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 to feed the growing energy demands of 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.
Poorest rural areas hit hard
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 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.
$600-a-day oxycodone habit
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.
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."
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.
Two loves: Mining and drugs
Drug use by miners who snort or shoot up underground has been a growing cause for concern among state regulators, and a law approved last year in the General Assembly imposed stringent drug-testing policies. All newly hired miners must be screened, and random testing requirements have increased. Those who fail risk losing their miner's license.
The impact of the new policies was immediate. "I can't find nobody to work," said Noah Vandyke, 60, a lifelong miner who runs Pioneer Coal. "The younger generation, you can't hardly find one that will pass a drug test."
Since the new testing policy went into effect in July, Vandyke has lost eight crew members who were fired because of drugs or quit, possibly to avoid having their miner's license revoked for a "dirty" urine sample.
"Every family in the area has been affected by drug abuse," Vandyke said, "and it ain't just coal miners." In recent years, two of his sisters have died because of drugs, and two brothers, both injured miners, are deep in the grip of addiction.
Unlike some operators, Vandyke is known as a boss who will not turn a man away for trying to get help at the methadone clinic. One of those is his on-again, off-again "scoop man," Jeff Vandyke, who shuttles coal inside the mine in a huge, spoon-shaped electric cart. The two men are not directly related — Vandyke is a common name in the area — but their lives have been intertwined since the elder miner gave the younger his first job underground 15 years ago.
Like Noah, Jeff Vandyke, 34, grew up in Buchanan County near the town of Grundy. With his horizons blocked by the mountainsides, he found a new world underground. "There's nothing like coal mining," he said. "You know that nobody else will ever go where you're going. Just the people in that mine, that day."
The mines led Jeff Vandyke to another love: drugs. He got his first prescription for OxyContin after a rock fall accident that left him with broken ribs, shoulder damage and spinal injuries. Disabled and addicted, he thought he could get away from drugs by leaving, so he moved with his brother to Arizona and got a job as a trucker. Soon they were buying pills along the Mexican border, 1,000 at a time, he said. Methamphetamine kept them awake, and OxyContin kept them high.
By 2003, Jeff Vandyke was back home and drifting deeper into addiction. He lived for more than a year in a broken-down trailer with the electricity, water and heat cut off. He spent most of his days on a couch in the dark, stirring every few hours to warm the air under his blankets with a propane camping stove.
The crippling pain and nausea of withdrawal pushed him to get help. He drives to a Kentucky clinic for a two-week supply of liquid methadone and says he has been clean for three years. He and his girlfriend, Daisy Ratliff, live with her two sons in a trailer with a thick coal seam visible on the hillside in their back yard. She has brightened the black lockbox where Vandyke stores his methadone with stickers of hearts, stars and red letters that spell "I LV U."
"My truck's paid off," Vandyke says, his long, blond hair tucked under a camouflage cap. "I've got four bows, three shotguns." He takes time off from the mines in the fall to hunt deer, grouse and squirrel for winter meat.
And yet, some of the damage from his drug years can't be undone. Vandyke's father no longer speaks to him, and he and his brother haven't said a word to each other in nearly two years, ever since he said his brother shot at him with a .38 and tried to steal Ratliff's car.
Salves for pain and fear
"I'll probably never get off methadone because of the shape I'm in," said Mick Wampler, a disabled coal miner who lives in a small room at the end of a narrow hallway in his sister's house.
Wampler, 47, started working in the mines four days after his 18th birthday. His mother needed the money after floods wiped out the family's home in Haysi, Va. But he never had the nerves for it, he said, and the sight of accidents sent him over the edge. He watched one friend lose an arm to a rock hauler and saw another electrocuted by a 900-volt mining cable. Wampler began taking Valium just to go underground.
"A lot of people are scared on the job," he said. "They'll use alcohol, anything." After falling off a loader and breaking his leg, Wampler got a prescription for oxycodone. A diabetic, he had needles, and shooting up was easy. Soon he was hooked on high-potency Fentanyl patches, ripping them in two to wring out the drug, which he would cook up with vinegar and inject through the veins in his feet. "It was as good as heroin," he said. He dabbled in that, too.
Years of negative publicity about OxyContin have made doctors wary of it and other oxycodone-based drugs, local health officials say, but records show that sales of the drug have increased. In 2006, 746,901 grams of oxycodone were distributed for retail sale in Virginia, nearly triple the amount sold in 1999, according to the Virginia Department of Health Professions. Although sales have slowed since 2001, they increased 9 percent from 2005 to 2006.
Police in the region say pain pills are entering Virginia from other states, even Mexico, where they can be casually bought along the border. They can also be ordered on the Internet through shady online pharmacies. The familiar schemes remain popular, too.
"We can't stop people from going doctor shopping," Tazewell Sheriff H.S. Caudill said. "We need a nationwide program to check if John Doe has already been to another pharmacy."
Doctors, meanwhile, have been giving out more methadone than ever. From 1999 to 2006, the amount of methadone distributed for retail sale in Virginia jumped from 30,531 grams to 146,479. An underground market for illegally diverted tablets and liquid doses is thriving.
"When we had problems with OxyContin being diverted, doctors started prescribing methadone," said Martha Wunsch, a researcher who has a grant from the National Institutes of Health to study southwestern Virginia's drug deaths.
Wunsch says that methadone in pill form, not the liquid version legally distributed through addiction clinics, is to blame for the bulk of fatal overdoses. In one study, she found that more than half of all fatal overdose victims had legitimate prescriptions for methadone tablets.
On its own, methadone can't deliver a "high" like oxycodone or other opiates, so users combine it with anti-anxiety drugs such as Xanax to intensify the effect, creating a toxic, often fatal, cocktail. Prescription pills have surpassed marijuana as the top drug of choice for new drug users nationwide, according to the White House's Office of National Drug Control Policy.
"There's not much to do around here," said Jeremy Lowe, 22, a miner who got hooked on Lortab (hydrocodone) after breaking his hand in an accident a year ago. Now he is one of the patients who wait in line at the methadone clinic every morning.
"A lot of my friends who went off to universities ended up coming back home and getting hooked," he said. "It's like it's fashionable to do drugs."
To many, the growing traffic at the Clinch Valley Treatment Center has made it a shameful symbol of the region's drug problem. Several Tazewell officials want to shut the center down or force it to move, seeing its for-profit business model and treatment mission as a conflict of interest. According to the clinic's policy, patients can buy methadone as long as they want; detoxification is voluntary.
The clinic's counseling staff members say that many patients need to be on some sort of drug to cope with severe, long-term pain and that methadone has made them functional. And for those who lack insurance or access to more personalized care, it is often the only affordable option.
"We need to change the way people look at successful drug addiction treatment," said the clinic's director, Sterlyn Lineberry. "Are we reducing harm to the individual? Is the person working? Taking care of their family?"
Wunsch, who used to run a methadone clinic in the region, says the biggest problem is the lack of state and federal support for more comprehensive treatment programs. And powerful stigmas persist. "A lot of people in southwest Virginia believe this is a moral weakness, not a public health problem," she said.
The hard way
Jeff Trapp knows people who have died from methadone but no one who has gotten off it the hard way. He has tried to decrease his dose, but the cravings come back every time. So instead, he drives.
Trapp sets his alarm for 12:30 a.m., waking after a few hours of sleep, and gets dressed in a dark room. His boss does not like that he goes to the clinic, and even less that it has made him late to work, and has threatened to fire him.
In the kitchen, Trapp makes coffee with the light low. There is a plastic bin above the cabinets to catch the rainwater where the roof leaks, and a picture of his wife at her high school graduation hangs on the wall. He carries another photo of her riding a motorcycle. She weighs 95 pounds, but she's a tough lady, he says.
When Trapp starts the pickup down the driveway at 1 a.m., the dogs stand on the doorstep and watch him go. Last year, he put 60,000 miles on the pickup, a 1993 Chevy. The road signs say his route is a designated scenic byway, the Trail of the Lonesome Pine, but Trapp drives it in the dark, and there is nothing to see.
"I don't want to be dependent on doing this every day," Trapp says. He could get permission for a two-week take-home supply of methadone, if he wanted it. He hasn't had a dirty test yet. But does he trust himself? No.
So instead, he drives.
"I don't want that temptation on me," he says. "I'd probably drink two bottles just to see how it felt."
He opens the window a crack to light another Winston, watching the shoulder for deer. When a car passes him on the left, Trapp recognizes the vehicle. He has seen it before, parked outside the clinic.
Staff photographer Andrea Bruce contributed to this report.