Heroin has become the deadly crest of a wave of addictive drug use in communities around the country.
With addicts desperate for a cheaper high than prescription drugs or seeking a more powerful fix, experts are seeing heroin addiction treatment admissions, overdoses and fatalities rising in nearly every region, including areas where the drug has seldom been seen before.
In Ohio, state officials say drug overdoses from heroin increased 25 percent between 2008 and 2009, and are continuing to rise.
In Cowlitz County, Wash., an unusually pure shipment of heroin killed seven people in just five days during April.
In St. Louis city and county, officials report heroin killed 310 people in the past two years alone.
Data from death certificates compiled by the federal Centers for Disease Control and Prevention for 2009, the most recent year available, showed heroin killed nearly 3,500 Americans, almost double the number that perished a decade ago.
Scripps Howard News Service analyzed those statistics and found heroin is a multi-generational threat, but becoming proportionately more deadly among those under 30.
Addiction experts and law enforcement officials say young people may be at particular risk as they move from the relatively certain effects of prescription painkillers to a street drug notorious for ebbs and spikes in potency.
A third of the 3,358 deaths recorded in 2009 occurred among people under the age of 30, including 93 deaths among teens. The bulk of the deaths -- 2,178-- clustered among people in their 30s, 40s and 50s.
In 2001 heroin killed 1,901 people. Twenty-two percent were under 30, including 45 teens.
Experts say there is no typical heroin user. They come from rich and poor neighborhoods, all levels of education, and can be young, middle-aged or old.
"The death certificates don't tell us how long a person had been using heroin, but given the patterns of opioid use we're seeing among people in their 40s and 50s, it's not that surprising that the heroin overdoses are spanning the generations too,'' said Dr. Wilson Compton, director for Epidemiology, Services and Prevention at the National Institute of Drug Abuse.
Federal risk surveys from 2011 show 2.9 percent of high school students have ever tried heroin, and that more than 350,000 Americans of all ages are addicted to the drug. A national surveillance network of hospital emergency rooms estimates that of nearly a million visits for illicit drug abuse in 2009, more than 219,000 were due to heroin.
Law enforcement and addiction experts say the current surge in heroin deaths reflects both the increased availability of the illicit drug in many U.S. communities and a large population of Americans willing to use it because it is cheaper and often more available than prescription opiates, such as OxyContin, that millions have become dependent upon.
In fact, addiction experts from Washington University in St. Louis said in mid-July that reformulation of OxyContin in 2010, aimed at making it harder to crush and dissolve in water for a quick high, seems to have prompted many users to switch to heroin.
The researchers' analysis of data from more than 2,500 patients entering 150 treatment centers in 39 states showed that OxyContin use had plunged by more than half since the formula change.
In interviews with about 150 addicts who had stopped using Oxy, when each was asked what drug they were using now, "most said something like, `because of the decreased availability of OxyContin, I switched to heroin,' '' said Theodore Cicero, a professor of psychiatry specializing in brain reactions to drugs who led the research. His team reported the early findings in a July 12 letter published in The New England Journal of Medicine.
But heroin is a devil's bargain for addicts.
Although a dose that is smoked, snorted or injected may cost $10 compared to the street cost of $50 and up for OxyContin and similar drugs, it's effects are uncertain, more or less powerful at the whim of how dealers "cut" their product with various fillers.
"From a medical perspective, heroin is identical to opioid addiction. It follows the same process in the brain,'' Compton said. "The great uncertainty is the differences in purity, and what may have been added to it. You never know what you're going to get, even if you're taking the same amount you did the last time."
In southern Ohio, "the pain pill addiction is still strong and the stories that we hear are that users start off with the Vicodin, the Oxycodone, the OxyContin. Their tolerance gets higher. It costs more money, and then they turn to heroin as a cheaper alternative,'' said Steve Gifford, program director at the Northland Rehab Center in Milford.
The results can be deadly. In Longview, Wash.,
a small batch of "hot heroin" -- unusually pure -- snuffed out seven lives during one five-day span in April by bringing on almost instant respiratory failure in the users.
In San Diego County, Calif., 721 people under the age of 25 were admitted to treatment centers for heroin addiction last year, three times the number admitted just five years before.
"We have got a heroin epidemic, but it's hidden,'' said Nancy Knott, a counselor with the Scripps Treatment Program in La Jolla, Calif.
St. Louis has been one of the hardest hit areas, with the city and county recording 116 heroin deaths in 2010, and 194 last year, even as the Drug Enforcement Administration and 32 other law enforcement agencies arrested dozens of dealers in the region. Local prosecutors have charged many of them with drug-induced homicide.
Although it follows much the same distribution channels as marijuana, heroin has become more available in some areas, experts say.
The Justice Department's National Drug Intelligence Center noted last year that heroin is "readily available throughout the U.S." The threat assessment also spotlighted the growing involvement of Mexican drug gangs in expanding the distribution of heroin the heartland America.
Once largely considered an urban street drug favored by older teens and young adults "heroin is really cutting across different demographics, it's really reaching into just about every part of the country, although it's more of a problem in a few areas,'' said Rusty Payne, a spokesman for the DEA headquarters in Washington.
East of the Mississippi, most of the heroin is from Colombia and comes in white powder form, Payne said. In the western half of the country, "it's mostly Mexican black tar, very nasty stuff, usually not as pure," the agent added.
The spread of heroin heralds not only more overdoses, but more people hooked on the drug, which is notoriously difficult to shake.
"It feels really good. That's why nobody ever stops once they start,'' said Conner Rehbein, a 21-year-old addict working to recover in a Baltimore treatment center.
Opiate dependence "is very, very difficult to break," said Jon Morgenstern, director of Treatment Research at the National Center on Addiction and Substance Abuse at Columbia University and director of addiction treatment at Columbia Medical Center in New York. "The treatment is very complicated and problematic. There are several medications that can help block the effects, but all have their own problems and side effects."
As the deadly progression from prescription pain medicines to heroin becomes better understood, "One of the things we really have to address is getting more focus on early intervention, on physicians and the medical system spotting these problems with prescriptions before people really get hooked and desperate enough to turn to heroin,'' Morgenstern said.
(Scripps Howard News Service correspondent Thomas Hargrove, Scripps National Investigative Unit multimedia reporter Kristin Volk, Jay Warren of Scripps TV station WCPO in Cincinnati, and Melissa Mecija of Scripps station KGTV in San Diego contributed to this report. Contact Lee Bowman at BowmanL(at)shns.com)