Deaths from drugs and alcohol in Boston soared dramatically in 2006, an increase fueled by cheap heroin, the allure of crystal methamphetamine, and the widespread availability of addictive prescription medications.
Boston health authorities are so alarmed by the spike in fatalities - 176 people died from substance abuse in 2006 - that they are scouring medical examiner reports on each case, hunting for clues that might further explain the precipitous rise. In that year, the number of people dying from drugs and alcohol climbed 32 percent, reflecting a decadelong trend sweeping the state.
The findings, detailed in a draft of the annual Health of Boston report obtained by the Globe, ranked substance abuse as the fifth-leading cause of death, with Bostonians three times more likely to succumb from drugs or alcohol than from homicide.
"It's really difficult when you talk to these parents of 25-year-old kids and they don't even suspect their kid has a problem, and then they're dead," Michael Botticelli, director of the state's Bureau of Substance Abuse Services, said, his voice catching. "It's hard when you feel like you're doing everything in your power to make a dent in it - and I do think we're making progress - but the challenges are enormous."
That was evident in just the past week: Boston police are investigating three deaths since last Friday that they suspect were related to drugs, a spokeswoman said. One person was found dead in Franklin Park; another, in a Brighton apartment; and a third crumpled in a stairwell in the South End, a neighborhood where more people die from substance abuse than in any other.
"We easily see an overdose a day," said Rich Serino, chief of Boston's Emergency Medical Services. "And some days, more."
Sometimes the users survive; sometimes they don't. Their arrival at such dire straits reflects the resurgence of heroin, which is an old drug of choice, and, increasingly, the compression of the journey to life-threatening addictions.
Substance-abuse specialists trace the roots of the latest spike in deaths back to the late 1990s, when heroin began to tighten its grip on New England. It was a classic case of market-driven economics: The drug was cheap, with a hit of heroin selling in some neighborhoods for less than a six-pack of beer.
And the heroin was so powerful that novice users didn't have to inject it. They could get high just snorting the powder, erasing some of the stigma that marked heroin in an earlier era, of arms pocked with needle tracks.
But once hooked, users inevitably turned to needles, which promised a more potent delivery method. And when that wasn't enough to satisfy their craving, addicts sought dealers who peddled heroin boosted with other narcotics, such as the powerful painkiller fentanyl, creating an especially potent brew.
"They use it once and they say, 'Oh that was fabulous,' and then it takes hold of a whole group, and it gets passed on," said Rita Nieves, director of substance abuse services for the Boston Public Health Commission. "Then, you see a spike in fatal overdoses."
Those deaths have not been confined to Boston: Statewide, annual opiate-related deaths climbed from 94 to 637 between 1990 and 2006, the latest year for which complete figures are available.
That jump coincides with the arrival of crystal meth in New England. Though not the scourge in the region that it is elsewhere, meth has resulted in more addicts seeking treatment, specialists said.
At the same time another new path to addiction started gaining popularity: prescription pain relievers, easily accessible in many a family bathroom.
"Our youth have become increasingly sophisticated, and they say, 'It's difficult to go buy booze, it's difficult to buy cigarettes, but I can open the medicine cabinet at home and find a whole host of things,' " said Kevin Norton, president of CAB Health & Recovery Services Inc., a Boston-area treat ment network.
They find Percocet, OxyContin, and other powerfully habit-forming pain pills. And so the path from casual user to desperate addict - once winding from tobacco to alcohol to marijuana, and then on to more dangerous substances - becomes perilously shortened.
Once cut off from family members' supply, users resort to street dealers who may charge $50 or more for a pill. No longer able to afford that steep price, prescription drug users switch to heroin and other comparatively affordable narcotics, which can sell for as little as $5 or $10 a bag. And they often progress to using multiple drugs at the same time, compounding the dangers.
"I see, across the neighborhoods, people talking about the combinations of drugs," said Beth Rosenshein, coordinator of the Charlestown Substance Abuse Coalition. "Oftentimes, people using heroin are also shooting cocaine or smoking crack or drinking."
Barbara Ferrer, executive director of the city's Public Health Commission, said she expects a team analyzing the fatal overdoses to complete its work within a couple of months.
"We're anxious to get this information. We're anxious to understand this, and we're anxious to look at our programming," Ferrer said.
Already, investigators know that more than three-fourths of the 2006 deaths were caused by drugs, with the remainder attributed to alcohol poisoning or alcohol-related diseases. And while the majority of victims were men - 122 - the number of women dying from substance abuse nearly doubled from 2005, when it was 29, to 54 in 2006.
This year, the state is spending nearly $128 million to treat substance abusers and to prevent people from getting hooked in the first place. That is a 58 percent increase from just five years earlier.
Phyllis Avery, who has spent roughly half her 43 years in the thrall of alcohol and crack cocaine, has seen the dead and near-dead on Boston's streets.
"It did scare me," she said, "but when you are caught up in your disease and you are using constantly, you block that out of your mind."
At a certain point, she said, addiction wears you out. That's when she enrolled in a new city initiative underwritten by $500,000 a year in federal funding, part of a broader campaign by the city to expand services. Like 70 other women this year, Avery is spending 10 to 30 hours a week with counselors and other recovering addicts, learning how to rein in anger and rebuild their lives.
"Life is so much better compared to what you go through when you're right in the middle of addiction," she said.
Maria Cramer of the Globe staff contributed to this report. Stephen Smith can be reached at firstname.lastname@example.org.
How to get help
Call the Massachusetts Department of Public Health substance abuse hot line: 800-327-5050.