More people died from drug overdoses in Western Virginia last year than from homicides, house fires and alcohol-related automobile accidents combined.

The region had 264 fatal drug overdoses in 2006, according to the state medical examiner's office. That's a 22 percent increase from 2005 -- and a 294 percent increase from a decade ago.

Most of the deaths were from prescription drug abuse, which has brought big-city woes to the rural landscape of far Southwest Virginia.

"This is a public health epidemic," said Dr. Martha Wunsch of Blacksburg, an addiction expert who is studying the problem through a research grant from the National Institute on Drug Abuse.

The plague of prescription drug abuse began spreading through the western corner of Virginia long before 2001, when abuse of the painkiller OxyContin reached crisis levels.

In recent years, it seemed like some progress was being made.

Federal prosecution put an end to misleading marketing of OxyContin. A prescription-monitoring program was expanded to cover the entire state. The number of fatal overdoses leveled off between 2003 and 2005.

But the 2006 spike in drug deaths is one of several indicators that things may be going from bad to worse.

"Back in the heyday of OxyContin, it had really gotten bad," said Richard Stallard, head of the Southwest Virginia Drug Task Force. "But right now, it is the worst I've ever seen it."

Stallard said his task force, which covers the counties of Dickenson, Lee, Scott and Wise in the state's westernmost tip, is on pace to make more drug arrests this year than ever before.

Drug treatment centers are also seeing their caseloads swell. "It hasn't let up," said Beth Davies, director of the Addiction Education Center in Pennington Gap.

It seems that wherever Davies goes -- to the grocery store, to a concert or just for a walk down Main Street -- she bumps into someone she knows through group therapy.

With populations declining or remaining flat in many of the affected areas, officials were at a loss to explain just why this rural epidemic has yet to level off the way crack cocaine did in many cities.

Some fear that prescription drug abuse in the coalfields is so prevalent that it will become associated with the region as much as coal mining and bluegrass music.

"It's almost a way of life," Davies said. "It's almost part of the fabric of the counties here."

Silent suffering

Unlike in big cities, where gunfire and sirens often announce the latest drug-related death, the dying in far Southwest Virginia is more silent, more private. When police find an overdose victim lying dead on his sofa, it seldom makes headlines.

Quietly, though, the region in some ways suffers as much as the most crack-infested inner-city neighborhood.

The 264 drug overdoses in Western Virginia accounted for 40 percent of the state's total drug overdose deaths, even though the area contains just 20 percent of the population.

Prescription drugs were responsible for more than 200 of the 264 deaths in the region, which stretches from Harrisonburg to Martinsville and all the way west to Lee County.

One of the most common ways for prescription drugs to enter the black market is through doctor shopping, or the practice of abusers going to multiple physicians and feigning ailments to obtain a cache of pills they then sell on the street.

Other people with legitimate pain sometimes sell their medication or end up abusing it themselves.

Far Southwest Virginia, with its high rate of disability and injuries because of hard-labor industries such as coal mining, has long been a hotbed for prescription drug abuse.

A detailed breakdown of drug deaths by county was not available for last year. But according to a 2005 report from the medical examiner, the counties of far Southwest Virginia -- including Buchanan, Dickenson, Lee, Russell and Tazewell -- had per capita rates of drug deaths that ranged from 34 to 44 fatalities per 100,000 residents.

The statewide rate was seven deaths per 100,000.

In the wrong hands

Methadone was the region's most deadly drug last year, causing 78 overdoses.

A potent narcotic developed during World War II as an alternative to morphine, methadone is prescribed by doctors as a painkiller, either as a pill or wafer. A liquid form of methadone is dispensed by drug treatment centers to curb addiction to opium-based drugs such as OxyContin and heroin.

According to Wunsch's research, virtually all of the methadone overdoses are from the pill form used as an analgesic.

Wunsch, a professor of addiction studies at the Edward Via Virginia College of Osteopathic Medicine, said the preliminary results of her research show two distinct groups of victims: young people who generally do not have prescriptions for pain medication they use as a party drug, and an older population more likely to be suffering from chronic pain and depression.

Ever since problems with OxyContin gained the attention of law enforcement, politicians and the news media, doctors in the area have been prescribing methadone more frequently, Stallard said.

But in recent years, police have again been finding more OxyContin in the hands of abusers. Stallard said the drug comes from places such as Northern Virginia, North Carolina, South Carolina and Tennessee.

"We've seen it become an imported drug," he said. "We are aware of people who will carpool to where they know they can get a prescription for it."

Deaths from oxycodone, the active ingredient in OxyContin, are on the rise again after several years of decline. The medical examiner said oxycodone caused 48 fatal overdoses last year, compared with 36 the year before.

Oxycodone is now the second-leading cause of overdose deaths in the region.

Drugs doled 'like candy'

As fatal overdoses from oxycodone, methadone and hydrocodone continue to rise, so does the amount of the drugs prescribed by doctors.

Nearly 747,000 grams of oxycodone were distributed for retail sale in Virginia last year, almost triple the amount from 1999, according to the state Department of Health Professions.

Although oxycodone distribution shot up from 288,000 grams in 1999 to 555,000 grams in 2001, the increases have since leveled off at 10 percent or less over the past five years.

But that's still too much for Davies, who said many doctors continue to prescribe potent medications "like candy" in today's climate of offering a cure for every ailment or mood disorder.

Others say the medical community is finally making adjustments for the undertreatment of pain across the country.

"In 30 years, we've come a long way in terms of using these drugs in a very responsible way," said Judith Paice, president of the American Pain Society.

As the country's population ages, there's more need than ever for better pain management, Paice said.

Attention dwindles

On a March night in 2001, when OxyContin was still a new word in the coalfields and the wounds it caused were still fresh, more than 700 people packed a high school auditorium in Lee County for a town meeting called to address the problem.

Six years later, another rally was held. It took place July 20 near the federal courthouse in Abingdon, where the company that makes OxyContin and three of its executives were fined $634.5 million for overpromoting the painkiller.

This time, no more than 100 people showed up. Most were recovering addicts and family members of overdose victims from places such as Florida, Georgia, Massachusetts and California. Only a few people from Southwest Virginia dotted the crowd.

Davies, who was at both events, said the low attendance at the second rally -- which could have been a victory celebration of sorts -- highlights a problem she sees in the community.

"There's a lack of will to come together and say we've got to do something about this," she said.

Jill Carson, a member of the Virginia Organizing Project, a grass-roots community group, said the region may be unwilling to acknowledge another problem on top of its struggling economy, high disability rate and other socioeconomic woes.

Davies calls it "a watershed of despair."

In a region long dependant on one dominant industry, coal mining, Davies said there's a culture of not speaking out against the power structure, whether it's a coal company or a pharmaceutical firm.

"People have been so beaten down for so long in so many ways," she said. "Some people say they are lazy and don't care, but it's not that at all. People are very wise, and they know where the power is, and it's not wielded here in the community."

But there has been some progress, such as the opening of a 30-bed drug treatment center in Lee County that operates out of a donated nursing home building and is supported by local donations.

John Dreyzehner, co-chairman of the Appalachian Substance Abuse Coalition for Prevention and Treatment, says he senses a growing commitment.

"I think if the problem is in the community, the solution is in the community, and I think the community is stepping forward to address the problem," Dreyzehner said.

"But that doesn't mean it will happen overnight."