As opioids flooded tribal lands across the U.S., overdose deaths skyrocketed

In Oklahoma, with 38 Native American tribes, the deluge of pain pills rivaled hard-hit Appalachia

Image: Zach Williams and his wife, Laurie, help their twin daughters with homework after dinner in Ada, Okla. A Native American pharmacist for the Chickasaw Nation, he is in recovery after a long addiction to opioids.
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ADA, Okla. — Zach Williams checked himself into a hotel room, sat down on the edge of the bed and waited. Chills soon racked his body, and he started to shiver. He couldn’t keep food down. He was drenched in sweat.

For two days in 2018, the 37-year-old Native American pharmacist for the Chickasaw Nation pushed through the wrenching symptoms of opioid withdrawal, determined to go cold turkey. On the third day, he stumbled outside to his Chevy truck, where he kept a stash of pain pills hidden among his children’s dolls and McDonald’s Happy Meal toys.

Williams had spent years hooked on opioids. Alone and hurting in a hotel parking lot, he faced yet another day.

“I felt like death,” he recalled. “I loathed the person I was. … I became a slave to opioids.”

[A Native American tribe plans to build an opioid treatment center, but neighbors have vowed to block it]

At the height of the opioid epidemic, Native Americans overdosed and died at a rate that rivaled some of the hardest-hit regions in Appalachia. Nationwide, from 2006 to 2014, Native Americans were nearly 50 percent more likely to die of an opioid overdose than non-natives, a Washington Post analysis found.

Native Americans more likely to die of a prescription opioid overdose

Average yearly deaths, 2006-14

Native Americans

16.44 per 100K

Oklahoma

All others

11.04

U.S.

4.64

6.81

Native Americans more likely to die

of a prescription opioid overdose

Average yearly deaths, 2006-14

Native Americans

16.44 per 100K

Oklahoma

All others

11.04

4.64

6.81

U.S.

Native Americans more likely to die

of a prescription opioid overdose

Average yearly deaths, 2006-14

Native Americans

Native Americans

All others

All others

16.44 per 100K

11.04

Oklahoma

4.64

6.81

U.S.

Native Americans more likely to die

of a prescription opioid overdose

Average yearly deaths, 2006-14

Native Americans

Native Americans

All others

All others

16.44 per 100K

11.04

Oklahoma

4.64

6.81

U.S.

In recent months, the novel coronavirus has added to the trials of Indian country, long plagued by health disparities, poverty, housing shortages and isolation. Arizona’s White Mountain Apache Tribe and the Navajo Nation, with land that stretches over three Western states, have struggled with some of the highest per capita infection rates in the United States.

But tribal leaders say they have not lost sight of the ongoing devastation caused by prescription opioids.

As more than 3,000 cities and counties — along with most states — pursue billions in settlement dollars from opioid manufacturers and distributors, tribal leaders are fighting for a fair share of the proceeds through a series of lawsuits filed by Indian tribes.

The rate of pills shipped to

Oklahoma was nearly as high as

that of states in the opioid belt

Average number of yearly pills per person, 2006-14

5

75

150+

The rate of pills shipped to Oklahoma

was nearly as high as that of states

in the opioid belt

Average number of yearly pills per person, 2006-14

5

75

150+

The rate of pills shipped to Oklahoma

was nearly as high as that of states in the opioid belt

Average number of yearly pills per person, 2006-14

5

75

150+

Opioid distributors shipped an average of 57 pills per person to Oklahoma.

Opioid distributors shipped an average of 57 pills per person to Oklahoma.

States in the opioid belt received an average of 60-66 pills per person.

States in the opioid belt received an average of 60-66 pills per person.

The rate of pills shipped to Oklahoma was nearly as high as that of states in the opioid belt

Average number of yearly pills per person, 2006-14

5

75

150+

Opioid distributors shipped an average of 57 pills per person to Oklahoma.

Opioid distributors shipped an average of 57 pills per person to Oklahoma.

States in the opioid belt received an average of 60-66 pills per person.

States in the opioid belt received an average of 60-66 pills per person.

Several of the tribes that have sued are in Oklahoma, home to more than 482,000 Native Americans in 38 federally recognized tribes, including the Cherokee, Choctaw and Chickasaw nations. The patchwork of tribal lands is spread across most of the state’s 77 counties. Here, the opioid death rate for Native Americans from 2006 to 2014 was more than three times higher than the nationwide rate for non-natives, the analysis of federal health data shows. And within the state, Native Americans were about 50 percent more likely to die than non-natives.

Opioid distributors shipped an average of 57 pills per person per year to Oklahoma from 2006 to 2014. That’s far higher than the national average of 36 and just under the number of pills shipped to states in the opioid belt in and around Appalachia, according to a Post analysis of a once-confidential Drug Enforcement Administration database. The Post and the owner of the Charleston Gazette-Mail in West Virginia obtained the data after waging a year-long legal fight.

Pills flooded tribal lands in Oklahoma

Average number of yearly pills per person, 2006-14

5

75

150+

DELAWARE

COUNTY

DELAWARE

COUNTY

Cherokee

Nation

Oklahoma

City

Muskogee

Nation

Tribal lands

Chickasaw

Nation

Choctaw

Nation

Oklahoma Tribal

Statistical area

JEFFERSON

COUNTY

ADAIR

COUNTY

JEFFERSON

COUNTY

ADAIR

COUNTY

100 MILES

Pills flooded tribal lands in Oklahoma

Average number of yearly pills per person, 2006-14

5

75

150+

DELAWARE

COUNTY

Cherokee

Nation

Oklahoma

City

Muskogee

(Creek)

Nation

Tribal lands

Oklahoma Tribal

Statistical area

Chickasaw

Nation

Choctaw

Nation

JEFFERSON

COUNTY

ADAIR

COUNTY

100 MILES

Pills flooded tribal lands in Oklahoma

Average number of yearly pills per person, 2006-14

DELAWARE

COUNTY

5

75

150+

Bartlesville

Bartlesville

Tulsa

Cherokee

Nation

Tulsa

Cherokee

Nation

Muskogee

(Creek)

Nation

Muskogee

(Creek)

Nation

Tribal lands

Oklahoma City

Oklahoma City

Oklahoma Tribal

Statistical area

Lawton

Lawton

Choctaw

Nation

Choctaw

Nation

Chickasaw

Nation

Chickasaw

Nation

JEFFERSON

COUNTY

ADAIR

COUNTY

50 MILES

Number of pills shipped to Oklahoma per person, per year

Average county yearly total, 2006-2014

5

75

150+

Bartlesville

Bartlesville

Guymon

Guymon

Cherokee

Nation

DELAWARE

COUNTY

DELAWARE

COUNTY

Tulsa

Tulsa

ADAIR

COUNTY

ADAIR

COUNTY

Tribal lands

Muskogee (Creek)

Nation

Oklahoma Tribal Statistical area

Oklahoma City

Oklahoma City

Lawton

Lawton

Choctaw

Nation

Chickasaw

Nation

JEFFERSON

COUNTY

JEFFERSON

COUNTY

50 MILES

At least 370 Native Americans in Oklahoma overdosed and died — with a death rate roughly equivalent to that of West Virginia, federal data shows. Experts say the number of deaths for Native Americans is likely to be far higher because they are often mistakenly classified as white on death certificates.

“We were preyed upon,” Chickasaw Nation Gov. Bill Anoatubby said from the tribe’s headquarters in Ada. His tribe’s jurisdictional territory, dotted with cattle and casinos, covers 7,648 square miles in 13 south-central Oklahoma counties.

“It was unconscionable,” Anoatubby said.

Nationwide, 169 cases have been brought on behalf of 413 federally recognized tribes against companies accused of fueling the worst drug epidemic in American history. The cases were consolidated two years ago with the city and county cases in federal court in Cleveland.

Some lawyers for the cities and counties have privately suggested a nationwide payout ranging from $25 billion to $50 billion for all the plaintiffs — including the tribes, which are sovereign nations. The lawyers said a settlement could come as early as this summer.

Image: At the Chickasaw Nation's headquarters in Ada, Gov. Bill Anoatubby says tribes were “preyed upon” by drug companies. Native Americans in Oklahoma were about 50 percent more likely to die of opioid overdoses than non-natives from 2006 to 2014, federal data shows.

Opioid distributors have been trying to negotiate a settlement deal ahead of trials, which are set to begin in the coming months in New York and West Virginia. The distributors — McKesson, Cardinal Health and AmerisourceBergen — have offered $18 billion to settle the lawsuits. In February, 21 states rejected the offer.

The litigation, considered the United States’ largest and most complex civil case, has been compared to the tobacco case of 1998, in which four companies agreed to pay an estimated $240 billion over more than two decades to resolve state lawsuits. Native American tribes, however, were not involved in those lawsuits and received no settlement money.

“The opioid crisis devastated Indian country by every measure,” said Lloyd Miller, a lawyer representing tribes that include the Muscogee (Creek) Nation in Oklahoma. “So did lung cancer. But when the tobacco litigation was all wrapped up, not a dime was allocated to tribal governments to deal with the devastation that cancer had left behind and the addiction issues. That will not be repeated.”

Image: At the height of the epidemic, Eck Drug & Gift in Waurika, Okla., dispensed just over 2.3 million pain pills. Owner Dana “Biff” Eck said he did not recall doctors prescribing anything out of the ordinary and that he filled valid prescriptions. “We're just a small-town pharmacy trying to take care of our people,” he said.

Two small-town pharmacies

On a Saturday morning in February, Main Street in Waurika, Okla., was all but deserted, a dusty strip of boarded-up storefronts. The town of about 2,000 residents, five miles from the Texas line, is the largest in Jefferson County. Most of the county falls within the jurisdictional territory of the Chickasaw Nation.

Inside Eck Drug & Gift, a sign with a photo of a bottle of pills reads: “Prescription opioids can be addictive and dangerous. It only takes a little to lose a lot.”

Six years ago, the Eck family was given Southwestern Oklahoma State University College of Pharmacy’s first Heritage Award for service to the university and the pharmacy profession. The store’s slogan for years was: “A family of pharmacists serving your family.”

The pharmacy has earned another distinction.

From 2006 through 2014, just over 2.3 million pain pills were shipped to Eck Drug & Gift, according to the DEA’s prescription pill database. An additional nearly 2.5 million pills were shipped to Moore Drug, also in Jefferson County, population 6,400.

In all, opioid distributors shipped more than 5.4 million prescription pain pills to Jefferson County — an average of 94 pills per person each year. That is 2.5 times the national rate and more than twice the rate of the state.

The majority of pills were distributed by AmerisourceBergen and McKesson, two of the nation’s largest opioid distributors and defendants in the consolidated lawsuit in Cleveland.

A spokesman for AmerisourceBergen said the company is committed to mitigating the diversion of drugs “without interfering with clinical decisions made by doctors, who interact directly with patients and decide what treatments are most appropriate for their care. … We are committed to collaborating with all stakeholders on ways to combat opioid abuse.”

A spokesperson for McKesson said in a statement that the company distributes prescription opioids and other medications in response to orders placed by pharmacies and did not influence “the volume of opioids prescribed or consumed in this country.”

“We are deeply concerned by the impact the opioid epidemic is having on families and communities across our nation,” the statement said. “We are committed to engaging with all who share our dedication to acting with urgency and working together to end this national crisis.”

Of the five Oklahoma pharmacies with the highest rates of pills, two are in Jefferson County

Based on county population, 2006-14
PharmacyPills per personTotal pills
Clinic Pharmacy, Harmon County711,840,570
City Drug Store, Choctaw County547,383,810
Moore Drug, Jefferson County432,490,010
Eck Drug & Gift, Jefferson County402,325,220
Gene Lafitte Pharmacy, Johnston County393,766,890

Dana “Biff” Eck, a second-generation pharmacist who has owned Eck Drug & Gift since 1985, said he was surprised by the number of pills shipped to Jefferson County.

“That would amaze me that that many went through here,” Eck said. “We did a lot, but I don’t remember that much.”

“We’re just a small-town pharmacy trying to take care of our people,” he added.

He said that he does not recall doctors prescribing anything out of the ordinary and that he filled valid prescriptions for as many as 120 pills at a time. He said the culture and attitude toward treating pain has shifted over the past 20 years, from when doctors were told to treat pain as “the fifth vital sign.”

“Back in the day, if you were not treating pain, you were not a good doctor,” said Eck, who added that he is now dispensing about a third fewer pain pills than he once did.

In Ringling, Okla., population 1,000 and about a half-hour drive from Waurika, Moore Drug has been in Tom Hildebrant’s family since 1934. Hildebrant, a pharmacist who has run the store since 2012, said he was unaware of federal data showing millions of pain pills shipped to his store at the height of the epidemic.

“That really surprises me,” Hildebrant said. “I know there’s been a big problem, but I didn’t know Jefferson County had been singled out. I wouldn’t think we fill any more prescriptions than anybody else.”

Other counties also experienced an influx of millions of pain pills. In Eastern Oklahoma’s Adair County, where half the residents are members of the Cherokee Nation, distributors shipped more than 8 million prescription hydrocodone and oxycodone pills from 2006 to 2014 — 42 pills per person per year, The Post’s analysis shows.

Nearby Delaware County, where 1 in 3 residents are Cherokee members, received more than 12 million pain pills.

“The human and economic toll inflicted on the Cherokee Nation and many other tribes around the country is just truly hard to fathom, and yet it continues and will continue until funds are available to undo some of the harm that has been caused,” said Richard Fields, a lawyer representing the Cherokees and a dozen other tribal nations.

Image: Native American tribes across the country are working to provide treatment for opioid addiction. Here, patients in a recovery program wait on a bus for a ride home from a center operated by the Swinomish Tribe in Anacortes, Wash.

Despair in Indian country

Tribal leaders and health experts say the pills flowed for a number of reasons.

Native Americans have higher-than-average injury rates from work in industries such as farming, logging and fishing, said Anthony Dekker, the former chief clinical consultant for addiction medicine and chronic pain management at the federal Indian Health Service. In rural areas, he said, Native Americans have also struggled with a lack of access to quality health care and long-term, non-pharmacological treatment options.

A 2019 audit by the U.S. Department of Health and Human Services found that some Indian Health Service hospitals did not follow required procedures when prescribing and dispensing opioids to Native Americans.

Drug companies are also to blame, tribal leaders say.

In 2017, the Cherokee Nation, the nation’s largest federally recognized tribe, filed the first tribal lawsuit against the opioid industry.

The history of the Cherokee Nation in Oklahoma has been marked by tragedy. The Cherokees and other tribes were forced off their land after the Indian Removal Act of 1830. During the “Trail of Tears,” tens of thousands of Native Americans were made to travel hundreds of miles from their ancestral lands in the Southeast to areas west of the Mississippi River. Many suffered from disease or exposure, and thousands died along the way or shortly afterward.

Now with members spread across 14 Oklahoma counties, the Cherokee Nation is alleging in its federal lawsuit that opioid distributors and pharmacies for years ignored clear signs of suspicious ordering.

Tribal leaders said overdoses and deaths soon followed: Social services, as well as medical, welfare, law enforcement and foster-care systems were overwhelmed by families struggling with addiction.

Cherokee Nation Attorney General Sara Hill said the wreckage of opioids “permeates life in the Cherokee Nation.”

The tribe’s lawsuit alleges that overdose deaths more than doubled among tribal members between 2003 and 2014 and that for adults, overdose deaths now outnumber those from car accidents. In addition, for every lethal overdose, the tribe logged 10 admissions to drug treatment centers and 32 emergency room visits, according to the complaint.

“I’ve definitely seen the impact in our hospitals,” Hill said. “We’ve seen it in our child welfare cases where children are brought into custody. We’ve seen it in the uptick in the clinics.”

The drug distributors have repeatedly said they are not responsible for opioid overdoses and deaths, and they have unsuccessfully sought to dismiss the cases against them. The top three distributors, along with an opioid manufacturer, reached a settlement of $260 million with two Ohio counties in October 2019. Thousands of cases are pending.

In February, U.S. District Judge Dan Aaron Polster, who is overseeing the consolidated case in Cleveland, sent the Cherokee lawsuit back to federal court in Oklahoma. Polster wanted one tribal lawsuit for a “bellwether” trial to help predict how other tribes might fare if their cases come before a jury. The tribe was chosen because, among other reasons, it is the largest in terms of population and was one of the first to file a nationwide opioid case.

The move, welcomed by lawyers for the tribe who worried that individual cases had hit a bottleneck, will allow the Cherokees to move forward with their own litigation against multiple companies. A trial date has not yet been set.

Other Oklahoma tribes, including the Chickasaw Nation, remain part of the lawsuit in Cleveland.

Chickasaw leaders say they are hoping to recoup some of the addiction-treatment money they have invested in recent years.

When the tribe’s insurance carrier wouldn’t pay for members to stay for 90 days in residential treatment facilities, the tribe decided to make up the difference with its own funds — and help pay the monthly household bills for those in treatment.

“They still have electric bills,” said Jay Keel, the Chickasaw Nation’s secretary of Family Services. “They still … are trying to feed their children. They can’t keep their family hanging.”

The Chickasaw Nation also started an “amnesty” program, guaranteeing job protection to tribal employees who went into treatment. The goal, tribal leaders say, is to encourage people to acknowledge their addiction and get help.

Image: Zach Williams, who struggled for years with addiction, eats dinner with his family. He said he became addicted to opioids after being prescribed painkillers, including OxyContin, for a sports injury.

From injury to addiction

Williams, the Chickasaw Nation pharmacist, called the tribe’s efforts a lifeline.

Like thousands of others during the past 20 years, Williams said his addiction started with an injury. As the quarterback for the Whippets, his high school football team in Northwest Oklahoma, Williams, a member of the Cherokee Nation, was gearing up to play in college. Then, in 1999, he collided with a linebacker.

Williams broke his neck, ending his football career. He went to the University of Oklahoma to become a pharmacist, but the neck pain lingered. Williams said he was eventually prescribed painkillers that included OxyContin. His life spiraled.

Purdue Pharma, the manufacturer of OxyContin, said in a statement that the company is “working toward a settlement that would speed the delivery of resources and vital medicines that States and local communities, including Native American tribes, can use to address and abate the opioid crisis.”

“We sympathize with all those affected by opioid abuse across America,” the statement said.

Williams said he continued to take painkillers every day after he got married, had three children and began working as a pharmacist for the Chickasaw Nation.

After Williams’s unsuccessful attempts to stop on his own, he said he finally worked up the courage to ask for help. Chickasaw leaders sent him to residential treatment in Texas and covered his bills. Now back at work and in a tribal outpatient recovery program for the past 22 months, Williams said he’s spending far more time with his wife, son and twin daughters.

He questions why so many pain pills poured onto tribal lands for years but said he holds himself accountable for his own recovery. Inside his trim, red-brick home off a two-lane country road, the walls are covered with photographs of his family and a sign that reads: “When life gets too hard to stand, kneel.”

About this story

Prescription opioid death rates are based on data compiled by the Centers for Disease Control and Prevention and analyzed by The Post. Pill shipment rates are based on data compiled by the Drug Enforcement Administration and analyzed by The Post. Population figures are from the U.S. Census Bureau. Story editing by Peter Finn. Copy editing by Wayne Lockwood. Photo editing by Nick Kirkpatrick. Graphics by Danielle Rindler and Adrian Blanco. Design and development by Allison Mann.

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