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.
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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 says heroin is 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 in suburban Chicago, the sleek urban core of Portland, Ore., and places in between and beyond.
It remains a small part of America's drug problem; cocaine, Ecstasy, painkillers and tranquilizers are all used more, 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.
The surge is easily explained. 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. Whereas a gram of prescription opiates may go for $1,000 on the street, that same gram of heroin will sell for $100, authorities say.
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 Minnesota: Taking the message to the masses
The night before Valentine's Day, some 250 people filed into a Baptist church in Spring Lake Park, Minn., a bedroom community north of Minneapolis that brags of its "small-town charm and friendly folks." There were moms and dads of addicts, as well as children whose parents brought them in hopes of scaring them away from smack.
From the stage, Dan Douglas gripped a microphone as a photograph appeared overhead on a screen: A woman in the fetal position on a bathroom floor. Then another: A woman "on the nod" -- passed out with drug paraphernalia and a shoe near her face.
Douglas didn't mince words. "You just don't win with heroin," he declared. "You die or you go to jail."
It was the third such forum held over two weeks in Anoka County, which encompasses 440 square miles of urban neighborhoods, rural homesteads and suburban centers that are home to nearly 340,000 souls. Since 1999, 55 Anoka County residents have died from heroin-related causes. Only one other Minnesota county reported more heroin-related deaths -- 58 -- and it has a population three-and-a-half times greater than Anoka's.
In 2009, when Douglas began supervising a drug task force, authorities were focused on stamping out meth labs. Heroin, with its dark and dirty image, just wasn't a concern. Then investigators noticed a climb in pharmacy robberies and started finding Percocet and OxyContin during routine marijuana busts.
As prescription drug abuse rose, so, too, did federal and state crackdowns aimed at shutting down pill mills and increasing tracking of prescriptions and pharmacy-hopping pill seekers. Users turned to heroin.
"It hit us in the face in the form of dead bodies," says Douglas. "We didn't know how bad it was until it was too late here in our community."
Douglas says authorities are doing what they can: educating doctors about the dangers of overprescribing painkillers, holding events where residents can dispose of prescription opiates, and aggressively trying to get drugs off the street. But, he says, "law enforcement cannot do this alone."
The idea for the forums came not from police but rather from Pap, a third-grade teacher whose youngest son died of a heroin overdose.
Tanner was an athlete who graduated from high school with honors. In the fall of 2012, he was pursuing a psychology degree at the University of Minnesota, and dreamed of becoming a drug counselor. He had not, to his mother's knowledge, ever used drugs, and certainly not heroin.
Then one day Tanner's roommates found the 21-year-old unconscious in his bedroom.
Amid her grief, Pap realized something needed to be done to educate others. She met with county officials, and the community forums began soon after. At each, Pap shared her family's story.
"Our lives have been forever changed. Heroin took it all away," she told the crowd in Spring Lake Park.
Douglas says most heroin-related deaths he has seen involve victims who struggled with the drug for years. The detective usually tries to shield his own boys, ages 7 and 11, from what he sees on the job. But after meeting parents like Pap, Douglas shared his heroin presentation with his oldest son, complete with the sobering pictures.
"Could I still be blindsided? Absolutely," he says. "But it's not going to be for lack of information on my part. ... I don't want to scare my kid. I don't want to scar my kid. But I sure as hell don't want to bury him."
In Ohio: OD antidote helps save some
Brakes screech. The hospital door flies open. A panicked voice shouts: "Help my friend!" Medical technicians race outside with a gurney. An unconscious young man is lifted aboard, and the race is on to stop another heroin user from dying.
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. But not all. 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. My daughter's on heroin,'" says Candy Murray Abbott, who helped her own 27-year-old son through withdrawal.
Abbott and childhood friend Tammie Norris, whose daughter was also a heroin user, decided last year to bring attention to the problem in their hometown, using Facebook to organize poster-waving demonstrations by everyone from recovering addicts to parents and grandparents of children who died of overdoses.
Norris could only shake her head at the surge in attention to heroin after Hoffman's death. "Well, duh," she says, "it's been happening to our kids every day -- and nobody sees it."
A couple decades ago, the big problem in Hamilton was cocaine. That shifted to prescription drug abuse, which morphed into heroin as pharmaceuticals grew harder to come by. Now 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. Once, they had five overdose runs in a single day.
Users run the gamut, says EMS veteran Jennifer Mason -- from streetwalkers to business executives. They die in cars, public parks, restaurant bathrooms, a university building. Mason has found people turning blue with needles still in their arms.
Sojourner Recovery Services, an addiction treatment organization in Hamilton, has a six-month waiting list for beds for male addicts.
Romanello's hospital saw 200 heroin overdose cases last year, and countless related problems: abscesses from using unsterile needles, heart-damaging endocarditis and potentially fatal sepsis infections.
Overdose patients usually bounce back quickly after given naloxone, known by the brand name 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. Attorney General Holder has called for more first responders to carry it. Last month, Ohio's Republican governor signed into law a measure allowing 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 have that fear of dying. You've blocked the heroin, and they have to have it. They go back out to get more. You haven't fixed their addiction."
In Oregon: A former addict fights back
Before 9 o'clock every weekday morning, the secret to one of the most successful drug rehabilitation clinics in Portland, Ore., waits behind a locked door. Meet David Fitzgerald, leader of the mentor program at Central City Concern, which claims a 60 percent success rate for treating heroin addiction.
The lock, Fitzgerald says, is a necessity because his addicts will take every opportunity offered, including early access to the "mentor room."
Inside, the walls are covered in photos, including a collage from last year's group picnic. Recovering addicts smile and hold plates of food. Seven months later, Fitzgerald looks over the faces. Are they all still sober? Are they all still alive?
"Most of them," he says. "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 that went to 40 percent.
"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."
Fitzgerald, 63, speaks with a laconic prison patois, a reflection of 20-plus years incarcerated, all the while addicted to various drugs. The worst was heroin. In 1997 he got sober, and in 1999 he joined Central City Concern, then a burgeoning outfit.
Fitzgerald saw that the usual path for treating addiction wasn't working. Addicts were processed through detox for seven or eight days, then handed a list of tasks that included finding work, meeting with a probation officer, and locating the drop site for their daily food box.
"Like they're going to do any of that," Fitzgerald scoffs. "First thing they do is see somebody they know, get that fix."
Central City Concern instead accompanies clients to housing appointments, keeps their daylight hours filled with to-dos and requires they spend idle hours at the facility, where they also sleep.
It's a bare-bones staff operating on a razor-thin budget, and 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, who remembers clearly the first time she fired heroin into her veins.
"I heard one time somebody say it's like kissing God," says Padgett. "It is. It's like getting to touch heaven."
Padgett's six-year tumble involved, in order: heroin smoked, heroin shot intravenously, homelessness, one overdose, two close calls, a suicide attempt, arrest, jail, arrest, jail, arrest, jail and, finally, a one-shot, last-chance stop at Central City.
Before sobriety, she found herself selling to people younger than herself, suburban kids rolling up in their parents' cars.
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.
Fitzgerald knows that many of the clients he sees at 25 may be back in rehab at 35, but he tries to remain optimistic that some of what they learn at Central City will, ultimately, make a difference.
"That's about all you can do," he says, "hope some of it sticks."
• Associated Press National Writer Sharon Cohen contributed to this story. Forliti reported from Minnesota; Sewell from Ohio; Duara from Oregon.