Try this: Hold your breath for two minutes.
That's what Dr. David Chaffin tells his residents at Marshall University's Joan C. Edwards School of Medicine.
"He's walking around the room, slowly talking, already your brain is saying breathe, the longer you hold your breath, the louder and more insistent and persistent that voice gets," describes Mary Aldred-Crouch, director of clinical development at Starlight Behavioral Health, in Huntington. "Now you're turning blue, your brain's screaming at you: Breathe!
"That's addiction."
The urge to breathe, Crouch said, is like the urge that recovering addicts feel for substances like oxycodone and heroin.
That's what's gripping West Virginia, killing hundreds of people every year (most of them young), ruining thousands more lives and shattering families all over the Mountain State.
"Opiates are not what those with an addiction want to do," Chaffin said. "It is what they have to use."
The statistics are numbing. West Virginia leads the nation in overdose deaths. We take more prescription drugs, per capita, than any state except Kentucky. Wholesale drug distributors - not even including the two largest distributors - shipped 200 million pain pills to West Virginia over a recent five-year period. That's about 111 pills for every man, woman and child.
Behind the statistics are people like Kate Grubb, whose daughter, Jessie, is in her fourth stint of rehab in the past six years.
"Who'd think that your kid could be a heroin addict?" Grubb said. "It's just so hard to even know where to begin."
How did this happen?
How did it get to the point where the president of the United States is coming to Charleston to spotlight West Virginia's, and the nation's, ongoing opioid epidemic?
It hasn't always been like this.
Dr. Carl "Rolly" Sullivan has run the Addiction Program at West Virginia University Hospitals since 1985. In the 1990s, about 90 percent of his patients were in treatment for alcoholism, he said.
By 2002, it was 90 to 95 percent prescription painkillers.
"They were just coming in droves," Sullivan said. "It was a staggering transition."
In 2009 or 2010, it flipped again.
Today, his clinic treats 425 patients in Morgantown, and 40 more by tele-medicine in Mercer and McDowell counties - the vast majority, for heroin.
"I probably saw three heroin addicts in the entire 1990s," he said. "I mean there were none!"
The waiting list for his clinic is more than a year.
The root causes of the epidemic, which are not necessarily unique to West Virginia, date back to the mid-1990s - to two changes in federal policy and the launch and promotion of a revolutionary new drug to treat pain.
Go to the doctor, and one of the first things he'll do is measure your vital signs - blood pressure, breathing rate, pulse and body temperature.
In the mid-1990s, there was a push to change that.
"There was a movement that started in the public, some thought it was fueled by the pharmaceutical industry," Sullivan said. "Doctors were inadequately treating pain."
The American Pain Society, a group of doctors and scientists that works on pain prevention and relief, began pushing for doctors to ask their patients more about what kind of pain they were in.
"Vital signs are taken seriously," Dr. James Campbell, president of the American Pain Society, said in 1996. "If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly."
People listened.
In 1999, the Veterans Health Administration launched the "Pain as the 5th Vital Sign" initiative, which required VA doctors to ask patients about their pain - on a 0 to 10 scale - at all visits.
The Joint Commission for Accreditation of American Healthcare Organizations - which accredits 21,000 hospitals and health care organizations - followed suit.
Doctors and nurses across the country were soon asking all their patients to rate their pain on a numeric scale.
"When we did that, a lot of people said they were in pain," Sullivan said.
(Incidentally, a 2006 study published in the Journal of General Internal Medicine concluded that "measuring pain as the 5th vital sign does not improve quality of pain management.")
And just as a whole lot more people realized that they were in pain, a powerful new painkiller came along to treat them.
In 1992, about 30,000 people nationwide were admitted to hospitals for overdoses or other problems related to prescription opioids, according to data from the U.S. Food and Drug Administration.
That number was relatively stable for the next five years. By 1997, it was about 35,000 - a slight increase, but nothing major.
But then, hospital visits for opioid problems took off.
By 2002, there were about 80,000 admissions a year. In 2006, it was 130,000.
What happened?
In late 1996, Purdue Pharma introduced a new drug - OxyContin, a controlled-release version of the pain killer oxycodone. It's designed to slowly release its active ingredient over the course of a day, so a patient in chronic pain needs to take only one or two pills a day, instead of five or six, as was the case for other types of oxycodone medications.
That also meant, though, that each OxyContin tablet had much more of its potent active ingredient than other painkillers available at the time.
OxyContin also came with two quirks on its FDA-approved label, one that made it ripe for abuse and one that made it easy to prescribe.
"Swallowing broken, chewed or crushed OxyContin tablets could lead to the rapid release and absorption of a potentially toxic dose of oxycodone," the drug's initial label read.
It was a veritable how-to guide for abuse.
"This was like an invitation to a junkie," wrote Sam Quinones in his new book, "Dreamland: The True Tale of America's Opiate Epidemic."
The FDA also allowed Purdue Pharma to downplay the threat of addiction posed by OxyContin.
"Oxycodone products are common targets for both drug abusers and drug addicts," the label said. "Delayed absorption, as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug."
Because OxyContin was time-released, the label claimed, it was less likely to be abused, even though it contained large amounts of its active ingredient.
The labeling claim was entirely unique to OxyContin.
"No other manufacturer of a Schedule II narcotic ever got the go-ahead from the FDA to make such a claim," wrote New York Times journalist Barry Meier in his 2003 book, "Pain Killer: A 'Wonder' Drug's Tale of Addiction and Death."
Armed with a favorable label, Purdue Pharma embarked on an aggressive marketing campaign, touting its drug not just for cancer patients, but to primary-care providers, for muscle aches and injuries, broken bones and for post-surgery pain, according to the FDA.
"OxyContin's commercial success did not depend on the merits of the drug compared with other available opioid preparations," said a 2009 study by Dr. Art Van Zee, published in the American Journal of Public Health. The drug, Van Zee wrote, was not significantly safer or more effective than lower-dose versions of oxycodone.
The difference was the marketing.
"This wasn't like some sort of accidental thing, it wasn't a conspiracy, it was just a marketing plan by the pharmaceutical companies," said John Temple, a WVU professor and the author of the new book "American Pain." "And they were spectacularly successful, to our detriment."
In 2001 alone, Purdue spent $200 million to market and promote OxyContin.
The company developed a database, Van Zee wrote, of the doctors who prescribed the most opioids around the country. They sponsored dozens of all-expenses-paid conventions for doctors to come to vacation destinations to learn about pain management.
An army of sales representatives fanned out to doctors' offices across the country. The more they sold, the more they got paid.
In 2001, Van Zee wrote, the average sales representative got $55,000 a year in base salary and $71,500 in bonuses. The number of sales representatives more than doubled from 1996 to 2001.
"They went to doctors' offices everywhere, especially in Southern West Virginia, but really all over Appalachia," Sullivan said. "They went into every little doctor's office you can imagine."
There were about 920,000 OxyContin prescriptions nationwide in 1997. In 2002, there were about 7.2 million, Quinones wrote.
There was no response from state officials.
"We not only were asleep at the wheel, we didn't even know there was a bus," said Delegate Don Perdue, a retired pharmacist of 35 years.
At the same time, a change in federal law helped change the public's attitude toward prescription drugs.
In 1997, the FDA released new guidelines, allowing direct-to-consumer advertising for prescription drugs. For virtually the first time, pharmaceutical companies could now advertise their drugs on television and the radio. (New Zealand is the only other country in the world that allows this.)
"Direct-to-consumer advertising stimulates patient demand for pharmaceuticals, may influence physician prescribing habits and likely increases drug spending," a 2007 study in the American Journal of Medicine concluded.
The change did not directly apply to prescription painkillers. Direct-to-consumer advertising for narcotic drugs like OxyContin is still banned. But the change helped shift the public's attitude toward prescriptions drugs in general, Perdue said.
"Let's say a child, 8 years old, sees these ads on TV. They conclude it's OK. The drugs are safe, they're on TV, they're like peanut butter," he said. "That kind of cavalier attitude toward taking drugs has become pervasive in our society."
"Stocking pharmacy shelves with pure oxycodone pills in the mountains was like throwing dry timber on a smoldering fire - the whole forest blew up," Temple wrote in "American Pain."
"Between 1998 and 2001, a cluster of nine counties on both sides of the Kentucky/West Virginia border received more prescription narcotics per capita than anywhere else in the country. The pills were everywhere, and it was a casual thing."
By now, the opioid epidemic is a nationwide problem, as evidenced by the fact that it's on the president's radar. But it was here first and, to some extent, it's still worst here.
Of the six states hit hardest and earliest by OxyContin abuse - West Virginia, Kentucky, Virginia, Pennsylvania, Ohio and Maine - five are Appalachian.
The reasons are myriad.
"Joblessness and that kind of thing lends itself to a certain amount of despair," Perdue said. "People start trying to escape their reality."
The West Virginia Republican Party has been quick to blame disappearing coal jobs and the president, but the crisis far predates Barack Obama's presidency.
"Low education levels, high rates of unemployment and job-related injuries are closely linked to abuse of alcohol, illicit drugs and prescription medications," a 2009 report from the Appalachian Regional Commission found.
Person after person interviewed for this report mentioned those job-related injuries as a reason why pain killers grabbed hold of Appalachia first.
The painkillers came here, in essence, because there were people in pain.
"West Virginia was ripe for the picking," Sullivan said. "We had a lot of blue-collar workers who were in farming and timbering and coal mining and things that were likely to produce injuries."
Temple said the same thing, and noted that a lack of health care providers in coal communities, back in the 1990s, helped pills spread as well.
"In a mining camp, there aren't a lot of doctors," he said. "That doctor is going to be more likely to opt for the quick fix and give people pills to fix their pain and get them back into the mine, rather than give them rest or therapy or those things that can actually cure pain.
"There sort of emerged a culture of trading pills."
On Friday, David Hughart, a former Massey Energy Co. official, testified in the criminal trial of his former boss, Massey CEO Don Blankenship. On cross-examination, Blankenship's lawyer asked about a 2013 arrest, when police found Hughart with 120 tablets of Opana - a newer opioid painkiller - that he'd planned to use and sell.
Hughart was first prescribed an opioid painkiller in the 1990s, according to testimony at his sentencing hearing.
He said Friday that he'd gotten the prescription after a mining injury, and that it had flared up again. After being on painkillers for four or five months, he said, "I just became addicted to it."
By now, though, the epidemic has stretched far beyond the coalfields.
Gov. Earl Ray Tomblin's brother has battled opioid addiction. So has the state Senate minority leader's son. And the mayor of Charleston's son.
David Grubb was a state delegate and senator from Kanawha County in the 1990s.
"When you see your daughter lying on the bedroom floor, passed out, blue, with a tourniquet around her arm and a needle next to her," Grubb trailed off. "You never get that image out of your head."
His wife, Kate, found their daughter and gave her CPR.
"I still have flashbacks," she said.
The police and paramedics were there within five minutes. They gave her a dose of Narcan, a drug that counteracts the effects of opioids. It saved her life.
That was on Aug. 15 of this year. That was after at least six years of addiction - including "two pretty good years" - and three stints in rehab.
David and Kate Grubb think an ex-boyfriend introduced their daughter, Jessie, to heroin in 2009, but they're not really sure. She's now in rehab for a fourth time, in Ann Arbor, Michigan.
"We were very stupid, ignorant and trusting," Kate Grubb said.
"Kind of innocent and naive," is how her husband put it. "It's a part of the world that we just weren't really conscious of."
At some point in the past five or so years, heroin began to rival pills as the predominant opioid in the region.
That's the drug that has afflicted Jessie Grubb and, by extension, her parents and her four sisters.
Over the past several years, local, state and federal officials have made efforts to crack down on pills - going after "pill mill" pharmacies, pain management clinics and over-prescribing doctors. In 2010, the FDA approved a new version of OxyContin, one that is more difficult to abuse. In 2012, West Virginia strengthened its database to track prescriptions.
"But once you've created an addict or created an addiction, that doesn't go away just because the drugs go away," Temple said.
At the same time, heroin started flowing in from bigger cities - where it has been around for decades - to rural areas, where it was virtually unknown, but where there was a new population of opioid addicts.
"You want to talk about the free market?" Perdue asked. "Talk about prescription drugs versus heroin, because the price [of heroin] went down and the use went way up."
There are differences between prescription painkillers and heroin. At least you know what's in the pills. Heroin could be laced with who knows what. But on a molecular level, heroin and oxycodone are almost identical.
"There's no real difference between having a heroin addiction and having a pill addiction," Temple said. "It's the exact same problem. It's just a morphing of the addiction."
Sitting in their living room on Charleston's East End, its bright walls covered with quilt patterns and family pictures, Kate and David Grubb struggle to put into words the toll that addiction has taken on their family.
For a year after they discovered their daughter's addiction, Kate Grubb told nobody.
"You're so embarrassed and ashamed," she said. "And then, eventually, you come to grips with it and you meet a bazillion people in the same situation."
Their daughter did well in school, "99th percentile on all the tests," Kate said. She did theater. She got suspended from high school once - for protesting the war in Iraq.
But, on drugs, she became almost a different person.
"The main thing is betrayal," Kate said. "Because everything you ask her when she's in active addiction, the answer is a lie."
She said she relies on family, wonderful friends and prayer to help her cope.
David Grubb said he tries not to think about his daughter's struggle, to focus on other things. Otherwise, how can you get through the day?
But it hits you at the oddest moments.
"You'll be walking down the street," he said, "and, bang, it just hits you, and for no apparent reason, you'll cry."
Staff writer Ken Ward Jr. contributed to this report. Reach David Gutman at david.gutman@wvgazette.com, 304-348-5119 or follow @davidlgutman on Twitter.