Nick Mullins is a founder of Breaking Clean, an environmental communications firm. He blogs at thethoughtfulcoalminer.com.

Before going to work as an underground coal miner, I worked for a subcontractor installing large mine-ventilation fans throughout the Appalachian coal fields. My co-workers were a rough sort. Some had worked as underground miners, while others had known only industrial construction or demolition. Several of them abused pain medications.

I was not a user, so they would ask me if I’d turn them in. My typical response: “Do what you want to do, but if I catch you high on the worksite, or operating a piece of equipment, I’ll make sure you never work here again.”

(Monica Akhtar,Erin Patrick O'Connor/The Washington Post)

My attitude did not change after I began working in a mine closer to home just outside Clintwood, Va. The company I worked for, one of the largest in the region, had a zero-tolerance drug-abuse policy. But the problem was still apparent. We would lose a few co-workers with each random drug test, and stories abounded about smaller mines in neighboring states losing entire work crews.

Some may judge me for not turning people in. But before I rushed to judgment, I considered the reasons they were addicted, and how they were living.

Coal mining is one of the most dangerous jobs in the United States. According to the U.S. Bureau of Labor Statistics, underground bituminous coal miners are three times more likely to suffer serious injuries and illnesses than workers in any other private industry.

Many of those I worked with who were abusing were not “pill heads.” They had weighed a difficult choice: take pain medication to be able to continue to work, or risk fighting for disability compensation that’s seldom enough to pay the bills. Those taking medication on the job were often ashamed of their dependency. In many cases, they avoided working in positions that could get someone hurt.

Mine regulatory agencies have made efforts to reduce the problem, encouraging coal companies to work with miners facing addiction and requiring mandatory drug testing. Few miners will seek help, however, fearing that admitting a drug problem would ensure a pink slip when layoffs came down the line. Even if they decided to risk entering a recovery program offered by the company, good treatment is hard to come by in our area.

In Clintwood, there is only one rehabilitation-detox facility around. It is an hour away, accepts only private insurance or direct payment, is perpetually booked, has lengthy waiting periods, and keeps a few beds available for those taken into custody by law enforcement. The only treatment alternative is a methadone clinic a similar distance away, where the addiction is switched over and “controlled.” Again, the patient must have private insurance or pay out of pocket.

If a miner does manage to get clean, he still has to work every day with pain. It is a dire situation based on economic dependency, and sadly, it has spread far beyond the mining industry and deep into our local communities.

With recent reports showing that many millions of pain pills have been shipped into Appalachia by pharmaceutical companies, evidence is building that the abuse epidemic is not entirely the fault of the addicted. Not only has Wall Street benefited from the trillions of dollars of coal reserves that have been mined here, but it is also continuing to exploit us, reaping profits from the poverty and human suffering left in the wake of a century of coal extraction.

Over the past three decades, I have seen many lives destroyed by this epidemic, including a relative who committed suicide, multiple classmates who fatally overdosed, and many more broken families dealing with their addicted loved ones. If we are to end this problem, we need not only the regulations and facilities to deal with it, but also hope for a future free from the dominance of coal.