Heroin in Charlotte has become so easy to get that dealers deliver to the suburbs and run specials to attract their young, professional, upper-income customers.
These lawyers, nurses, cops and ministers are showing up in the detox ward at Carolinas Medical Center, desperate to kick an opiate addiction that often starts with powerful prescription painkillers such as OxyContin and Vicodin.
The center analyzed the patients' ZIP codes to find out where heroin had taken root, says Robert Martin, director of substance abuse services at the medical center.
"Our heroin patients," he said, "come from the five best neighborhoods."
What Martin and others like him are witnessing is a growing and more dangerous wave of drug addiction sweeping the country, ensnaring a new population - several hundred thousand Americans - in the heroin trap and importing crime to America's suburbs. Feeding the frenzy: Prescription painkiller addicts are finding their drug of choice in short supply, so heroin becomes their drug of last resort.
As addicts move from legitimate prescriptions to the black market of pure, precisely measured narcotic pain pills to the dirty world of dealers, needles and kitchen table chemists, health officials and police are noting sharp increases in overdoses, crime and other public health problems.
"When you switch to heroin, you don't know what's in there from batch to batch," says Karen Simone, director of the Northern New England Poison Center, which in September documented a spike in heroin overdoses in Maine, New Hampshire and Vermont. "It's a big jump to go to heroin. It may be strong; it may be weak. They don't know what they are getting. Suddenly, the whole game changes."
WHAT'S DRIVING THE SHIFT
America arrived at this moment after a decades-long increase in the number of people using, and abusing, powerful pain pills. The narcotics had become easier to obtain - some pain clinics issued prescriptions by the thousands - and many found a quick path to the black market.
To stem the abuses, authorities over the past decade began cracking down on clinics, and drug companies began creating pill formulations that made them harder to crush and snort for a quick high. Thus, opiate addicts have found it more difficult, and expensive, to get their fix. An 80 mg OxyContin can cost $60 to $100 a pill. In contrast, heroin costs about $45 to $60 for a multiple-dose supply.
OxyContin, a narcotic painkiller in the opiate family, came on the market in 1996. By 2001, it became the nation's best-selling brand name narcotic pain reliever. Although it's a highly effective drug for people suffering from chronic pain from diseases such as cancer, the Drug Enforcement Administration noted high levels of abuse, particularly in West Virginia and Kentucky, where it became known as "hillbilly heroin."
Once tighter restrictions were in place, prescription painkiller abuse declined, particularly among young adults 18 to 25, according to the most recent National Survey of Drug Use and Health. At the same time, the number of heroin abusers rose sharply.
•The number of people who say they regularly abuse painkillers dropped from 5,093,000 in 2010 to 4,471,000 in 2011, according to the National Survey on Drug Use and Health. Young adults who said they regularly abused painkillers dropped from a high of 1.62 million in 2006 to 1.22 million in 2011, the survey found.
•The survey estimated that 281,000 people 12 and older regularly used heroin in 2011, up from a decade low of 119,000 in 2003.
•Another study that measures the number of people seeking treatment for heroin found increases in 30 of 39 states reporting data in 2011 to the Substance Abuse and Mental Health Services Administration. In 2011, 238,184 sought treatment for heroin addictions, up from 224,198, SAMHSA spokesman Brad Stone said.
A LETHAL SUBSTITUTE
Doctors, substance abuse counselors, police and federal agents from Portland, Maine, to San Diego, in cities such as Charlotte and small towns in central Pennsylvania, also report surges in heroin use. In Illinois, the state crime commission in March called heroin an epidemic after authorities noted that the Chicago metro area ranks first in the nation for people admitted to the emergency room for heroin use.
Public health authorities in Portland, Maine, which struggled with pain killer abuse for nearly a decade, expected an increase in heroin abuse and are dealing with the fallout of overdoses, says Ronni Katz, substance abuse prevention program coordinator for the city. Portland issued an alert Feb. 5 about a potent batch of heroin that apparently led to a rash of overdoses.
"One substance will go down, but another will go up. And unfortunately, I think (heroin abuse) is going to grow," Katz said.
The trend to heroin bore out in Mark Publicker's 24-bed detox ward at Mercy Hospital Recovery Center in Portland, where as many as half the patients are addicted to opiates. Publicker saw a startling change six to eight months ago as patients, who once favored oxycodone, reported intravenous heroin as their opiate of choice.
IV heroin is particularly dangerous because addicts may share needles, exposing themselves to blood-borne diseases such as HIV and hepatitis, and can easily overdose when injecting heroin directly into their bloodstream, Publicker said.
"As bad as oxycodone is, heroin is worse," Publicker said. "It's worse because here in Maine, it's injected. We're talking about a novice population of drug injectors who are not educated about needle use."
Most frightening, he says, is how young the users are. "We're talking 18-, 19-, 20-, 21-year-olds," he said.
One young patient who entered treatment in February started using painkillers properly prescribed after ankle surgery but became addicted within a year, Publicker said. About 18 months ago, she switched to IV heroin and shared needles with her boyfriend.
"I don't think this is an atypical story," Publicker says.
Supervisory Special Agent Tom Lenox of the DEA's San Diego's office says he, too, has seen teens progress from popping pills to smoking heroin. "It's unbelievable that we're talking about this stuff with teenagers," he said.
In Charlotte, many of the opiate addicts in the Carolinas clinic got their start with powerful painkillers prescribed after surgery or a broken bone, said Martin, the substance abuse services director. As doctors cut off their prescriptions and the black market supply withered, they turned to cheaper, easier-to-find heroin.
The going rate for a tiny balloon filled with a dose of heroin costs $9, Martin said. A heavy user may take up to 10 doses a day. In contrast, prescription pain pills containing oxycodone sell for up to a dollar a milligram - $80 for an 80 mg pill.
"A lot of dealers, if you buy nine balloons, they give you one free," he says. "You can call or text a dealer, and they'll deliver."
'HEROIN IS HUGE'
Once considered an urban drug, heroin has found an unwelcome home in small towns and suburbs.
In Minnesota, one in five people seeking treatment is addicted to opiates, says Carol Falkowski, the former drug abuse strategy officer for Minnesota and a member of the Community Epidemiology Working Group at the National Institute of Drug Abuse, which tracks trends in drug use.
"Heroin is huge. We've never had anything like it in this state," she says. "It's very affordable. It's very high purity. Most people did not believe that heroin would happen here in Lake Woebegone, but it really has a grip, not only in the Twin Cities, but all around the state."
In Elizabethtown, Pa., a borough of 12,000 people in Lancaster County, Police Chief Jack Mentzer noted prescription pill addicts gradually turn to heroin over the past 18 months.
"Folks are looking for that better high," Mentzer said. "Lots of them started with prescription drugs. When that didn't do it, they would start crushing them. And when that didn't work, they turned to more of the street drugs."
With the street drugs came the crime wave.
"The No. 1 thing that we see are the crimes that are directly or indirectly related to the drug abuse," Mentzer said. "They will do almost anything for a quick dollar, stealing from mom and dad, committing burglaries."
In Delaware, heroin investigations have soared over the past two years, says Sgt. Paul Shavack, spokesman for the Delaware State Police and a former commander of the state's drug task force.
In 2011, Delaware State Police conducted 578 heroin investigations. Last year, the number of investigations more than doubled to 1,163, Shavack says. This year, heroin continues to be the top street drug, and the whys in Delaware are the same as in other states from coast to coast: It's cheaper and easy to get. Crime, too, has spiked - particularly burglaries and thefts from vehicles, Shavack says.
"You look for your next hit or your next high," he says. "You have to have money to do that, so they look for quick-turn items like jewelry and electronics. They sell (the items) very quickly and go get their next bundle of heroin."
For many, it's simple economics, says DEA Special Agent Amy Roderick in San Diego.
When pain pill addicts in San Diego can't find or afford OxyContin, which sells for as much as $100 a pill there, they'll purchase heroin for $80 a gram, she said.
"You're just getting more bang for the buck," Roderick said. "Once you're addicted to an opiate, you're addicted. If you can't get what you want, you'll take what you can get," even if it means using a needle to get high.
Many of the heroin users and dealers whom federal agents arrest in San Diego are younger than 30, and some are as young as 17, she said.
"They're telling us as we're arresting them, 'We can't find the Oxy. We can't find the Vicodin,' " Roderick said. "It's a very dangerous drug. Once you're addicted, it takes over your life."