A. Thomas McLellan, CEO of the Philadelphia-based Treatment Research Institute, said that the city data reflected trends seen recently in a few other places - particularly New Mexico and West Virginia, which have by far the highest overdose death rates in the nation - and that he expected to eventually see an upsurge in heroin mortality nationwide.
The vast majority of heroin addicts begin with prescription pain pills, some legitimate. Addiction follows. "Then you find out that you can't afford it, you find out that it is difficult to maintain, and the only alternative is heroin," said McLellan, former deputy director of the White House Office of National Drug Control Policy.
Why would a national trend show up early here?
"We have the cheapest and most potent heroin nationwide. It has been that way for the last 25 or 30 years," said Roland Lamb, director of the city's Office of Addiction Services. The most recent federal data show that street-level heroin in Philadelphia jumped from 41 percent pure in 2010 to 64 percent in 2011, the highest of 15 Eastern cities for heroin from South America, he said.
The rise in heroin in the city is showing up in various ways. After several years with little change, overdose deaths involving heroin increased from 138 in 2010 to 287 in 2012, exceeding last year's gunshot fatalities, Lamb said, citing statistics from the Philadelphia Medical Examiner's Office.
Admissions for treatment of heroin addiction also rose in 2012 after a five-year average decline, and now account for 24 percent of all admissions for drug treatment.
Philadelphia has long had a robust treatment system that draws patients from as far away as Puerto Rico, although methadone maintenance programs are now close to capacity, Lamb said. Pennsylvania law on insurance coverage for substance-abuse treatment is considered among the strongest in the nation.
Lamb said the heroin increase was almost certainly fueled by the decadelong rise in illicit use of prescription drugs.
"We are seeing a huge sea change in how people are being introduced to drug use," he said. "No longer do you have the vision of someone being approached in a dark alley [and asked], do you want to do some drugs?"
Research has found that prescription painkillers and, increasingly, heroin are most prevalent in rural areas, followed by suburbs and then cities. Whites make up 37 percent of Philadelphia's population, but accounted for 67 percent of admissions last year for heroin addiction, the most lopsided of any major drug category.
The switch from prescription drugs to heroin worries public-health authorities. Prescription pills, for all their problems, are produced largely by pharmaceutical companies under strict quality control, and their effects are predictable. Heroin varies from batch to batch, raising the risk of overdose as well as the possibility of contamination as it is mixed on the street.
And heroin is almost always injected, raising the risk of infection and disease transmission.
"You risk people sharing needles, and that increases the number of potential HIV cases," said Jose Benitez, executive director of Prevention Point Philadelphia, a needle-exchange program that is given much of the credit for reducing the percentage of HIV cases traced to contaminated needles, from 47 percent in 1991 to 10 percent in 2010.
After distribution of about one million clean syringes annually for several years, Benitez said, the number rose to 1.2 million in 2011 and 1.7 million last fiscal year, and will likely reach from 1.8 million to 2 million this year.
The program, unlike its smaller counterparts in New Jersey, has received no encouragement or funding from Harrisburg.
In its report Monday, the Washington-based Trust for America's Health scored states on a range of possible actions taken to fight prescription-drug abuse. Pennsylvania, which was 14th in fatal drug-overdose rates in 2010, achieved four out of a possible 10.
New Jersey, which was a far lower 40th among the states in drug deaths, achieved seven.
Among the differences: New Jersey has passed laws that encourage people to dial 911 to report overdoses by granting the caller immunity from prosecution; it allows trained laypeople to use naloxone, which reverses overdoses; and it has agreed to expand Medicaid as part of the Affordable Care Act, making substance-abuse treatment available to hundreds of thousands of people.
Both Pennsylvania and New Jersey experienced increases in drug-overdose fatalities between 1999 and 2010 that were less than the national average. Rep. Gene DiGirolamo (R., Bucks) has introduced a "911 Good Samaritan" bill and another that would strengthen the state's prescription-drug-monitoring program, although, due to opposition from physicians, it would not make it mandatory for prescribers, he said.
He also is circulating a resolution that calls on the state attorney general to conduct a wide-ranging investigation of the proliferation of prescription opioid drugs.
In an interview Tuesday, DiGirolamo said he wanted the investigation to look into how prescription narcotics were marketed, the types of incentives given to doctors for prescribing, the activities of for-profit "pill mills," and other areas.
"Our kids are dying," DiGirolamo said, "our prisons are getting filled up with people that are committing crimes because they are addicted."
He added that a police chief in his district told him that three out of every four people arrested for all crimes were addicted to drugs, and added, "We need to start taking it seriously."