Users have described it as a highly addictive drug that produces a surge of euphoria, or rush. U.S. Attorney General Eric Holder has defined its use as an "urgent public health crisis." Heroin - aka smack, H, skag, junk, brown sugar, horse and black tar - killed a record number of Ohioans in 2012, according the state Department of Health.
In Ohio, Attorney General Mike DeWine says heroin is an epidemic affecting all parts of the state - from the cities to the suburbs to rural counties - and it cannot be ignored.
"That's why we're looking at helping communities establish grassroots efforts and to get the word out about the danger we're facing and the impact heroin is having on our society, all over the state," DeWine said.
Fatal drug overdoses remain the leading cause of accidental death in Ohio, above car crashes, a trend that began in 2007 and started spiking around 2011.
These newest available figures help put the problem into perspective:
The state reported that 680 people died of heroin overdoses in 2012, up from 426 deaths in 2011, a 37 percent increase.
The heroin increase also drove the overall number of fatal drug overdoses to a record of 1,272 deaths in 2012, up from 1,154 the previous year, according to the state's data.
DeWine said solving the problems requires everyone working together at the neighborhood level.
In November, his office announced it had created a heroin unit designed to help communities fight the war on heroin and set aside $1 million for the effort.
His office assigned several agents/investigators to work inside the heroin unit, selected attorneys to handle heroin cases and named part-time employees to work with local communities putting grassroots groups together that organize and promote education/prevention programs.
He said when his office is asked, it is is poised to help.
He said that although many communities understand the problem, others do not and are in denial.
"But we are seeing more of these grassroots efforts, these groups taking shape and working hard to educate people and raise awareness," he said.
Additionally, his office has trained about 500 police officers on how to better handle situations involving heroin including overdoses.
DeWine's office has estimated that 11 deaths a week in Ohio can be attributed to heroin.
The staff surveyed all 88 county coroners for information about heroin cases. Not all of them track deaths from heroin overdoses, but the ones that do reported increases.
Along with statewide efforts to crack down on heroin dealers, there is heavy emphasis on educating people, including teens and children in school.
Drug courts, including those for juveniles, have also been springing up as society sees an increasing number of addicted teens.
DeWine said drug courts can offer offenders identified as heroin addicts all three pieces of the "more holistic approach" his office now focuses on: treatment, law enforcement and education/prevention efforts.
Edward Dyer, program director of Community Solutions Association in Warren, agreed. Dyer said court, health and counseling professionals started seeing a spike in heroin problems about four years ago.
Dyer said 60 percent of the people his agency sees are from the drug court. He said among that population, well over 50 percent have an opiate problem of one form or another.
"When we sit down and talk to people, one of their biggest concerns is heroin addiction," he said. "Even when we do programs with high school students they talk a lot about heroin. So many people have been impacted by it or know someone impacted by it. It's everywhere," he said.
Dyer said alcohol remains the most common issue with marijuana and opiates "in terms of drugs of abuse that get them into trouble."
Dyer said during one recent program, at least half of the 16 high school students present could give personal stories about someone addicted. He said the experiences they shared included a number of heroin-related deaths. He said that the Trumbull County Drug Court, which was established about 14 years ago, has always seen a degree of opiates, but the number has climbed significantly over the past five or six years.
Dyer said heroin addiction has been increasing as prescription painkiller abusers turn to the cheaper and more readily available drug. He said efforts are under way to explore alternative ways to treat addiction including behavior analysis.
"We know that painkiller addiction is one of the gateways to heroin, or opiate, addiction. Part of the process is to determine is this truly a pain issue someone is having, or an emotional issue. In some cases, we really are dealing with people who have tremendous physical pain. That pain could go back to a sports injury in school or an accident or something. We need to look at a non-medical means of coping with that pain," Dyer said.
Some experts said that in the past, where an emphasis had been placed on cracking down on dealers, statewide efforts taking shape now focus more on prevention and education.
Capt. Jeff Orr of the Trumbull Ashtabula Group Law Enforcement Task Force and Trumbull County Sheriff's Office said he agrees with that approach.
"Law enforcement needs to be not just out there arresting people, but trying to do something about the problem. It's an addiction, not easy to get off of it. What good does it do to put someone in a cell when we know they'll be back on the street again doing the same things?" he said. "It's worth it to try to do what we can to educate people and prevent the problem."
Orr said many area police are more likely to see heroin and opiate transactions than other drug activities. He said heroin is at the top of the list of problems investigators address.
"It's everywhere. It doesn't matter where you are or what you're doing. It crosses all lines, all boundaries. It's in every economic, social, ethnic or racial group," Orr said. "When we go into schools and talk to kids, the first question I ask, the first words out of my mouth, are if there's anybody you know who might have a drug addiction problem. The majority of them say yes. Eventually, the conversation inevitably gets to heroin. It's a problem. It's a killer and it's real. It's something we all need to deal with."