Across the U.S., officials are sounding an alarm on heroin use. The U.S. Attorney General calls it an "'urgent public health crisis'" and network television news routinely describes it as an epidemic.
But is the "epidemic" real? Many insist the problem is a serious threat. But a number of experts question whether there's been an explosion in the number of heroin users, or if something else is at play: a new demographic of users who are white, suburban or rural, middle-class and largely female.
"We have a syndrome in this country; when you have a young white woman at risk, it makes national headlines," said Roseanne Scotti, state director of the New Jersey Drug Policy Alliance.
"There's no doubt [heroin has] gotten more attention since it's become an issue that's perceived as affecting people in the suburbs," Scotti added. "But for more than 20 years, it hasn't been an issue. People died of overdoses all the time. It never got any news coverage, none at all."
Some are even more blunt, saying the "new face of heroin" has led to unwarranted exaggeration and hype.
"It's a return of 'white women in peril,' " a phenomenon that goes back to the opium scares of the late 19th century, said Jeffrey Miron, an economist at Harvard University and the Cato Institute who specializes in the economies of illegal drugs.
The history of the United States is studded with scares about new epidemics, said Miron. He cites the cocaine scares of the early 20th century, heroin scares of the 1960s, the bouts of Reefer Madness in the 1930s and 1970s, and the more recent battles against methamphetamine, as examples.
Miron's skepticism, some might call it cynicism, targets those who are sounding the warnings.
"The business of the those who enforce this prohibition is to convince people that there's an evil to combat," Miron said. "They give it free advertising, people hear about it a lot more, it drives interest."
The size of the problem
"If you look at heroin abuse over the entire population, it's an extremely small number," said Lawrence Payne of the Drug Enforcement Administration in a recent interview. "But the spike in the growth is significant and alarming."
In the 1960s, first-time heroin users were typically members of a minority, under 17 years old, male, and from the inner city.
Now, heroin users are 90 percent white men and women whose gateway drug was a prescription painkiller. They're in their early 20s and live in the suburbs or rural areas, according to a study published last month in the medical journal JAMA Psychiatry.
Police on the front lines of the war on drugs say they've seen the spike in heroin use with their own eyes.
Many law enforcement officials interviewed by Philly.com say that heroin is more widespread than at anytime in recent memory. Lt. Charles Jackson, an officer on the Philadelphia Police narcotics squad, describes heroin as "the new crack."
"You see more younger people using heroin today than you'd ever imagine," Jackson said. "Now it's something that's commonplace."
According to the economist Miron, however, when the DEA's "extremely small number" is doubled, or even tripled, the total number of heroin users is "a number that is still pretty small." He adds that it's unlikely that the total number of all substance abusers has actually grown.
"I keep wanting to challenge any of these police chief or public health officials who say there's been an epidemic or an explosion," Miron said. "Let me see your data."
And there lies the problem. The available data are surprisingly out-of-date.
Researchers and public health officials express frustration and agree there really are no good numbers when it comes to heroin use. Compounding their frustration, many government officials often incorrectly cite what little data are available.
In 2010, heroin overdoses in the United States killed about 3,000 people, according to federal Centers for Disease Control and Prevention statistics released last year. The CDC is expected to release more current data sometime this month, said a CDC spokeswoman. Unfortunately, researchers say, that data will be three years old and usable only as an historical snapshot.
"Our reporting systems are a mess," said Dr. Theodore J. Cicero, a professor of psychiatry at Washington University in St. Louis, and lead author of the study in JAMA Psychiatry that examined 50 years of heroin use in the United States. "It's hard to get a figure on what the number of users is. We just don't know."
Cicero and other addiction specialists said that without up-to-date data, developing an effective policy to attack the use of heroin is profoundly difficult.
According to the National Institute on Drug Abuse (NIDA), nearly half a million people were addicted to heroin in 2012. The total number of people who used heroin at least once that year was estimated to be 669,000. But the number could be significantly higher, Cicero said.
The rise of prescription painkillers
Indeed, many are in agreement on at least one thing: Opioid painkillers, such as oxycodone, were overprescribed and too easily available for decades, leading many to become addicted. Opioids are different from the non-steroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen and naproxen, which are non-narcotic.
An estimated 2.1 million people in the United States abused prescription painkillers in 2012, according to the NIDA. Most abusers lived in the suburbs and had access to health insurance that originally paid for the painkillers, making them affordable. But many of the legal prescriptions ran out.
Heroin use began to spike as the government cracked down on pill mills and Oxycontin was reformulated to prevent users from snorting it. Most experts agree that when the illicit supply of pills began to dry up and became too expensive, many switched to heroin.
"Now they're using [heroin] as a default drug," said Cicero of the 2,700 addicts he surveyed for the JAMA study. "They'd really prefer to go back to prescription drugs, but they couldn't afford them. They wanted to get high, but mostly they didn't want to get sick" with withdrawal.
CDC data from 2010 shows that the total number of drug overdose deaths (38,000 in 2010) outnumbered deaths from gunshot wounds (31,000) or motor vehicle crashes (35,000).
But "overdose deaths" are not the same as heroin deaths.
Prescription painkillers killed 16,651 people - four times the number attributed to heroin deaths. Well-meaning officials often mistakenly conflate all drug overdose deaths with heroin overdoses.
Heroin killed 3,038 people that year. Five times as many people died of overdoses of prescription opioid painkillers, twice as many people died of overdoses on benzodiazepines like Xanax, and even cocaine deaths eclipsed those brought on by heroin by more than 1,000 overdoses.
Physicians say that until the nation gets a grip on its appetite for prescription opioid painkillers, the number of people using heroin is likely to increase.
Prescription opioid painkillers are "the bridge to heroin," said Dr. Jeanmarie Perrone, director of medical toxicology in the Department of Emergency Medicine at the Hospital of the University of Pennsylvania.
"We clearly have a problem with the treatment of pain and the diagnosis of pain," said Perrone, who has worked at HUP for 20 years.
Perrone said she has seen an increasing number of patients in her emergency room with heroin overdoses, but that number is dwarfed by prescription drug overdoses. And that's where the true epidemic lies.
Over the past two decades, hospitals have become too quick to dispense opioid painkillers, she said. Patients, believing the painkillers are safe and nonaddictive, have come to expect them. Those patients are often subject to a rude awakening.
"We see people discharged from the hospital with opioid dependence," she said. "Literally, I saw someone in the hospital today who became dependent on the meds. She's a lovely young girl with a medical problem. She's still in pain but doesn't want to go through withdrawal again."
It used to be that patients feared taking opiate painkillers of any kind, she said. Perrone treats older patients who remember when the drugs were associated with death.
"I see little old ladies with a hip fracture," Perrone said. "They'll need to get an X-ray and I'll offer to give them morphine."
They refuse to take it.
"'That's what they give people who are dying,' they say [about the powerful painkillers]. And it's true," Perrone said. "Now we give them to everyone."