This is the first article in a three-part series. Read part two: "How families can work together to fight heroin addiction
." Read part three: "As heroin use rises, treatment experts reflect on their efforts."
They lived in tattered boxes, abandoned cars and the backyards of dilapidated houses.
It didn't matter. They were addicts in their teens and twenties. All they needed was heroin.
"I didn't care about my family. I just really had no purpose," said Blake Landry, 23, once a promising high school soccer star in Arizona who started heroin when she was 20. "I was just, 'Well, I'm going to be a heroin addict for the rest of my life and that's how it is.'"
Leaving sports and school behind, she morphed, in her own words, from a "pretty girl" to a "ghetto Barbie," sinking into a lifestyle once thought to leave young people like Landry untouched.
This is the new face of heroin addiction in America: young, white and increasingly female. Heroin use is reaching epidemic proportions, moving away from the inner-city and into the suburbs, bringing along its deadly consequences.
In October 2014, the Centers for Disease Control and Prevention released a study of heroin overdose deaths with data from 28 states. From 2010 to 2012, the death rate in these states doubled to 3,635 deaths from 1,779, adding to the nearly 10,000 deaths linked to another type of opioid: prescription painkillers.
And this troubling trend shows no signs of reversing. Researchers said demand for heroin has never been higher and that supply, due to a bevy of factors, has risen to meet it. The Drug Enforcement Administration's 2014 National Drug Threat Assessment Summary reported that heroin seizures in the United States increased 87 percent from 2009 (2,540 kilograms) to 2013 (4,761 kilograms). This comes at a time when marijuana legalization has caused drug trafficking organizations to look for other sources of income, and prescription pain pills have become more difficult to score.
"Twenty years ago, heroin was seen as an inner-city problem. It was associated with ghettos, poverty and a primarily minority population," said Theodore Cicero, vice chairman for research in the department of psychiatry at Washington University School of Medicine in St. Louis. But heroin use data showed the drug breaking down these traditional boundaries.
The DEA's survey found that 29.1 percent of participating state and local law enforcement agencies called heroin the greatest threat in their community, second only to methamphetamine at 31.8 percent.
"We have a whole constellation of worries we didn't have before," Cicero said.
As communities scramble to confront the new killer in their midst, policymakers and academics are trying to figure out how well-off suburban kids like Landry end up with needles in their arms. It's an effort that must correct old stereotypes and shore up the stigma that once kept heroin out of most people's reach, Cicero said.
"We're facing a perfect storm of increased availability, low cost and the attraction of the high that comes from injecting heroin," he said. And once young people are addicted, the battle back to regular life is nearly impossible to win.
Cicero has been studying opioids, or the family of drugs derived from the opium poppy, for more than 20 years. He began by tracking prescription painkiller abuse, which skyrocketed after the release of OxyContin in the mid-1990s.
However, in recent years, the focus of Cicero's research shifted to heroin, mirroring the progression increasingly taking place among drug users. His May 2014 study (paywall) on heroin addiction showed that more than 60 percent of addicts abused prescription painkillers before transitioning to the more dangerous street drug.
The logic behind this link is the same explanation Cicero offered for heroin's move to the suburbs: economics.
Heroin is cheaper and more accessible than painkillers that require a doctor's prescription. According to the DEA, legislative efforts to decrease the amount of prescription painkillers circulating in American communities are succeeding, leading opioid addicts to turn to heroin. The Drug Threat Assessment Summary reported that 79.5 percent of first-time heroin users previously abused prescription drugs.
Although users often tell Cicero that heroin offers the best high there is, he's found that many addicts would have preferred to keep using painkillers.
"They tell me, '(Prescription opioids) are legal and very safe.' You can look at the pill and see what it is, read the number on it, find the dose," he said. But when attaining the same high requires more and more of the hard-to-get pills, the economic incentives for giving heroin a try quickly add up.
The U.S. Substance Abuse and Mental Health Services Administration's 2013 National Survey on Drug Use and Mental Health reported that 681,000 Americans used heroin in 2013, which included 169,000 first-time users aged 12 or older. That's more than double the amount of heroin users in 2003, when 314,000 Americans admitted to using the drug.
Cicero's research explored the make-up of this user population over time, highlighting how heroin's shift to the suburbs has increased the drugs popularity among both whites and women.
In the 2010s, the group of heroin users had been 90.3 percent white and 9.7 percent non-white, a dramatic change from the 1960s, '70s and '80s, when the population was more balanced. Additionally, women now represent 51.6 percent of heroin users, a 34.4 point increase from the 1960s.
The end of the road
Heroin's transformation from stigmatized street drug to most accessible opioid is a commentary on how behaviors become socially acceptable, Cicero said.
Drug educators were always aware that many teens experimented with cigarettes, alcohol and marijuana, but, even as prescription painkiller abuse became increasingly common over the last two decades, the choice to try heroin was viewed as a big leap, unattractive to all but the most troubled drug users.
The popularity of prescription painkillers created a more direct path.
As more people turned to heroin for generally economic reasons, the fear surrounding its use dissipated. It is often sold as powder that can be snorted or smoked, which allows people to avoid, at least initially, shooting it up.
"The stigma is going away as people begin to see heroin used by friends or acquaintances that they didn't think would be taking it," he said.
Landry's story illustrates the progression from drug to drug that's now increasingly commonplace. At 16, she started smoking marijuana, doing 'shrooms and, eventually, trying methamphetamine. At 20, she was addicted to heroin, homeless and living out of a car with her boyfriend.
Although health officials and lawmakers would find the growing popularity of any illegal drug problematic, heroin is a particularly harrowing foe. Because addicts come to rely on intravenous delivery, increased heroin use leads to higher risk for hepatitis and HIV, diseases spread through the use of dirty needles.
Additionally, abuse is a natural reaction to heroin exposure, given that the opioid family is the most addictive strain of drugs. All opiates work by connecting with receptor sites in the brain that reduce the perception of pain, and heroin is a perfect fit, making it even more difficult to resist, said Dr. Bradley Lander, clinical director of addiction psychiatry at The Ohio State University's Wexner Medical Center.
In 2013, 517,000 heroin users were biologically dependent on the drug, SAMHSA reported, which represents more than 75 percent of total users. In comparison, 57 percent of cocaine users in 2013 were dependent.
In short, heroin is "the end of the road" in the drug world, Cicero said. Injecting it with a needle offers the most powerful high on the market, which addicts have described to him as a whole body orgasm. It's a sensation that users give up their entire lives to chase.
To buy sacks of dope, Landry danced for men, hung out with gangs and sold her father's wedding ring. She lost her grip on everyday life, breaking relationships with friends and family members in pursuit of her next high.
Cicero said that heroin addicts don't quit until they hit rock bottom, have an overdose scare or, as in Landry's case, get arrested.
In 2011, Landry and her boyfriend were driving on East Shea Ave. in Phoenix when they were stopped by police. Police searched the vehicle and found marijuana on the floor under a seat. They also found a small jewelry box containing heroin.
Landry admitted it was hers and was booked for possession, beginning her journey to recovery.
Today, Landry is 23 and writes songs to perform in the chapel of the Changing Lives Center treatment facility in downtown Phoenix. At the center, she builds connections with women who also have survived tragic situations, including other recovering addicts.
However, many heroin users miss out on happy endings. Confusion about the purity of heroin bought on the street leads to thousands of overdose deaths each year, and the difficult withdrawal process causes many who try to quit to fail, Cicero said.
This situation, as well as broader research on the drug, has ignited a national conversation around how to stop heroin use in its tracks.
"All of our targeting for prevention and treatment has been focused on poverty-stricken, minority populations. We weren't ready," Cicero said.
As the country grows more aware of the new face of heroin addiction, experts said they're hopeful that people will put their energy and resources behind adjusting outdated strategies and improving drug education programs.
"Think about the cost to our society. Does that make America a better place if we turn our back to this and let it go crazy?" said Doug Coleman, special agent in charge of the U.S. Drug Enforcement Administration's Phoenix division. "No, it doesn't. Everything that we do has to be about, 'Are we gonna be able to save these kids?'"