HUNTINGTON, W.Va. -- In the emergency room at Cabell Huntington Hospital, Dr. Allen Holmes sees patients jump off the bed at the lightest touch to their backs. He hears bizarre excuses.
"My doctor is out of the country for two years," they say. "My dog ate my pain medication."
They check in to the ER for one reason: They want pills.
As head of the hospital's emergency department, Holmes finds himself on the front lines of West Virginia's prescription drug abuse epidemic. In the four years since he's been doing this work, he's watched it get worse.
He sees people in their early 20s whose doctors have prescribed them the highest possible doses of narcotic painkillers. He sees old people trying to play the system. He suspects some are addicted, while others want to sell the pills to make ends meet.
Holmes thinks he's too skeptical sometimes.
"And I feel bad about that," he said. "But on the other hand, I feel like I would be contributing to the problem if I leaned too far the other way."
Some West Virginia doctors have been accused of running alleged "pill mills" where people get addictive medications without proper exams.
Well-meaning providers are grappling with a host of challenges in prescribing powerful prescription drugs.
"It's really a complicated issue because we need to have balance," said Dr. Alvin Moss, director of the Center for Health Ethics and Law at West Virginia University and the West Virginia Center for End-of-Life Care.
These medicines help cancer patients suffer less, he said. They help elderly people die with their pain controlled.
The drug abuse epidemic, though, has made some doctors afraid to prescribe them.
"I talk to a lot of doctors now who say, 'I just don't prescribe opioids in my practice," Moss said.
There's no question, though, that West Virginia's consumption of the most abused opiate painkillers has skyrocketed over the past decade.
A Gazette review of data from the federal Drug Enforcement Agency, combined with Census figures, shows that between 1999 and 2009, West Virginia's per capita consumption of these drugs has soared:
* Oxycodone: 294 percent increase
* Hydromorphone: 319 percent increase
* Hydrocodone: 296 percent increase
* Fentanyl: 348 percent increase
* Morphine: 199 percent increase
* Methadone: 462 percent increase
Consumption of two opiate drugs -- codeine and meperidine -- declined by about 50 percent each during the time period. Many hospitals have stopped using those drugs because of side effects, Moss said.
Data for every state could not be obtained from the DEA for this time period. But West Virginia's not the only place with a growing demand for pain medicine.
Nationwide, Americans' use of opiate painkillers -- synthetic versions of opium that include OxyContin and Vicodin -- has increased at least 10-fold in the past 20 years because of a shift toward more aggressive pain treatment, according to the federal Centers for Disease Control and Prevention.
"If only the people that needed pain medication had it available to them, there wouldn't be a [black] market," said state Chief Deputy Attorney General Fran Hughes, whose office sued the makers of OxyContin in 2001 and received a $10 million settlement three years later. "There's obviously a supply that exceeds the legitimate demand."
Evan Jenkins, a Democratic state senator from Cabell County and director of the West Virginia State Medical Association, calls prescription drug abuse "one of our most challenging health and criminal issues."
"If we squeeze this so much and make it too restrictive, we are going to have people suffering unnecessarily," he said. "This is a delicate balance between being able to maintain its availability and its uses in an appropriate manner, and to also go after, strongly, the dark side."
Dr. M. Khalid Hasan, a Beckley psychiatrist and member of the state Board of Medicine, puts it more bluntly.
Some of his colleagues' careless prescription practices frustrate him. "They're writing [prescriptions for] too many damn narcotics."
'The fifth vital sign'
Every room in Holmes' department has the same sign: How do you rate your pain?
Many physicians used to be leery of prescribing narcotic painkillers. Things changed in the 1990s.
Both the American Pain Society and the American Society of Anesthesiologists released guidelines encouraging expanded use of opiates to manage chronic pain.
West Virginia and other states passed laws saying doctors could not be disciplined or criminally punished for treating intractable pain with controlled substances, even if the dosage exceeded the average dosage, as long as they practice within accepted medical guidelines.