More than 12 million Americans reported using prescription painkillers in 2010 without a prescription or just for the high that they cause. Nearly 3 out of 4 drug overdose deaths are now caused by prescription painkillers. In 2008, some 14,800 deaths were attributed to the pills – more than cocaine and heroin combined. More than 475,000 emergency room visits were directly linked to prescription painkiller misuse or abuse in 2009, roughly double the number of five years earlier.

The global production of oxycodone, marketed as OxyContin in the United States, increased from two tons in 1990 to 135 tons in 2009. More than two-thirds of that supply was manufactured in the US, which, according to the United Nations Office on Drugs and Crime, increases the risk of its subsequent overprescription and diversion into illicit channels. Experts trace the rise of painkiller misuse in the US to 1996. That’s when the pharmaceutical company Purdue Pharma introduced OxyContin, a narcotic and derivative of opium. Andrew Kolodny, chief medical officer of Phoenix House, a national nonprofit treatment agency, describes OxyContin as essentially a “heroin pill.” It was made of oxycodone, a narcotic used to treat pain at the end of life. But the new pill would allow the company to reach a much wider audience.

“[Purdue] wanted a product that would be prescribed for common, moderately painful chronic conditions,” says Dr. Kolodny, who is also president of Physicians for Responsible Opioid Prescribing, an advocacy group. At first, the medical community balked. Using opioids for chronic problems seemed too risky given the nature of the pills’ highly addictive properties. But Purdue Pharma launched an aggressive marketing campaign arguing that it was a compassionate way to treat patients and, because of its extended-release characteristics, would be less prone to abuse. But before long, numerous cases of addiction to the painkillers began to surface. In 2007, Purdue Pharma pleaded guilty in federal court to misleading doctors and the public about OxyContin’s risks and paid a $600 million penalty. Kolodny says that the overprescribing of painkillers has now led to an “epidemic” of addictions, both among pain patients and recreational users.

And once a person becomes addicted to painkillers, it isn’t a long journey to heroin – itself a derivative of morphine developed in the late 1800s as a painkiller. Joseph Gfroerer of SAMHSA co-wrote a recent study that found that, of those who had tried heroin, about 80 percent had previously used painkillers without a prescription. From Los Angeles to Long Island, Chicago to New Orleans, parents and police are struggling with a rise in heroin use in suburban neighborhoods. The rise is being driven by a large supply of cheap heroin in purer concentrations that can be inhaled or smoked, which often removes the stigma associated with injecting it with a needle. But much of the increase among suburban teens, as well as a growing number of adults, has also coincided with a sharp rise in the use of prescription painkiller pills, which medical experts say are essentially identical to heroin. These painkillers, or opioids, are prescribed for things such as sports injuries, dental procedures, or chronic back pain. Yet in a disturbing number of cases, experts say, they are leading to overdependence and often to addiction to the pills themselves, which can then lead to heroin use. Once hooked, users look for doctors who will sell them prescription drugs and, failing that, turn desperately to the street, where the price can be as high as $80 for a single pill. When that becomes too expensive, users often resort to the drug that produces the same kind of high that painkillers do but is far cheaper: heroin.

The latest rise in heroin abuse was made more visible by the recent overdose death of actor Philip Seymour Hoffman. But use of the drug has been growing steadily across many levels of society for at least the past five years. And unlike the heroin surge in the 1970s, the current use of opiates is far more concentrated among suburban and rural whites than among African-American and Latino communities. The heroin that addicts used to shoot up with was 2 or 3 percent pure. Today, the street purity of the drug can be as high as 80 percent. That potency helps explain both the drug’s wider appeal and its new danger. Heroin once had to be injected for users to get the high they were looking to achieve, but it is now concentrated enough that they can smoke or snort it to get a similar effect – methods that make heroin easier for people to use it without feeling like a junkie. The higher purity is also more likely to trigger an overdose for those who do inject it.