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.For more stories in this series click 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.