Last month, 18-year-old Samantha Jenkinson from Hull became the first person in the UK to die from an overdose of OxyContin. But the prescription painkiller has already killed 300 in America. Paul Tough traces the spread of 'hillbilly heroin' from the Appalachian backwoods to the teen party scene in Britain

Paula is taking me on a driving tour of Man, the West Virginia town where she has spent her entire life. Because I don't know my way around the hollows and gullies and creeks that carve through these hills, Paula is at the wheel. And because Paula isn't a morning person, we've set out on our tour at midnight.

The tour Paula is leading isn't sanctioned by the local chamber of commerce; it's a pillhead tour: an addict's-eye view of the radical changes that a single prescription drug, OxyContin, has brought to the town. 'That's my best friend's trailer right there,' Paula says, pointing out a comfortable-looking single-wide across the creek. 'She's somebody that you couldn't look at and know she was an oxy addict. She was a cheerleader in junior high. She's married. You can't just look at somebody and tell.'

A few years ago, Paula says, Man was like any small town in America: you could buy a variety of illegal drugs, as long as you knew the right person to talk to. Pot was big; there was occasionally some cocaine around and a few pills for recreational use. But these days, she says, the only drug for sale in Man is OxyContin, a narcotic painkiller that users crush - to disable its patented time-release mechanism - and then snort or inject for a powerful and immediate opiate high. Legally, it's sold only by prescription for the treatment of chronic pain. In practice it's available just about everywhere around here, for cash. The going rate is a dollar a milligram, or $40 for a 40mg pill.

Paula is a thoughtful 24-year-old with wispy blonde hair, serious eyes and faded jeans. She's fidgety; as she drives with one hand, she's rummaging through her handbag with the other, looking for her pack of Marlboro Lights. She finds them, removes one and stabs the dashboard lighter. 'I'll show you some places over here,' she says, as she turns her car off the main road, over a bridge and down into a rough indentation that holds a couple dozen trailers and prefab homes. 'This is Green Valley. We just call it the valley. It's a pretty good neighbourhood,' she says, then interrupts herself. 'Well, except that's a dealer there.'

She points to a trailer with a pickup out front and a light burning inside. I crane my neck to get a look at a real-life drug den, but the tour has already moved on. Paula is pointing out a trailer on the other side of the road: 'That's a small-time dealer there, nothing big,' she says. Then she points to another one, and then another: 'That's a dealer... That's a small-time dealer... That's a dealer... Her son's a dealer, but I don't know if he lives there... He uses, that boy in there... They use really, really big.'

We're driving slowly around the circular dirt road that is the only path through Green Valley. The neighbourhood doesn't feel dangerous - no graffiti, no pit bulls, no broken bottles lying around. Still, Paula is pointing out criminal activity in every second home, peering through the front windshield and gesturing left and right.

The first time Paula did an oxy (as she calls the pills), in the summer of 1999, it didn't do much for her. 'That first 10mg pill, I didn't really feel nothing off it,' she says. 'But the second time I did it, I did two 20s, and I was high.' She liked the effect. 'When you get that oxy buzz,' she says, 'you're happy. Your body don't hurt. Nothing can bring you down. It's a high to where you don't have to think about nothing. All your troubles go away. You just feel like every-thing is lifted off your shoulders.'

What Paula calls 'that oxy buzz' comes from OxyContin's only active ingredient: oxycodone, an opioid, or synthetic opiate, developed in a German laboratory in 1916. Chemically, it is a close relative of every other opium derivative and synthetic: heroin, morphine, codeine, methadone. And just as every opiate does, oxycodone creates a physical dependence in most of its users and a powerful addiction in some of them. 'At first you do them to get high,' Paula says, 'and then after you're addicted, you don't do them to get high - you do them to survive.'

The earliest reported cases of OxyContin abuse were in rural Maine, rust-belt counties in western Pennsylvania and eastern Ohio and the Appalachian areas of Virginia, West Virginia and Kentucky. The problem travelled through these regions, as word spread from town to town, county to county, up and down the Appalachians. There are a few defining characteristics that the first affected regions share: they're home to large populations of disabled and chronically ill people who are in need of pain relief; they're marked by high unemployment and a lack of economic opportunity; they're remote; and they are areas where prescription drugs have been abused in the past. 'There's always been a certain degree of prescription-drug abuse in this area,' says Art Van Zee, a physician in Lee County, Virginia, 'but there's never been anything like this. This is something that is very different and very new, and we don't understand all the reasons why. This is not just people who have long-term, substance-abuse problems. In our region, this is young teenagers, 13 and 14-year-olds, experimenting with recreational drug use and becoming addicted.'

In Man, Paula said, it was like OxyContin came out of nowhere. One day no one had heard of oxys, and a month later, the pills had become a way of life for hundreds of locals. When Paula wants to buy an OxyContin pill, she simply drives to a dealer's house and knocks on the front door in broad daylight. If she knows the dealer well enough, she'll go on in and snort the pill there. If not, she'll hand over the cash, put the pill in her pocket and drive away. Sometimes she'll be the only person there; other times, there will be a dozen cars lined up out front.

The dealers have the benefit of a captive market: OxyContin, like any opioid, is very difficult to quit abusing. And given the pill's ubiquity here in Man, and the fact that the nearest rehab clinic is two hours away, this is an unusually hard place to quit using it. Nonetheless, Paula is trying. Six months ago, she and her best friend decided they were going to quit cold turkey. They took a couple of days off work, locked themselves in her friend's trailer and started to detox. 'That was the worst three days of my life,' Paula said. 'Honestly, I prayed to God to let me die. That's how bad it is. If you can get past the third or the fourth day, you're pretty much fine, but most people don't make it.' Paula and her friend didn't make it: at the end of the third day, they went out and got a pill.

Although heroin and OxyContin have a similar unhappy effect on the lives of the people addicted to them, there is a critical and simple difference between the two: heroin is illegal; OxyContin, when used as directed, is legal. More than that: the pill is made by Purdue Pharma, a successful and well-regarded pharmaceutical company, headquartered in Stamford, Connecticut. It is prescribed to 1m patients in the US for the treatment of chronic pain, and it is closely regulated at every stage of its manufacture and distribution by the Food and Drug Administration and the Drug Enforcement Administration.

This fact has meant a major conceptual shift for law-enforcement officials, who are used to combating narcotics produced by international drug lords, not international corporations. As Scott Walker, the director of Layne House, a drug treatment facility in Prestonsburg, Kentucky, says: 'You don't have the Coast Guard chasing OxyContin ships. This isn't something you can stop at the border. It's growing from within.'

Part of what makes the spread of OxyContin abuse so difficult to track, let alone to stop, is that the drug moves not physically but conceptually. When crack cocaine spread from the big cities on either coast toward the centre of the US, it travelled gradually, city by city. OxyContin abuse pops up suddenly, in unexpected locations: Kenai, Alaska; Tucson; West Palm Beach, Florida. At the Gateway Rehabilitation Center in Aliquippa, a suburb of Pittsburgh, Jay, a recovering OxyContin addict and a former small-time dealer, offered an explanation for OxyContin's sudden geographical shifts. 'It's the idea that passes on,' he told me. 'That's how it spreads. There aren't mules running the drug across the country. It's dealt by word of mouth. I call a friend in Colorado and explain it to him: "Hey, I've got this crazy pill, an OC 80, an OC 40. You've got to go to the doctor and get it. Tell him your back hurts."'

Jay is 26, a college graduate and former nurse. He started doing oxys in 1999, and his consumption quickly rose to 240mg a day. He was clean when we met and trying to stay that way. But when he talked about the drug's potential as a small business, he couldn't help getting excited.

Unlike heroin, Jay explained, OxyContin doesn't require investment or muscle or manpower to move across the country. OxyContin abuse is a contagious idea - a meme, if you will. Because OxyContin, the medicine, is readily available in pharmacies everywhere, all it takes to bring OxyContin, the drug, to a new place is a persuasive talker like Jay.

In order to understand the dilemma of OxyContin, you need to understand the long-fought war among doctors over pain and addiction. For centuries, opium and its derivatives have been considered a double-edged sword - the most effective painkiller on earth and also the most addictive substance. For most of the 20th century, opiates were considered too danger- ous to use in all but the most critical pain treatments. The assumption was that their medical use would inevitably lead to addiction. In the late 80s, for the first time, public and medical opinion began to swing decisively in the other direction. Patient advocates and pharmaceutical companies encouraged the medical community to rethink its approach to opioids, especially in the management of cancer pain. Their campaign was persuasive. Between 1990 and 1994, morphine consumption in the US rose by 75 per cent, and in 1994, the Department of Health and Human Services issued new clinical guidelines encouraging the use of opioids in the treatment of cancer pain.

Purdue Pharma was a leading player in the pro-opioid campaign. The company contributed generously to patient-advocacy organisations, including the American Pain Foundation, the National Foundation for the Treatment of Pain and the American Chronic Pain Association, and underwrote dozens of scientific studies on the effectiveness of opioids in the treatment of pain. In 1985, the company began marketing MS Contin, a time-release morphine pill that was used to treat cancer pain. As attitudes on opioids shifted, Purdue began promoting it for non-cancer pain as well.

Dr Russell Portenoy is chairman of pain medicine and palliative care at Beth Israel Medical Center in New York City, and the co-author of a groundbreaking 1986 study that supported the long-term use of opioids to treat non-cancer pain. 'Between 1986 and 1997, within the community of pain specialists there was increasing attention on the role of opioids,' Portenoy says, 'but there was relatively little diffusion of that idea to family doctors and other non-specialists.' That began to change, he says, with the FDA's approval of OxyContin in 1995: 'There was a sea change that occurred with the release of this drug.' For the first time, GPs began to prescribe strong, long-acting opioids to treat chronic non-cancer pain. Portenoy says the change was due to four factors that came together at about the same time. 'The reasons were partly cultural - the attitudes of the medical and regulatory communities had been gradually shifting for a decade. They were partly medical - studies had been coming out showing that patients with low-back pain, headaches and neuropathic pain might benefit from long-term opioid therapy. They were partly pharmacological - OxyContin made it easier and more convenient for patients to receive long-term opioid therapy. And they were, finally, related to marketing, because Purdue Pharma was the first company to advertise an opioid pill to GPs in mainstream medical journals.'

In addition, the company began an innovative indirect-marketing campaign just before OxyContin's release. Because of regulations on the marketing of narcotics, the company was unable to use direct-to-consumer advertising. Just as Nike advertises the concept of sports instead of shoes, so Purdue would market the concept of pain relief to consumers, but not OxyContin. In 1994, the company launched Partners Against Pain, a public-education programme that at first concentrated on cancer pain and later expanded to include other forms of long-term pain. Through videos, patient-pain journals and an elaborate website, Purdue promoted three ideas to doctors and patients: that pain was much more widespread than had previously been thought, that it was treatable, and that in many cases it could, and should, be treated with opioids. Partners Against Pain didn't promote OxyContin specifically - the company's marketers knew that simply expanding the total market would also increase their bottom line.

OxyContin was seen by many doctors as the solution to the long rift between pain specialists and addiction specialists. Purdue Pharma believed that OxyContin's time-release function would mean a lower risk of addiction than other opioid medications. Over the next few years, sales of OxyContin exploded. OxyContin prescriptions in the US have more or less doubled in number each year since its release. The company's revenues from the pill jumped to $1.14bn in 2000 from $55m in 1996. Last year, American doctors wrote more than 6.5m OxyContin prescriptions. Purdue's attempt to expand the opioid marketplace beyond cancer patients was also remarkably successful. Five years ago, cancer patients were still the main market for long-acting opioids, but the largest group of prescribers is now family physicians.

According to Portenoy, this change in the number and kinds of doctors prescribing OxyContin is fundamentally linked to the spread of OxyContin abuse. 'It's not the drug, per se,' Portenoy says. 'It's rapidly expanding access, plus the reality of doctors prescribing it who may not have the skill set required to prescribe it responsibly.'

Purdue's field reps were the first wave of OxyContin apostles, spreading word of the pill's effectiveness door to door - doctor by doctor, pharmacist by pharmacist. But Purdue's officially sanctioned word-of- mouth marketing campaign was followed by another, unsanctioned one. This time the news was that the miracle pill had an Achilles heel, that its time-release matrix could be eliminated in a matter of seconds by the simple act of crushing the pill with a spoon, a lighter, even a thumbnail, and that the resulting powder, when snorted or mixed with water and injected, produced a very potent high. The apostles this time were not Purdue's reps but casual drug abusers. And just like Purdue's, their marketing campaign was enormously successful.

In a steel-mill suburb northwest of Pittsburgh, the leader of the second wave of OxyContin apostles was Curt, a young man who in 1998, at the age of 23, found himself kicked out of the Air Force and living back in his hometown. He worked the midnight shift running cranes at the mill, and he dealt a little marijuana during the day.

In April 1999, someone in his circle was prescribed OxyContin. Curt assumed that it was just like any other pain pill. But at a party, he figured out the trick of crushing the pill and snorting the powder, and he quickly spread the word. 'I showed a lot of people,' Curt says. 'At first they were like, "You're crazy." But then they'd do it, and that would be it. People tell me now, "Yeah, you're the one who showed me how to snort this thing."'

Oxys quickly became very popular in Curt's circle of friends, and Curt found a comfortable niche for himself between supply and demand. 'I knew people all over the county that were getting prescriptions,' he says. 'They'd call me and say, "I'm getting OCs now and I want to get rid of them." They knew there was money there, but they didn't know who to sell to. They usually gave me a heck of a deal. For every one I sold, I made one. And then I'd give them their money and the next month I'd get their scrip again.'

Before long, he had 10 people giving him their pills to sell, mostly women in their thirties and forties on welfare or disability. 'It's so weird the people that got into this,' Curt says. 'Some of them were innocent mothers. I had one that was in her sixties. She never did drugs. She'd sell every last one of her pills, and it would pay for all her other medication.' Curt would keep careful track of which day of the month each of his suppliers filled her prescription. 'A lot of times I would drive them to the pharmacy.'

On the demand end, Curt had between 25 and 50 steady customers. 'I had a cell phone at that time, so I was doing a lot of driving,' he says. 'People would gather at their houses, and they'd bring all their friends over, 10 of them that'd use it. They'd all gather when they knew I was coming, because they wanted the pill immediately.'

Curt has been in recovery for a few months now; since he got out of rehab, he's been cut off from almost all his old friends, and he fills his spare time fixing up his sister's house, fishing and reading up on psychology, which he plans to begin studying. He's a man of boundless energy and focus, and he has taken to the 12-step process with an unusual intensity; in his first 60 days clean, he told me, he attended 138 Narcotics Anonymous meetings. That same energy served him well back in his oxy days, when he was cutting steel at the mill all night and driving around making pick-ups and deliveries all day.

It was only a couple of months after OxyContin arrived in town that Curt and most of his customers realised they were addicted. At first, they were happy just to take a pill whenever one was around, for fun, but soon they found themselves experiencing severe withdrawal symptoms if they didn't have a pill every day. Everyone's tolerance built up quickly - one week they were able to get by on a 20 a day, the next week they'd need a 40, and a couple of weeks later, it had to be an 80. 'No one knew what was going on,' Curt says. 'These are a bunch of pot smokers, drinkers, just mellow people. This drug just took us by storm. A whole community, at least 100 people I know around here. They're all into the addiction. These are guys I used to smoke pot with and drink beer with in the woods. I grew up with them all, having parties and that. And now there's not one of them - not one of them - that don't use pills.'

Purdue Pharma wasn't aware of significant problems with OxyContin abuse until April 2000, when a front-page article in The Bangor Daily News claiming that OxyContin 'is quickly becoming the recreational drug of choice in Maine' landed on the desk of Purdue's senior medical director, Dr J David Haddox. In the summer of 2000, the company formed a response team, made up of medical personnel, PR specialists and two of the company's top executives, which has guided the company's OxyContin campaign ever since.

It's fair to say that in public-relations terms, Purdue's reaction to the OxyContin problem has been less than successful. It is now facing potential class-action suits from former patients, as well as one from the attorney general of West Virginia, John Ashcroft called OxyContin a 'very, very dangerous drug'. Donnie Marshall, then head of the DEA, said that unless he received 'more co-operation' from Purdue, he was 'seriously considering rolling back the quotas that DEA sets to the 1996 level,' which would have meant a 95 per cent cut.

Purdue's PR problems seem rooted in the company's deep-seated belief in the inherent safety of and public need for its product. It is an article of faith for the company that illegal traffic in its drug is the work of 'bad guys' and 'professionals,' in Haddox's words. In fact, Purdue says that its internal data indicates that the levels of OxyContin abuse in the country are no greater than expected. 'We have had increased numbers in the past year or so,' I was told by Robert Reder, Purdue's vice president of medical affairs and drug safety, 'but our estimation is they're commensurate with the distribution of the drug.' The abuse situation, according to Reder's numbers, is normal. The real victims, the company says, are their 'legitimate patients,' who would be denied OxyContin if its distribution were restricted.

The lack of co-ordination between Purdue and the government agencies that regulate it has had serious repercussions in affected communities, as local police, small-town mayors and individual doctors and pharmacies have been forced to make up their own policies on the fly. Six US states have introduced regulations making it harder for Medicaid recipients to receive OxyContin. After a spate of pharmacy robberies near Boston, dozens of drug stores pulled OxyContin from their shelves - only to be ordered by the state pharmacy board to begin carrying the drug again.

Purdue's executives see the company as an unwitting victim of criminal activity. The company's critics prefer to compare Purdue to tobacco companies and handgun manufacturers, who are likely to be found liable for deaths caused by their products.

When I returned to the Gateway rehabilitation Center, I got a clearer sense of the way in which OxyContin is taking hold in urban and suburban America. I also learnt about an unexpected secondary effect of OxyContin abuse: in cities like Pittsburgh, the crackdown on OxyContin is resulting in a sharp rise in heroin abuse.

I sat for an afternoon in a glassed-in conference room, looking out on Gateway's parking lot and groomed grounds, and talked with Andy and B, two addicts and former low-level dealers. Before trying OxyContin, they had used their share of recreational drugs, but they didn't consider themselves part of a hardcore drug community. Aside from the track marks on his arms, B, 21, looked like every disaffected college kid in America. He was a professional sloucher, dressed in an orange T-shirt, army shorts and trainers, with a mop of brown hair. Andy wore a sparse goatee, a hooded sweatshirt and a baseball cap with a Japanese character on it. I asked him what it meant, and he said he didn't know.

B began using OxyContin in 1998, when a friend told him about the pills. He soon started dealing to support his habit, buying pills from a dozen or so people and then selling them from his apartment to friends and friends of friends. His sources were all legitimate patients, sick with cancer, carpal-tunnel syndrome, lupus or chronic back problems. But, as B explained, they would often supplement their prescriptions with something weaker and cheaper, then sell the OxyContin. 'Some of them were old sick ladies who've never done drugs,' B said. 'They didn't understand what oxy can do to people. They just wanted that money.'

Andy laughed. 'Old people are supposed to keep young people off drugs,' he said.

B described the casual feel of his drug deals. For the first several months that he was selling, he said, everything was friendly when he'd go to pick up pills from his suppliers. 'Most would say, "Hi, honey, come on in." You go into their house and sit down and have something to drink and talk for a while and see how their family's doing, and they see how mine's doing.'

But as the police and news media began to sound the alarm about OxyContin abuse, local doctors grew anxious. Many switched their patients to harder-to-abuse drugs, and B lost most of his connections. The supply dried up, prices rose and people started ripping each other off.

A friend told him that shooting heroin was just like shooting OxyContin, only cheaper. He'd never imagined he might take heroin, but the expense of OxyContin was killing him. 'I was spending 100 bucks a day on oxy,' B said. 'That's why I switched to heroin. You get really high off two bags, which is 30 bucks a day. That's a big saving.'

Andy agreed. It took him only a month and a half to go from using OxyContin for the first time to shooting heroin, he said. 'I've always said that I'd never, ever touch heroin. But then oxys came along and that's the same thing, just cleaner. And that got me into shooting dope. If I'd never touched OxyContin, I wouldn't have done heroin.'

In Pittsburgh, Andy and B's stories aren't unique. Gateway's doctors report a sharp increase in admissions of young heroin addicts who started out on OxyContin. 'Ninety per cent of my friends that were addicted to oxys are now addicted to heroin,' B says. 'I know probably 30 or 40 heroin IV drug users now because of OxyContin.'

OxyContin entered the lives of casual drug users as a Trojan horse, disguised as something it is not. It has never become a popular drug among existing heroin or crack addicts, who already have a cheaper mechanism for getting high. OxyContin does the most damage when it enters a community of casual drug users - Curt's pot smokers and beer drinkers - who think of pain pills as just another interesting diversion for a Saturday night. In networks like Curt's or Paula's, before OxyContin, no one ever did heroin or crack; those were seen as an entirely different category of drug: something that will take over your life.

When you hold it in your hand, an OxyContin pill doesn't seem any different than any of the mild narcotic preparations that have for years seeped out of the pharmaceutical pipeline and into the lives of casual drug users. What B and Andy and Paula and Curt failed to realise is that, despite appearances, OxyContin actually belongs on the other side of the drug divide - it might look like a casual Saturday-night drug, but it's a take-over-your-life drug.

To Art Van Zee, the doctor who has seen his small community in western Virginia 'devastated' by OxyContin abuse, the answer to the crisis is to take OxyContin off the market. Van Zee is circulating a petition asking the FDA and Purdue to withdraw the pill until a safer formulation can be found. 'The bottom line is, there's much more harm being created by this drug being available than good,' he says. 'There are already very good medicines available that are equally effective.'

But for many people, 'drug communities' like Curt's are not worthy of a whole lot of official sympathy or regulatory concern - especially not when their interests are considered next to those of patients in pain, who are using OxyContin the way it is meant to be used and whose lives have been improved as a result. For doctors who have seen their patients transformed by OxyContin, there is something mystifying, even infuriating, about the suggestion that it should be withdrawn or even restricted, just because a bunch of kids in Kentucky didn't know what they were snorting.

'There is no question that increasing opioid consumption for legitimate medical purposes is going to lead to some increase in the rates of addiction,' Portenoy of Beth Israel says. 'But the fact is, the trade-off is worth it. At the moment, the attitude is that if one housewife in Alabama becomes addicted, then the drug must be pulled and the company shut down. But we're talking about millions of people whose lives can be brought back from total disability by the proper use of opioids. Any actions taken by law enforcement or the regulatory community that increase the stigma associated with these drugs, or increase the fear of physicians in prescribing these drugs, is going to exacerbate an already terrible condition and hurt patients.'

The 10th point in Purdue Pharma's 10-point plan to reduce OxyContin abuse is reformulation. The company says that it is spending millions of dollars to create a new version of OxyContin, or perhaps an entirely new medication, that would have all the benefits of OxyContin and none of its dangers.

In some recent interviews, Purdue's representatives sound enthusiastic about this idea. But when pressed, Haddox admits that what Purdue's scientists are looking for is a 'holy grail,' a drug that will activate the receptors in the brain that control pain relief and leave alone those that control euphoria. And this isn't a new initiative, it turns out, but one that the company has been working on for many years.

There are often suggestions from Purdue that this reformulation may take 'a few years' - it's also entirely possible that it will never happen. Opioids, including OxyContin, may remain the double-edged sword they have always been. And regulators may simply decide to accept a certain amount of unintentional damage in the treatment of pain, and leave local police chiefs and drug counsellors - as well as individual addicts - to find solutions to the OxyContin problem on their own.