.

"Over time - and usually fairly quickly - we actually develop tolerance to the sedative effects of these drugs," O'Neil said, "and we develop tolerance to the euphoric or buzz effects."

The body, though, doesn't develop tolerance to opiates' respiratory-depression effects -- the way they make the lungs breathe shallower and slower. As an addict takes more opiates to get the same feeling, the drugs can make them stop breathing.

Mixing drugs with each other or with alcohol also can be deadly, he said.

Injecting, snorting or smoking a drug increases the likelihood of addiction, O'Neil said. The drugs reach the brain faster and at higher concentrations because they bypass the digestive system.

"It also overloads other organ systems," he said, "like the heart or respiratory systems."

Some states have made fighting prescription drug overdoses a top priority. In Utah, for instance, legislators in 2007 passed a law creating a program aimed at reducing deaths by prescription drugs by 15 percent.

The state researched overdose deaths to determine which factors made some Utahans more likely to die from prescription drugs. A statewide media campaign educated people on the dangers of prescription drug abuse. Utah also created clinical guidelines for practitioners prescribing opiate pain medications.

In 2008, Utah saw a nearly 13 percent decrease in prescription-drug overdose deaths from the previous year.

In Ohio, then-Gov. Ted Strickland signed an executive order last year creating a state Prescription Drug Abuse Task Force. In October, the task force released a final report of 20 recommendations related to areas like treatment, law enforcement, and public health.

West Virginia House of Delegates Health and Human Resources Chairman Don Perdue said he wants to see the Mountain State take similar steps.

"Unless we develop a sense of urgency about this problem, we will not do anything that's effective," the Wayne County Democrat said. "It's not penetrating the consciousness of the public in the way that it should."

'He wanted to get better'

Nick Bills' family doesn't know where he got the fentanyl patch that killed him. At the time, he had a prescription only for Vicodin, Bloomer said.

But prescription drugs are easy to find, said Bloomer, who is recovering from painkiller abuse.

When she and Nick abused drugs together, they had a friend with cancer who sold his OxyContin pills and fentanyl, a drug 80 times stronger than morphine. They knew people who worked for a company that collected unused drugs from nursing homes and rehabilitation centers. Instead of disposing of them like they were supposed to, they sold them.

When Nick's arm healed enough for him to work again, he found a new job as a heavy-equipment operator, running cranes and bulldozers.

Bloomer snuck him pills while he was working. At eight months pregnant, she stopped in a gas station daily to buy a piece of pizza. She dug her fingers through the crust, stuffed pills inside and dropped off the pizza at his job site.

One day, the two went driving around. By that time, Bloomer said, they couldn't get high any more. They wanted to not feel sick from withdrawal.

They looked for "old people's cars" like Cadillacs in the driveways, Bloomer said. They stopped at the houses and pretended to be lost. She asked to use the bathroom and scoured the medicine cabinets.

"I can remember going home, and we didn't get anything," she said. "We had to crawl back home, and we were so ashamed. And that's when we would look at each other like, 'This is sad, this is serious.'"

Bills can't imagine her son doing that.

"He would do anything for anyone," Bills said. "Any favor was not asking too much. He just was loveable - that other side, I didn't see."

Nick did his best to hide his addiction, Bloomer said, especially from his family.

"He wanted to get better," she said, "but he was too afraid for people to find out that he was sick."

He had always been a private person.

"Drinking brought him out of that shell," Bloomer said, "and so did pills. I think it was his way of being the person that he wanted to be."

Last month, Bills spent her second Christmas without Nick.

"It's almost harder as time passes on," she said.

The numbness is wearing off.

She thinks of him when she sees birds or stars. He always noticed those things.

Some days, when she drives over the mountain above her home, she sees brilliant pink and red clouds. Nick loved it there. When she hits a certain point along the road, she feels like she's in the sky.

Coming Monday in The Charleston Gazette: Doctors grapple with treating real pain vs. supplying pill seekers.

This series was conceived and produced as a project for The California Endowment Health Journalism Fellowships, a program of the USC Annenberg School for Communication & Journalism.

Reach Alison Knezevich at alis...@wvgazette.com or 304-348-1240.

What are the most abused prescription drugs in W.Va.?

1. OxyContin, Percocet

2. Vicodin

3. Xanax

4. Methadone

5. Morphine

Source: W.Va. Prescription Drug Abuse Quitline

Need help finding treatment for substance abuse?

| W.Va. Prescription Drug Abuse Quitline:

Call 1-866-WV-QUITT or visit www.wvrxabuse.org

| Federal Substance Abuse and Mental Health Services Administration:

Call 1-800-662-HELP or visit www.samhsa.gov/treatment