Rural areas hit hard by injection drug abuse are struggling to deal with the fast-growing problem, according to The Wall Street Journal. IV drug abuse is bringing large increases in HIV and hepatitis C to these communities.

The hardest-hit areas are in Appalachia and Midwestern communities east of the Mississippi River, the article notes.

Last month the Centers for Disease Control and Prevention said prescription painkiller abuse is largely to blame for a big increase in the rate of hepatitis C among young people in rural areas of four states. Acute hepatitis C infections more than tripled from 2007 to 2012 among young people in rural areas in Kentucky, Tennessee, Virginia and West Virginia. About 73 percent of those hepatitis C patients said they injected drugs. Injecting drugs can spread the hepatitis C virus and HIV when people share needles.

The public health costs of the crisis could be enormous, the article notes. Untreated hepatitis C can cause cirrhosis or cancer of the liver, and may require a liver transplant. New hepatitis C drugs can cost more than $80,000 per patient. Lifetime costs for treating HIV can reach $400,000.

“The cost of this epidemic is spectacular,” said Judith Feinberg, a University of Cincinnati doctor who treats intravenous drug users for hepatitis and other health issues.

In March, Indiana Governor Mike Pence declared a public health emergency as the state battled an outbreak of HIV linked to intravenous use of the painkiller Opana. The governor authorized a short-term program in one county to exchange used needles for sterile ones, to reduce the risk of contaminated needles being shared. Pence then signed a law that extends the program, allowing Indiana localities with health emergencies to begin their own needle exchanges.