INDIANA, Pa./CHILLICOTHE, Ohio (Reuters) - As deaths mount in America’s opioid crisis, communities on the front lines face a hidden toll: the financial cost.

A vial of Naloxone and syringe are pictured at a Naloxone training class in Louisville, Kentucky, November 21, 2015. REUTERS/John Sommers II

Ross County, a largely rural region of 77,000 people an hour south of Columbus, Ohio, is wrestling with an explosion in opioid-related deaths - 44 last year compared to 19 in 2009. The drug addiction epidemic is shattering not just lives but also stressing the county budget.

About 75 percent of the 200 children placed into state care in the county have parents with opioid addictions, up from about 40 percent five years ago, local officials say. Their care is more expensive because they need specialist counseling, longer stays and therapy.

That has caused a near doubling in the county’s child services budget to almost $2.4 million from $1.3 million, said Doug Corcoran, a county commissioner.

For a county with a general fund of just $23 million, that is a big financial burden, Corcoran said. He and his colleagues are now exploring what they might cut to pay for the growing costs of the epidemic, such as youth programs and economic development schemes.

“There’s very little discretionary spending in our budget to cut. It’s really tough,” Corcoran said.

Cities, towns and counties across the United States are struggling to deal with the financial costs of a drug addiction epidemic that killed 33,000 people in 2015 alone, data and interviews with more than two dozen local officials and county budget professionals shows. (For graphics on the opioid crisis click here: tmsnrt.rs/2hO4YC7)

The interviews and data provide one of the first glimpses into the financial impact on local governments but it is far from complete because there is no central database collating information from counties and states. So, the true scale is still mostly hidden from view.

Opioids, primarily prescription painkillers, heroin and fentanyl - a drug 50 to 100 times more powerful than morphine - are fueling the drug overdoses.

President Donald Trump last month called the epidemic a “national emergency” but has not yet made an official national emergency declaration. Such a move would give states access to federal funds to fight it.

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BUILDING A PICTURE

Counties grappling with rising overdoses face higher costs in emergency call volumes, medical examiner and coroner bills, and overcrowded jails and courtrooms, said Matt Chase, executive director of the National Association of Counties, which represents 3,069 county and local governments.

At his group’s July annual meeting, a presentation where county officials shared tips on tackling the opioid crisis, and the budget problems the crisis is triggering, played to a packed room, Chase said.

The organization is in the early stage of collecting information to build a more complete picture of the financial impact of the crisis on county budgets, Chase said.

Indiana County, Pennsylvania, a mountainous, predominantly rural region, provides a snapshot of how the crisis is stressing local services and budgets.

Its county seat, the borough of Indiana, is home to a modern college campus and a main street lined by restaurants and American flags. Yet beneath its outward tranquility, the opioid epidemic is everywhere, said David Rostis, an undercover detective and head of the county’s drug task force.

On a recent ride-along in Rostis’ car, he points to a building where a doctor used to sell opioid prescriptions for sex; a large, affluent home where a teenager died of an overdose; a trail where a drug-related killing recently occurred; and the local gas station where a woman recently overdosed and died in her car while people passed by.

In 2016, the county’s drug overdose death rate was 50.6 deaths per 100,000, compared to the state average of 36.5.

Autopsy and toxicology costs there have nearly doubled in six years, from about $89,000 in 2010 to $165,000 in 2016, county data shows.

Court costs are soaring, mainly because of the expense of prosecuting opioid-related crimes and providing accused with a public defender, local officials say.

The county is using contingency funds to pay for the added coroner costs, said Mike Baker, the county’s top government official. Last year, the county drew $63,000 from those funds, up from $19,000 in 2014, he said. In 2014, the county saw 10 drug-related deaths. In 2016, the number had grown to 53.

In Mercer County, West Virginia, 300 miles (483 km) to the south of Indiana County, opioid-related jail costs are carving into the small annual budget of $12 million for the community of 62,000 people.

The county’s jail expenses are on course to increase by $100,000 this year, compared to 2015. The county pays $48.50 per inmate per day to the jail, and this year the jail is on course to have over 2,000 more “inmate days” compared to 2015, according to county data.

“At least 90 percent of those extra jail costs are opioid-related,” said Greg Puckett, a county commissioner who sits on a national county opioid task force. “We spend more in one month on our jail bill than we spend per month on economic development, our health department and our emergency services combined.”

West Virginia has been on the front line of the opioid crisis. In 2015, the state led the nation in drug overdose death rates for the third consecutive year. Preliminary numbers for 2016 recorded 883 drug overdose deaths, with 755 involving at least one opioid, up from 629 total deaths in 2014.

AUTOPSIES INC.

Few know the opioid crisis like the father-son duo Sidney and Curtis Goldblatt. The pair run two companies, ForensicDx for autopsies and MolecularDx for drug testing, out of Windber, Pennsylvania. Together they conduct autopsies for 10 Pennsylvania counties, including Indiana, charging between $2,000 and $3,000 per body.

In 2014, overdoses represented about 40 percent of the deaths they handled, the Goldblatts said. Last year, that shot up to 62 percent. Goldblatt senior has been performing autopsies for 50 years and says he has never seen anything on the scale of the current epidemic. When he started, a drug overdose was rare.

The pair opened ForensicDx in 2014 with a staff of three, serving only three counties. That’s grown to seven staff and 10 counties, mainly to meet demand from drug-related deaths, the Goldblatts said.

Indiana County’s ambulance service is also under financial stress because of the opioid crisis. The county’s primary ambulance provider, Citizens’ Ambulance Service, has lost more than $100,000 since 2016 alone on opioid calls, said Randy Thomas, director of operations.

The non-profit is reimbursed only if an opioid overdose patient is transported to the hospital. It doesn’t get paid for successfully treating people who have overdosed but then refuse to go to the hospital, Thomas said.

People brought back from the brink of death after a dose of the life-saving drug naloxone, also known as Narcan, often awake angry and combative and refuse hospitalization, Thomas said.

As costs related to the opioid epidemic increase, Indiana County commissioner Baker isn’t sure what will happen next. Unless the state or federal government intervene, the county will have to either cut services or increase taxes, Baker said.

“This has introduced an entirely different metric, an entirely different level of unpredictability in budgeting,” he said.

For all the budget problems Baker faces because of the crisis, the human toll is what distresses him most. Last fall, Baker’s nephew died of a fentanyl overdose. He was 23. Talking about his nephew’s death, Baker pauses to collect his thoughts.

“It is a most painful and difficult experience and I wouldn’t wish it on anyone in the world,” he said.