How Native communities in Washington state are fighting the fentanyl crisis

Practitioners burning sacred herbs for patients seeking addiction treatment. Tribal sweat lodges where Native Americans can meditate and purify their bodies. Gardens where rehab residents can grow their own medicinal plants.

Down the Pacific Coast, along the Salish Sea and across the inland Northwest, tribes and Native health providers say they have historically found success integrating cultural resources and traditions with Western medicines to treat substance use disorders. Studies, while limited, have found positive effects from culture-based interventions for addiction treatment.

But fentanyl, a synthetic opioid 50 times more potent than heroin, has become a particularly difficult scourge to eradicate.

Across the United States, the American Indian and Alaska Native population had the highest drug overdose death rates, with a 33% increase in drug overdose deaths from 2020 through 2021, the Centers for Disease Control and Prevention reported last year. Many of these overdoses stemmed from polysubstance use—mostly people unknowingly taking drugs mixed or cut with other substances, like fentanyl.

Few parts of Washington state are untouched by the disparity, from rural counties to urban metro areas to tribal reservations. Statewide, American Indian and Alaska Native residents have the highest rate of death from synthetic opioid overdoses, with at least 203 killed between 2018 and 2022, according to state Department of Health data. In King County alone, Indigenous residents died at more than nine times the rate of white residents in 2022.

As the spiraling fentanyl crisis inflicts a disproportionate toll on Indigenous residents, tribal leaders and health providers are calling on state and federal leaders to invest millions to save their families and communities.

"We all know the story'

Some Indigenous families have faced addiction issues for decades, a consequence of the centuries of violence and cultural genocide committed against tribes and their members in the United States—large-scale massacres, forced family separation, mass starvation, extermination of tribal identity at boarding schools.

Severed from economic resources and long neglected by federal and state governments, tribal communities disproportionately experience housing insecurity, poverty and worse health outcomes, all of which can make people more vulnerable to substance use.

As the fentanyl crisis increasingly impacts all levels of health care systems, law enforcement agencies and social service departments across tribal nations and county governments, it is difficult to calculate exactly how much has been spent.

Hundreds of millions of dollars have been spent to address the worsening fentanyl crisis in Washington, said Gov. Jay Inslee, "a fire hose of money that we're putting into the system."

Some of that has been targeted specifically toward helping Indigenous communities, Inslee said, noting legislators allocated 20% of this year's funds from the state's $518 million settlement with the three largest prescription opioids distributors to tribal nations.

But tribal leaders, health care providers and state officials agree more money is needed—particularly in Native communities—to staff health care centers, open more inpatient beds and medication-assisted treatment centers, and increase access to overdose reversal drugs such as naloxone.

"We all know the story," Lummi Nation Chair Tony Hillaire said while attending the Washington State Tribal Opioid/Fentanyl Summit in May. "We all have that story in our families: a brother; a sister; an uncle; an auntie; a niece; a nephew; a child gone too soon, to the drug epidemic—to this fentanyl crisis."

Last month, five members died of fentanyl overdoses in just one week, leading Lummi leaders to declare a state of emergency.

"We don't want to normalize the burying of our children," Hillaire continued. "We don't want to say goodbye to our future leaders, our future fishermen. They're the future leads of the family, the future language speakers, the future elders who are going to leave a pathway behind for all of us."

"A compound fracture'

Highly addictive and deadly even in tiny doses, fentanyl pills are extremely cheap and readily available in the illegal drug market. Fentanyl addiction cases are straining existing clinics and treatment options across Washington state, in some cases leading to long waitlists.

The barriers to treatment can be high, and the roots of people's addiction often go unaddressed. For Indigenous residents disconnected from their tribal communities and relatives, finding and sticking with opioid treatment can be particularly challenging.

"It's like a compound fracture," said Esther Lucero, president and CEO of the Seattle Indian Health Board. "It's our worst nightmare, and then introduce a new drug like fentanyl that's no more than $5 a pill and ... this is just a recipe for a really, really serious problem."

The organization uses a model it calls Indigenous Knowledge Informed Systems of Care, or IndigiKnow. With a focus on providing health care to Indigenous residents, the health board blends modern treatment plans with traditional medicine and "culturally attuned" care, Lucero said—a model that has proved successful.

For 33 years, her organization ran Thunderbird Treatment Center, one of the few inpatient treatment centers dedicated to helping Indigenous residents address substance use disorders. The facility had the lowest recidivism rate in the state, Lucero said.

The health board closed and sold the 65-bed inpatient treatment center in February 2020 because rehabbing the dilapidated building would have been too expensive, Lucero said. The closure was a blow to Seattle's already squeezed addiction treatment options—at the time, the center made up nearly 20% of the city's stock of state-licensed inpatient treatment beds.

But using the sale money from the Rainier Beach property, the Seattle Indian Health Board has started work on a larger, more modern facility. By the end of next year, the agency plans to open a new 92-bed inpatient treatment center on Vashon Island, making it the largest in the state when it opens. Ten beds will be reserved for pregnant or parenting people, officials said.

The care there will be rooted in that blend of modern and traditional medicine, Lucero said, while also offering a variety of social services assistance. When patients arrive, they'll meet an intake specialist who will learn about their clinical needs, but also about whether they need a new state ID card or tribal enrollment card.

Even as tribes work to heal the resulting physical, financial and emotional wounds, such mass trauma has lasting impacts for subsequent generations, "impacting the individual down to the cellular level," said Dr. Michelle Johnson-Jennings, a clinical psychologist and co-director of the Indigenous Wellness Research Institute. Research has consistently shown addiction is a symptom of trauma, she said.

Combining culture-based care with opioid addiction treatment medications such as buprenorphine, often marketed by the brand Suboxone, and methadone, people can be better set up for recovery, said Trevor Dickey, an addiction medicine lead specialist at the Seattle Indian Health Board.

"When people have community, people do better," Dickey said. "The huge thing that traditional Indian medicine offers is a sense of community, a sense of purpose, a sense of spiritual grounding," he said.

"Making sure we're whole again'

When the new treatment center opens on Vashon Island, patients will start their mornings with a sunrise ceremony, and have access to other treatments such as sweat lodges, drum circles and tribal language classes, said Lucero of the Seattle Indian Health Board. Over the course of 45 days of treatment, clients will also learn work skills like building a resume or securing a food handler certification, she said.

Holistic services that address all facets of a person's well-being offer the best chance to help people begin and stick with their recovery, she said.

"When I think about a healing model, it's all about that trauma and making sure we're whole again," she said.

For many, that path of healing will be marked by challenges. For Sky Thomas, unraveling years of trauma will take years of work, he said. After experiencing displacement, estrangement and depression, rebuilding a sense of community, belonging and self-worth will be part of that journey, he said.

Thomas, a member of the Spirit Lake Tribe in North Dakota, arrived in Seattle in 2020. As he was growing up on his reservation, addiction haunted his family. Nearly all his relatives have died from drugs, he said, and it was his mother's death in 2019 from an opiate overdose that left him adrift and seeking alcohol to cope.

"I remember just consciously going into a liquor store and buying half a gallon of vodka," said Thomas, sitting in a meeting room with a case manager at Chief Seattle Club, a supportive affordable housing complex where he lives.

Blackouts from drinking would lead him to using meth to keep himself awake, and then taking "blues," a street name for fake oxycodone pills containing fentanyl, to mellow out—"an endless cycle," he said.

Eventually he turned to fentanyl, largely because of how cheap and readily available the drug is on the streets. This summer, he overdosed on fentanyl twice within a two-week period. That was his wake-up call to start treatment for his addiction, he said.

"We're going to keep pushing, I'm going to keep pushing. I hear it in you, you're fighting for your life," Kiersa Villarica, a housing stability case manager at Chief Seattle Club, told him. "All it takes is somebody to care about you and you care about yourself."

Thomas said he is now trying to embody walking the Red Road every day, a metaphor in some Native communities for living a spiritual life of balance, discipline, healing, respect for others and purpose.

"That's why I want help, because I don't want to die. I want to live, I really want to live," he said. "I do care. I can't go like that. I have one last caring nerve in my heart."

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