After reaching a record high of 223 in 2003, fatal drug overdoses in Western Virginia appear to be leveling off.

Of the 216 drug deaths in the region last year, most were caused by prescription painkillers -- a continuation of the trend that began in the late 1990s, according to the latest data from the state medical examiner's office in Roanoke.

Although the numbers represent a threefold increase from a decade ago, the region's death toll appears to have stabilized in the 200- to 220-range over the past three years.

"We seem to have reached sort of a plateau," said Dr. William Massello, an assistant chief medical examiner who performs autopsies on overdose victims and has been tracking the numbers. "But we're not going to know for sure until we see what happens in the next few years."

For several years now, far Southwest Virginia has seen a disproportionately high number of fatal drug overdoses.

Lee County, for example, recorded 11 drug deaths in 2003, or a rate of 46 per 100,000 residents. Other counties in the region, including Dickenson, Tazewell, Russell and Wise, had rates of more than 30 deaths per 100,000 residents.

The statewide rate is 6.7, according to the medical examiner's office.

Many of the people who wind up on Massello's autopsy table lived far from the cities where street drugs such as cocaine and heroin are more prevalent. In a region where occupations such as coal mining, logging and farming produce a high rate of injury and disability, medication prescribed to treat those ailments often winds up in the hands of drug abusers.

Another factor contributing to prescription drug abuse could be a struggling economy and other socioeconomic disadvantages confronting many residents.

"I don't want to paint a negative picture of Southwest Virginia ... but I think in an area like this, where people for whatever reason chose not to be actively engaged in society and are despairing, they are much more vulnerable to making these kinds of bad choices," said Dr. John Dreyzehner of Russell County, director of the Cumberland Plateau Heath District.

And in rural, conservative areas where the Bible Belt is cinched a notch or two tighter, prescription drugs may not carry the same moral stigma as alcohol when it comes to dealing with despair, said Dreyzehner, who is also co-chairman of the Appalachian Substance Abuse, Prevention and Treatment Coalition.

"The Bible doesn't say anything about it," he said of prescription drug abuse, "and it's coming out of a clean-looking pill bottle.

"There is a part of the culture that has made it OK to use legitimate medications illegitimately. I think the rationale may be: 'Well, these are drugs that are medicine so therefore they are safer than street drugs.' "

An estimated 80 percent of the drug deaths in the region were accidental overdoses, countering the popular stereotype of a depressed, suicidal person turning to a bottle of pills as an easy way to go.

But who, exactly, is taking the drugs with such lethal results?

Preliminary results from an analysis of the 223 deaths in 2003 by Dr. Martha Wunsch, an associate professor and chairwoman of the addiction studies program at the Edward Via Virginia College of Osteopathic Medicine in Blacksburg, show two groups of users.

The first group is the party crowd, about two-thirds of them white males between the ages of 18 and 25 who take multiple prescription painkillers, often mixing them with cocaine and tranquilizers, in search of a weekend high.

"These are the kids who are partying, and they shoot over the mark when they party," said Wunsch, who is studying the issue through a research grant from the National Institute on Drug Abuse.

Most of the people in the party group do not have prescriptions for the drugs they abuse, Wunsch said. Instead, they apparently obtain them from a black market created by doctor shoppers, or people who feign or embellish ailments to multiple doctors to accumulate a cache of drugs.

The second group of overdose victims is what Wunsch called a "sad and depressing" population: people who suffer from chronic pain that is often coupled with psychiatric disorders. These people, who are more likely to be women older than 40, sometimes are prescribed so many medications that they lose track of how much they took, and when, Wunsch said.

Massello's tally of last year's drug deaths, which was completed only recently because it can take months for laboratory tests to confirm a cause of death, shows that methadone continues to be the region's most deadly drug.

Of the 216 overdoses last year, 70 involved methadone. Fifty-one were caused by hydrocodone, a class of painkillers that includes Lortab and Vicodin, and 36 involved oxycodone, a group of opium-based narcotics that includes OxyContin.

Methadone comes in two forms. Pills or wafers are prescribed by doctors as a painkiller. A liquid form of the narcotic is dispensed by drug treatment centers to treat heroin and OxyContin addicts.

Although critics of a methadone clinic that opened last year in Roanoke fear that methadone will end up on the street, Massello said that virtually all of the methadone deaths handled by his office have been caused by pills or wafers.

Over the past three years, morphine deaths have more than doubled in Western Virginia, going from 15 in 2003 to 34 last year. Although the category of drugs includes heroin, Massello said the bulk of the overdoses comes from morphine-based painkillers such as MS Contin and Roxanol.

Physicians may be prescribing those drugs more frequently as a result of the attention that OxyContin and methadone deaths have received in recent years, Massello said.

It's still too soon to say for certain whether drug deaths in the region -- which decreased in 2004 for the first time in a decade before going up again in 2005 -- have leveled off, Massello said.

"I would like to think that when people start using the prescription-monitoring program, we might see a significant decrease," he said.

The program, in which prescriptions are entered into a statewide database accessible to doctors and police who might suspect a patient of doctor shopping, began three years ago in Southwest Virginia. Last month, it was expanded to cover the entire state.