"As a culture, we are just very used to, 'You have a problem, get a prescription,' " said Jay Unick, an assistant professor at the University of Maryland School of Social work, who studies how public policies affect behavioral health outcomes.
Jenna Bertino was 19 when she popped her first illicit pill, a 10mg Percocet. "I was just somewhere, and somebody said, 'Here, try this,' " she said. "They called them bananas so it had a harmless feel to it."
It felt good. "I went from spending $10 every couple of days to spending $200, $300 in a single day. It was no longer to get that feeling, it was just not to be sick." But there was just so much she could steal from her mother in Voorhees. About a year in, she heard that heroin cost $10 a bag.
"No one I knew used heroin," she said. But she started sniffing it.
"In a six- to nine-month span I found myself again in the same situation, with not enough money to be well. And somebody said, 'You can shoot it.' There was a fork in the road. I went the best way to make the pain stop, and I let somebody stick a needle in my arm. It was actually amazing."
Bertino got lucky. She was arrested for possession, thrown in jail, and offered an option of 90 days' residential treatment. Now 29 and living in Palmyra, she is pursuing a graduate degree. She celebrated five years in recovery on Oct. 27.
The pattern - from swallowing to sniffing (and snorting) to injecting - is being seen around the country, although time frames vary.
Camden County's Gloucester City, population 11,000, hosted five funerals in a six-week span in 2011, all due to heroin, the New Jersey State Commission of Investigation wrote in July in a report titled "Scenes from an Epidemic." A state Senate committee held a hearing on the issue three weeks ago.
"In the mid-2000s, heroin exploded overnight," Cambria County Detective Kevin J. Price told the Pennsylvania House Judiciary Committee last month during a public hearing on heroin. "During this process, we lost an entire generation of young adults to this addiction and epidemic."
The committee is holding another hearing Thursday in Glen Mills, Delaware County.
On Monday, the largest group of treatment professionals, the American Association for the Treatment of Opioid Dependence, will host a town hall discussion of how the medical community can address the prescription painkiller epidemic during its national meeting in Philadelphia.
"To me, the real trend is nonmedical use of prescription opiates. Heroin has its own negative reinforcement" - the needle, said Roland Lamb, director of the city's Office of Addiction Services and the conference chair.
"Right now, we have a lot of people who are naive about their drug use," said Lamb. New users don't know what they can handle.
Abuse of prescription narcotics dwarfs that of heroin. Legal painkiller prescriptions in 2010 were sufficient to medicate every American adult around the clock for a month, the Centers for Disease Control and Prevention reported two years ago. Most were intended for a medical purpose. Yet enough were diverted so that 12 million Americans age 12 or older engaged in nonmedical use of prescription painkillers - basically, to get high - the previous year, the CDC estimated. About 15,000 died from overdoses.
Only 3.6 percent of people who use painkillers for nonmedical purposes go on to heroin, the federal Substance Abuse and Mental Health Services Administration (SAMHSA) reported in August. At the same time, the rate of heroin use was 19 times higher among those who had abused pain-relievers than those who had not.
SAMHSA found a pattern to new heroin users. The biggest increases were among females, non-Hispanic whites, and young adults. Other surveys have found geographic patterns for new heroin users that are opposite what was seen in the past: greatest in rural areas, followed by suburbs and then cities.
Philadelphia may be different, Lamb and others said, because it has the cheapest and purest heroin in the nation, making the transition from prescription opioids easier.
"They act on the same receptors," said Charles P. O'Brien, a professor of psychiatry and founder of the University of Pennsylvania's Center for Studies of Addiction. "It's just that [opioids] are synthetic, and heroin comes from the opium poppy."
Ironically, efforts to combat prescription drug abuse appear to be driving some users to move to heroin, SAMHSA said. Purdue Pharma, which came under intense criticism for its aggressive marketing of OxyContin, reformulated the painkiller in 2010, making it harder to crush and then snort or inject. A series of arrests at large pill mills in Florida also has reduced the supply and raised the price.
The Food and Drug Administration two weeks ago proposed restrictions on the prescribing of opioid painkillers, raising some concern among doctors that it could create hardships for patients who need them, such as those being treated for cancer.
"I've heard this story so many times," Penn's O'Brien said of people getting dental procedures "and the dentists give them a month's supply of OxyContin."
The bottle then sits on a shelf, which is why some police departments are reporting burglaries in which "the house hasn't been ransacked - the bathroom has," said David Fialko, a prevention specialist at the Council of Southeast Pennsylvania, a nonprofit.
"Most of the kids that I talk to, they get their pills from their families, from their medicine cabinet," said Fialko, who advises locking pills in a drawer. "Even if you have a kid who won't take it," he said, maybe a visitor will.
Coleen Watchorn's son Stephen Jr., 28, was living in Pottstown when he died in August 2012 of a heroin overdose after years addicted to pills. Several doctors treating him for other ailments knew his history, yet continued to prescribe them, she said, noting that when she asked his neurologist to discuss the combinations with his other doctors, she was told that it was not his role.
Because he was a known addict, Watchorn said, "he should not have been given these drugs."