On a beautiful Sunday last October, Detective Dan Douglas stood in a suburban Minnesota home and looked down at a lifeless 20-year-old -- a needle mark in his arm, a syringe in his pocket. It didn't take long for Douglas to realize that the man, fresh out of treatment, was his second heroin overdose that day.
"You just drive away and go, 'Well, here we go again,'" says the veteran cop.
In Butler County, Ohio, heroin overdose calls are so common that the longtime EMS coordinator likens the situation to "coming in and eating breakfast -- you just kind of expect it to occur." A local rehab facility has a six-month wait. One school recently referred an 11-year-old boy who was shooting up intravenously.
Sheriff Richard Jones has seen crack, methamphetamine and pills plague his southwestern Ohio community but calls heroin a bigger scourge. Children have been forced into foster care because of addicted parents; shoplifting rings have formed to raise money to buy fixes.
"There are so many residual effects," he says. "And we're all paying for it."
Heroin is spreading its misery across America. And communities everywhere are indeed paying.
The death of actor Philip Seymour Hoffman spotlighted the reality that heroin is no longer limited to the back alleys of American life. Once mainly a city phenomenon, the drug has spread -- gripping postcard villages in Vermont, middle-class enclaves outside Chicago, the sleek urban core of Portland, Ore., and places in between and beyond.
Cocaine, painkillers and tranquilizers are all used more than heroin, and the latest federal overdose statistics show that in 2010 the vast majority of drug overdose deaths involved pharmaceuticals, with heroin accounting for less than 10 percent. But heroin's escalation is troubling. Last month, U.S. Attorney General Eric Holder called the 45 percent increase in heroin overdose deaths between 2006 and 2010 an "urgent and growing public health crisis."
In 2007, there were an estimated 373,000 heroin users in the U.S. By 2012, the number was 669,000, with the greatest increases among those 18 to 25. First-time users nearly doubled in a six-year period ending in 2012, from 90,000 to 156,000.
Experts note that many users turned to heroin after a crackdown on prescription drug "pill mills" made painkillers such as OxyContin harder to find and more costly. It's killing because it can be extremely pure or laced with other powerful narcotics. That, coupled with a low tolerance once people start using again after treatment, is catching addicts off guard.
In hard-hit places, police, doctors, parents and former users are struggling to find solutions and save lives.
"I thought my suburban, middle-class family was immune to drugs such as this," says Valerie Pap, who lost her son, Tanner, to heroin in 2012 in Anoka County, Minn., and speaks out to try and help others. "I've come to realize that we are not immune. ... Heroin will welcome anyone into its grasp."
IN OHIO: OD ANTIDOTE
HELPS SAVE SOME
Brakes screech. The hospital door flies open. A panicked voice shouts: "Help my friend!" An unconscious young man, in the throes of a heroin overdose, is lifted onto a gurney.
It's known as a "drive-up, drop-off," and it's happened repeatedly at Ohio's Fort Hamilton Hospital. The staff's quick response and a dose of naloxone, an opiate-reversing drug, bring most patients back. Some are put on ventilators. A few never revive.
"We've certainly had our share of deaths," says Dr. Marcus Romanello, head of the ER. "At least five died that I am acutely aware of ... because I personally cared for them."
Romanello joined the hospital about two years ago, just as the rise of heroin was becoming noticeable in Hamilton, a blue-collar city of 60,000 people. Now it seems to be reaching into nearly every part of daily life.
"If you stood next to somebody and just started a conversation about heroin, you'd hear: 'Oh yeah, my nephew's on heroin. My next-door neighbor's on heroin,'" says Candy Murray Abbott, who helped her own 27-year-old son through withdrawal.
Heroin-related deaths have more than tripled in Butler County, where Hamilton is the county seat. There were 55 deaths last year, and within one two-week period, the city's emergency paramedic units responded to 18 heroin overdoses.
Users run the gamut, says EMS veteran Jennifer Mason -- from streetwalkers to business executives. They die in cars, public parks, restaurant bathrooms.
Romanello's hospital saw 200 heroin overdose cases last year. Overdose patients usually bounce back quickly after given naloxone, or Narcan. It works by blocking the brain receptors that opiates latch onto and helping the body "remember" to take in air.
At least 17 states and the District of Columbia allow Narcan to be distributed to the public, and bills are pending in some states to increase access to it. In Ohio, a new law allows a user's friends or relatives to administer Narcan, on condition that they call 911.
Romanello says his patients are usually relieved and grateful by the time they leave his hospital. "They say, 'Thank you for saving my life,' and walk out the door. But then, the withdrawal symptoms start to kick in."
"You would think that stopping breathing is hitting rock bottom," adds Mason. "They don't remember that. ... You've blocked the heroin, and they have to have it. They go back out to get more."
A FORMER ADDICT
They smile down from photos: recovering addicts holding plates of food at a group picnic last year. From inside Central City Concern in downtown Portland, Ore., David Fitzgerald looks over the faces.
Are they all still sober? Are they all still alive?
"Most of them," says Fitzgerald, a former addict who leads the mentor program at the rehab clinic. "Not all."
Heroin cut a gash through the Pacific Northwest in the 1990s. Then prescription pills took over until prices rose. Now the percentage of those in treatment for heroin in Oregon is back up to levels not seen since the '90s -- nearly 8,000 people last year -- and the addicts are getting younger.
Central City's clients reflect that. In 2008, 25 percent of them were younger than 35. Last year the number went to 40 percent.
The crop of younger addicts presents a new problem -- finding appropriately aged mentors to match them with. But Fitzgerald has hope in 26-year-old Felecia Padgett. Before sobriety, Padgett found herself selling heroin to people younger than herself, suburban kids rolling up in their parents' cars. Using heroin, she says, was like "getting to touch heaven."
Fitzgerald doesn't yet have money to pay her, and Padgett herself is still in recovery. But she, and others like her, may play a crucial role in confronting the problem as the face of Portland's heroin addiction gets younger.
"A lot of them aren't ready at a younger age," Fitzgerald says. "The drug scene, it's fast ... it's different. It's harder than it was."