Though the death rate from drug overdoses in Philadelphia has held relatively steady since the late 1990s, the Pennsylvania suburban counties and all of South Jersey have had such sharp increases in body counts their rates have as much as tripled - putting many on a par with the city's rate, and in some cases surpassing it.
The scourge of primarily heroin addiction, which seemed to suddenly gain momentum outside the urban line in the mid-2000s, has only grown in lethality in suburban and rural communities regionwide and, indeed, across the two states, despite law enforcement's efforts to curb it.
Interactive graphics of overdose death rates (click image to view):
Some of the whys behind the surges are clear, but many aren't.
In 1999 in just the seven counties rimming Philadelphia, 310 drug deaths were reported. In 2013, the toll, apparently driven largely by heroin, was 781. That year in the city (with less than half the population), 402 died.
More than raw numbers of victims, however, the alarming story lies in the overdose mortality rates. Recently released federal data for 2013 show that when compared with the city's rate, Bucks County had pulled almost even. Delaware County, after two consecutive years of decreases, was still only slightly lower. Gloucester and Camden Counties soared past Philadelphia for the first time - although their rates were far from the highest in the Garden State. That distinction went to Cape May County, which also was three times the national average.
Chester County alone came in below the national average - a bit of good news dampened by the fact that the county's overdose death rate nonetheless had doubled since 1999.
Given the paucity of studies, "what you are seeing with the suburban areas is something we don't understand," said Magdalena Cerdá, a substance-abuse epidemiologist at Columbia University. "Research on drug overdoses historically has focused on urban areas."
What experts know is that today's heroin addicts tend to be younger, more affluent, and often naive about using - about how to get the best possible high without triggering an overdose that slows breathing until it stops. Typically, they got hooked on drugs not on the street, but in the medicine cabinet.
"Prescription pain pills often came first," said Camden County Freeholder Carmen Rodriguez, who helps coordinate the county's response to addiction.
Those with ready access to powerful, potentially addictive opioid analgesics likes Vicodin, Percocet, and Oxycontin are not so much the urban poor, Rodriguez said, as people in the suburbs whose doctors prescribe the narcotics, at least initially, which insurance plans generally cover.
The discovery, and aggressive marketing, of those long-needed pain medications in recent decades has led to a quadrulping of sales since 1999.
In a common, so-called gateway scenario, teens and young adults pilfer the pills from parents. As the scripts run out, or as the need for ever-stronger doses builds, they turn to the streets. There, a single 80-milligram Oxycontin costs up to $40 locally, according to the Drug Enforcement Administration.
But the illicit trade also offers an equivalent high - on heroin - for comparative pocket change, one that's hard to pass up if you're desperate to avoid withdrawal sickness.
"Here in Ocean County, you can get a dose of heroin for as cheap as $3 to $5," said Al Della Fave, press officer for the county Prosecutor's Office.
"When you're paying $40 a pill and then you hear you can pay $10 for the same effect, of course you're going to do it," a 25-year-old heroin addict matter-of-factly told researchers who published a 2013 paper titled "Every 'Never' I Ever Said Came True: Transitions From Opioid Pill to Heroin Injecting."
An international heroin glut has helped tamp prices. Cultivation of the opium poppy had been suppressed by the Taliban, but it grew rapidly as coalition forces pushed into Afghanistan a decade ago. Meanwhile, drug cartels in Mexico and South America increased heroin production to make up for lower demand for illegal marijuana in the United States.
Still, price isn't the only difference between prescription narcotics and heroin. The former are manufactured by pharmaceutical companies to exacting standards. In switching to heroin, users are suddenly experiencing a far more powerful and unpredictable narcotic. Along its distribution route from cartel to corner, it is cut in ways that vary wildly from one dose to the next, with adulterants ranging from Similac baby formula to Tylenol PM to the opioid anesthetic fentanyl, linked to a rash of heroin deaths last year.
Though heroin from Newark and New York has long been among the cheapest and purest in the nation, Philadelphia's has been "a couple of percentage points higher in purity level," meaning an even more intense, dangerous high, said special agent Timothy McMahon, spokesman for the DEA's New Jersey division.
Heroin samples bought in and around the city last year ranged from 50 percent to 90 percent pure, said Special Agent John Hamrick, the DEA's Philadelphia division spokesman.
"In the past, you had to inject it," said Louis Baxter, former president of the American Society of Addiction Medicine and a physician with an addiction treatment practice in Blackwood. "Now, it is so pure that people who are afraid of needles can snort it and smoke it."
Smoking heroin is almost as lethal as shooting it into a vein, Baxter said, because the lungs supply oxygen to the bloodstream near the heart, which pumps it to the brain.
Data on overdose deaths caused specifically by heroin are available for the nation as a whole and for the states. Last week, the National Center for Health Statistics reported that the heroin mortality rate in the U.S. had nearly tripled from 2010 to 2013. Pennsylvania's rate more than tripled. New Jersey's quadrupled.
On the county level, heroin-specific data are lacking. But damning anecdotal evidence abounds: Heroin is driving the increases in overall drug deaths.
If that broad trend is clear, some variations are not. In Philadelphia, where the drug death toll fluctuates year to year, 2013 brought a noticeable decline. An anomaly? Or the beginning of a trend? It is impossible to tell, said Sam Gulino, Philadelphia's chief medical examiner.
That is not the only curiosity. Every county in South Jersey, from the Delaware River to the Shore, exceeded the state's drug mortality rate. Every North Jersey county was below it.
"South Jersey is more rural," Baxter said. "For rescue services and access to a treatment facility, it is easier in North Jersey."
George Sheeron 3d died in South Jersey.
He grew up in Oaklyn, Camden County, and attended Collingswood High School. At 21, he started taking Oxycontin, as his mother, Lisa Hillman, later learned from his Facebook postings. He progressed to heroin about a year later.
By age 26, he was well-known as the lead singer and songwriter in his eponymous metal band. Sheeron, the group, played around Philadelphia and occasionally in New York; it won a battle of the bands at the Trocadero.
He was diagnosed with depression, but, his mother said, treatment programs would deal with either his addiction or his mental health issues, not both - a problematic division reported around the country. "He needed mental health help more than anything," she said.
On March 5, 2014, according to Hillman, a girlfriend persuaded him to sign himself out of an addiction treatment program - his fourth. Twelve days later, around 4 a.m. on St. Patrick's Day, a friend with whom he was staying near Collingswood found him dead in the bathroom, a needle in his arm.
"People have a perception of what a heroin addict is," his mother said. "They think they are homeless scumbags . . . somebody who lives in the streets. Who is low-down. [George] was just a nice kid who needed more help than I could give him."
The federal drug-mortality statistics for 2013 were collected before New Jersey and Pennsylvania began allowing police, as well as friends and family of addicts, to carry the overdose-reversal medication Narcan last year. It is administered when someone is found unconscious and barely breathing, although how many of the recipients would have otherwise died is unknown.
Camden County police reported 115 "saves" from late May through the end of the year. Fewer than half were in the city of Camden, and most of those were suburban residents. The county has launched an aggressive awareness campaign, including 20 billboards along major roads that warn: "Heroin. Pills. It All Kills."
The county also is working with legislators to try to increase funding for inpatient treatment facilities. Baxter, the addiction specialist in Blackwood, says more are sorely needed but to really make a dent in addiction requires a far broader, national campaign.
"We need to use the same approach we did with nicotine in the late 1980s and 1990s," he said. "They began teaching second, third, fourth graders about the perils of smoking, and how you die."