TAZEWELL COUNTY, Va.
The crowd is gathering early in the dirt parking lot outside the Clinch Valley Treatment Center, the only methadone clinic within 80 miles.
Third in line, Jeff Trapp smokes Winstons in his pickup, watching the cars turn off the highway and settle behind him, tires crunching on cold gravel, headlights glaring. It is 2:45 a.m., and Trapp has been awake for two hours. The clinic does not start dosing until 5.
Like Trapp, many of the patients who filled the lot one recent morning have jobs at far-off mines that start at 6 or 7. They sleep upright in their vehicles, slumped against the steering wheel, dressed for work in steel-toed black boots and coveralls lined with orange reflective strips. Dark rings circle their eyes where the previous day's coal dust didn't wash off.
"Everybody you see here works," says Trapp, his smoke-cured voice a low rumble. A $14 plug-in heater from "Wally" (Wal-Mart) whirs on the dash. "Ain't no spongers. No loafers," he says.
Work in the mines hasn't been as good as it is now in a generation. With per-ton prices doubling in the past six years, Virginia unearthed about $1.6 billion worth of coal in 2006, much of it destined for the Washington region.
Wages are up, bosses are hiring and rookie miners can start at $18 an hour — a small fortune in a region where, as Trapp says, "if you ain't working in the mines or in the prisons, you don't make money."
But it is a boom clouded by drugs. Nearly a decade after OxyContin slammed into southwestern Virginia and much of Appalachia, the abuse of prescription painkillers in the region is worse than ever, police and public health officials say.
Publicized efforts to crack down on drug dealers and manufacturers through tougher street-level enforcement and tighter prescription regulations have failed to curb the crisis, and the result is a quiet catastrophe unfolding largely out of sight, in private bedrooms and isolated trailers far from the drug war's urban front lines.
A record 248 people died of overdoses in Virginia's western region in 2006, more than those who died from homicides, house fires and alcohol-related car accidents combined. That was an 18 percent increase from 2005 and a 270 percent increase from a decade ago, state medical examiner records show.
The problem is most acute in Virginia's poorest rural areas, and it is not limited to miners. In 2006, accidental pain pill overdoses killed more people in Tazewell County (pop. 44,000) than in Fairfax County (pop. 1.1 million). In Wise County, where Trapp lives and the average per capita income is $14,000 a year, the fatal overdose rate for pain pills was 13 times those of Loudoun and Fairfax counties.
"The abuse and misuse of painkillers is the worst I have seen it in the 16 years I have worked narcotics in this area," said Lt. Richard Stallard of the Big Stone Gap police department. He is director of the Southwest Virginia Drug Task Force, which operates in Dickinson, Lee, Scott and Wise counties. His officers made 442 arrests through the first nine months of last year, an 86 percent increase from the same period in 2006.
In what is perhaps the most troubling sign of the problem's intractability, the single deadliest drug in the region in 2006 was the same one being legally distributed to addicts through treatment clinics such as the one Trapp visits: methadone.
A large black market has emerged for the drug, which is supposed to treat addiction or chronic pain with less risk than OxyContin and other oxycodone-based opioids. But methadone was linked to 78 deaths in western Virginia in 2006, and experts say that whatever ground was gained against the illegal use of OxyContin is being lost, engulfed in a widening circle of abuse that extends to painkillers, antidepressants and other prescription drugs.
Round-the-clock security is posted at Clinch Valley Treatment Center, a two-story cement building along Route 19 that was once a hamburger restaurant. It serves almost 1,000 patients, drawing them from steep-sided mountain "hollers" and tiny coal towns such as Dante, Dungannon, Honaker and other places where the winter sun casts long shadows but little light.
Every morning before sunup, Trapp drives 120 miles — from his home in Coeburn to the clinic and back — stopping once for coffee and gas at the Double Kwik in Lebanon. He has been going for two years, trading this dependency for the $600-a-day oxycodone habit that made his nose bleed and his wife cry. He is 54, with a pale moustache, a four-pack-a-day wheeze and the drained, sallow expression of someone who has not slept in a long time.
When the clinic doors open at 5, the crowd streams into the warm hallway, squinting in the indoor light. Trapp hands over $12.50 at a payment window, then lines up at another window for his dose: 80 milligrams of liquid methadone, mixed with juice in a little white cup. He must gulp it down quickly and get back on the road. His boss expects him at 6:30.
"This methadone makes you feel like a human being again," Trapp says.
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With disability rates as high as 37 percent in coal-mining areas such as Buchanan County, the region has many people with long-term pain management needs. As is the case with lots of aging miners, Trapp's addiction to pills began in a doctor's office, not a back-alley drug deal.
"Busted-up" from 30 years working as a heavy-equipment operator and mechanic on the massive excavators used for strip mining and mountaintop removal, Trapp needed multiple surgeries to fix seven ruptured and herniated discs. Doctors wanted to implant a magnesium rod to stabilize his spine, but Trapp refused.
"I've known too many people who've done it, and they can't tie their shoes," he said.
So Trapp loaded up on painkillers, first Percocet and later OxyContin. When the prescribed dose no longer did the job, Trapp took more. Then more. He began "doctor shopping," driving to Roanoke and Richmond to find physicians who would give him prescriptions.
When the pharmacies couldn't provide enough pills, Trapp found dealers who would. Friends were melting oxycodone tablets and injecting themselves — "bangin' OCs" — but Trapp was too squeamish to mess with needles. He crushed the tablets and snorted them like cocaine off his kitchen table. He didn't feel high, just "good." The relief was instant.
"I got hooked on those bad boys real bad," he says.
But when Trapp didn't have pills, the withdrawal symptoms left him "sick as a dog" and bedridden. "Every muscle in your body craves it," he says. "You can't sleep, can't eat. It's like the flu, but 10 times worse."
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In two years, Trapp put $60,000 of his retirement savings, maybe more, up his nose. His daughter begged him to get help, as did his wife, Sue, who works as a shift manager at a Hardee's and as a guard at Red Onion State Prison, the supermax facility where sniper Lee Boyd Malvo is being held.
Trapp was "wormed over" after three days into involuntary withdrawal when his wife took him to a clinic to get help in 2005. He couldn't walk, and he couldn't hold up his head. He began taking methadone that week.
Foreman Gary Boyd steers through the tunnels of Pioneer Coal No. 1 in a low-rise electric cart, sloshing across channels of cold, muddy water. His nickname, Stork, is stenciled on his scuffed plastic helmet, and a slug of dipping tobacco bulges in his lower lip.
"The good Lord put me on this Earth to be a coal miner," he says, "and I can't think of nothing I'd rather do." He ducks slightly when the ceiling height drops to 40 inches.
A bearish man with a soot-streaked beard, Boyd stands well over 6 feet tall outside the mine. But underground, in a 3 1/2-foot "low coal" operation such as this one in the mountains near Vansant, Va., Boyd mostly works on his hands and knees, crawling like an infant. He and the other men spend the entire shift, sometimes 12 hours or more, without ever standing up.
Compared with the large, corporate-owned mines that use the latest technology and enforce tighter safety codes, Pioneer No. 1, the company's only mine, is a mom-and-pop affair, run by a single operator and a 10-man crew. It extends horizontally into the mountain through a maze-like network of wide, low tunnels, and a red plastic sign along the access road outside reads "AMBULANCE ENTRANCE."
With narrower profit margins, small-scale outfits such as Pioneer, often known as "dog holes," typically pay less and don't offer benefits such as health insurance. But for miners who have been fired from corporate mines for drug violations or other infractions, smaller mines, which must still meet state safety standards, are a good fallback.
The "face," where Boyd's crew was working that day, was a half-mile into the mountain. A massive grinding machine called a continuous miner chewed at the coal seam with a spinning, snaggle-toothed steel cylinder. Water seeped from its mouth and trickled from its sides to cool the metal teeth and keep the dust down. The greasy, jet-black rock came off in chunks onto a conveyor belt.
As the machine worked, the tunnel walls cracked and groaned under the shifting pressure of the mountain. Crew members scrambled to stabilize the roof with wooden posts, wedging them into place with hammers.
"You're as safe as you would be in your mommy's arms — if you watch what you're doing," Boyd said. He checked a hand-held meter every few minutes to measure carbon dioxide, which is poisonous, and methane, which can explode. Flecks of coal dust swirled in the yellow beams of the miners' headlamps.