Heroin abuse is rising across the United States, according to a new government report that finds the strongest risk factor for a heroin use disorder is a prescription opioid use disorder. People addicted to opioid painkillers are 40 times more likely to abuse or be dependent on heroin, NPR reports.

The largest increase in heroin use is among women and white (non-Hispanic) Americans. Young adults and those with household incomes below $20,000 are most likely to use heroin. Most people who use heroin abuse multiple other substances, including opioid pain relievers and cocaine, the report from the Centers for Disease Control and Prevention (CDC) found.

More than half a million Americans used heroin in 2013, nearly a 150 percent increase since 2007. Heroin-involved overdose deaths almost doubled from 2011 to 2013. More than 8,200 people died from heroin overdoses that year.

“As a doctor who started my career taking care of patients with HIV and other complications from injection drugs, it’s heartbreaking to see injection drug use making a comeback in the U.S.,” said CDC Director Dr. Tom Frieden. He noted opioid painkillers and heroin essentially have the same active ingredient, but heroin is increasingly easy to obtain and much less expensive than prescription opioids.

Frieden called for an “urgent all-society response” to the heroin epidemic, which would include tracking the use of prescription painkillers and ensuring doctors only prescribe them as necessary. Other strategies include providing treatment to people who are addicted to painkillers and heroin; cracking down on smuggling and street sales of heroin, to increase the price and discourage abuse; and increasing the use of the overdose antidote naloxone.

“It is not enough to simply reverse overdoses,” Michael Botticelli, Director of National Drug Control Policy noted in a news release. “We must also connect overdose victims and people struggling with prescription drug and heroin use disorders to treatment facilities and doctors that offer medication-assisted treatment.”