Chronic pain can use a lot of pills per year. One every couple hours perhaps.
I knew WV was a bit militaristic but some google results and some division imply 10% of the population are military veterans. Its almost believable given how many WV residents I met in the Army, generally extremely nice people BTW. So if no one in WV takes pain pills but military vets, then the vets get a whopping two pills per day and everybody else gets precisely zip nada nothing.
Yeah sure most vets are not taking pain pills. But the guy with no working knees or limbs blown off in an IED, he's probably taking more than two per day, the casualties from one IED explosion could make up for a whole retired company or even battalion of people not ever taking pills. And of course the general population has its own segments of people who have permanent physical problems, or temporary, or are painfully slowly dying of cancer, etc.
Here's another interesting depressing bottom up analysis. Lets say a third of people die of cancer after a year of horrific pain taking ten pills per day and they die on average at age 50 (think of all those heavy smokers and heavy drinkers with annihilated livers, plus the numbers are simpler and to one sig fig don't matter anyway). So if it takes 3650 pain pills per cancer death and a third of the population dies of cancer, that means the average dead took 1000 or so pain pills in the year before they died, and unless we suddenly become immortal that divided by 50 year lifetime means the average person is taking 20 pills per year over the course of their life, even if they never take a pill in their lives until the last year of life before a cancer death and 2/3 of them never take a single pill in their entire lives if they die in car accidents or whatever not from cancer. Now of course not every terminal cancer diagnosis takes an entire year to die and not all medical interventions including cancer in remission take zero pills and not everyone with terminal cancer takes ten pills per day, but none of these assumptions are more than an order of magnitude off on average.
Not really the season for depressing analysis like this, but math is math and the general public is utterly innumerate, so its relevant to the discussion...
I would suspect from this bottom up analysis that dozens of pills per person-year is not too far off from other states numbers and by playing games with careful selection of subgroups you can manufacture all sorts of crazy "surprisingly high" numbers that are anything but.