The nationally recognized popularity of recreational intranasal oxycodone abuse among rural Appalachians is apparent to West Virginian healthcare providers. Three recent cases of narcotic-induced injury at WVU Ruby Memorial Hospital demonstrate the facial bone necrosis associated with "hillbilly heroin" abuse as well as other imaging features of narcotic-induced intracranial ischemia. This paper shows how diagnostic imaging may facilitate clinical evaluation of patients with narcotic abuse.