TAHLEQUAH, Okla. — Dr. Anna Miller sits with her legs pulled up, boots kicked off, in an exam chair at Cherokee Nation W.W. Hastings Hospital. She’s waiting for her first Suboxone patient of the day.

She knows the odds are stacked against these patients struggling to get off opioids. She’s seen firsthand how crooked the path to recovery can be. She also knows she has a few singular advantages, unique to Indian Country, in tackling the crisis.

But those advantages are double-edged — and all too swiftly can turn into obstacles.

There is, for instance, the fact that health care is free to members of Cherokee Nation, as it is for most Native Americans under longstanding treaties with the US government.

“The great advantage is that I basically have socialized medicine,” Miller said, though she’s quick to point out the care didn’t come without a cost: “Free is not the right word to use. It’s something that was earned by their ancestors in a treaty.”

Those treaties ensure that patients don’t have copays or deductibles to worry about when they receive medication or behavioral therapy to help wean them off opioids. That lifts a huge financial burden: The Suboxone alone can run hundreds of dollars a month.

At the same time, providers said, because there’s no cost, it can be hard to get patients to fully commit to sticking with the long process of recovery. They don’t lose a lot of money if they decide to drop out.

Then there’s the close-knit nature of the tribe. That can be a huge help to doctors — the medical staff knows exactly which neighbors or relatives to call to track down a patient who hasn’t shown up for his Suboxone strips.

But the strong connections binding the community can also drag down individuals trying to overcome addiction. It’s hard to break habits when you’re surrounded by so many friends with the same cravings for opioids.

The rate of drug-related deaths among American Indian and Alaska Native people has almost quadrupled since 1999, according to the Indian Health Service. It’s now double the rate in the US as a whole. Oklahoma — home to the 120,000 citizens of Cherokee Nation — leads the country in prescription painkiller abuse.

“It’s a problem for the entire country,” said Chuck Hoskin, the secretary of state for Cherokee Nation. “But we are up against it in Cherokee Country.”

About half of participants in Suboxone programs nationally reduce their prescription painkiller abuse over the three-month treatment. But once they stop taking Suboxone, the success rate has been shown to fall to just under 9 percent.

Despite the long odds, Miller and the only other doctor in the Suboxone program, Dr. Charity Holder, find the work worthwhile.

“When people really start to realize the enormity of the problem,” Miller said, “they realize maybe it’s not that these are bad people. It’s that they have a disease that needs treatment.”

These patients “are desperate for help,” Holder said. “If we just pay attention to this epidemic and take care of it, we’re going to get people back out there.”

She says that with optimism and determination. Yet she knows what her patients face when they leave the security of her office. “They go right back to their homes and to their exposure to narcotics,” she said.

Curtis Wilson knows that cycle well.

Curtis Wilson talks about his addiction.

An early addiction and a hopeless spiral

Wilson, now in his mid-30s, had been shooting heroin for about a year when he first took pain pills to get high with his uncle.

That was more than two decades ago — when he was just 12 or 13 years old. “It just kind of spiraled from there,” said Wilson, who is Cherokee and works building Indian homes.

That early introduction to opioids isn’t uncommon among Native Americans.

By 12th grade, nearly 13 percent of American Indian teens have used OxyContin, according to the American Drug and Alcohol Survey. And 2.6 percent of American Indian students in 12th grade have used heroin, nearly double the rate of the general population.

Wilson did pain pills for about 10 years, then stopped when he got together with his wife, Tracy. In 2004, after a bad accident, he turned back to pills. His drug of choice: K4 Dilaudid, a 4-milligram narcotic pill also known by its generic name, hydromorphone. He’d take between 12 and 14 pills a day, shelling out upwards of $800 a week on pain medication.

“I made sure all my bills was paid. The rest went up my arm or down my throat,” Wilson said.

For a few years, his wife didn’t have any idea what he was doing. He’d wait to get up until she left for work, then scoot over to the edge of the bed to shoot up. That changed in 2006, when Wilson went on a weeklong work trip to Little Rock, Ark. Just a few days in, he ran out of drugs. The withdrawal consumed him — nausea, diarrhea, twitching. He still had five days left on the build. Desperate, Wilson called his wife and told her that he needed help.

Cherokee Nation helped Wilson get into a five-day detox. It didn’t last long.

“Soon as I got out, I knew where I was getting the pain medicine,” Wilson said. He tried, once, to break his addiction by leaving the state. It worked for a few weeks. Then he came back to Cherokee Nation.

“The day we got back, I got some pills. The very day we got back,” Wilson said.

Tracy took their three children and left him more than once. “It about killed me,” he said.

Their three boys are grown now. One works on an oil rig — he gets to come home for Christmas — and another lives nearby. The third is getting treatment for his own addiction.

Wilson’s new babies are his two dogs, Oreo and Hoss, who jump onto his lap the moment he sits down and cry when he tucks them into a back room. He lives now in Sallisaw, a small town smack in the middle of Cherokee Nation. There’s a set of train tracks right outside his front door — he doesn’t notice the noise much anymore — that run north to the small town of Stilwell.

Family is Wilson’s soft spot — the boys, Tracy, and his sister, Cyndi Lindsey, who vividly remembers how quickly her brother changed when he started using painkillers.

“[He] didn’t care about life, didn’t care about anything but where he was gonna get his next fix from,” she said. “It felt like I had lost my best friend.”

Cyndi Lindsey says her brother's addiction damaged their relationship.

Wilson, who wears a baseball cap and speaks with an easy drawl, struggles to reconcile his addiction with what it’s done to his family. They struggle with that, too. “It can tear a family apart, and it can do it in a hurry,” Lindsey said.

At one point, he stayed clean for four or five months — then again, turned to shooting up and taking pills. He went to detox again. Shortly after, Wilson was diagnosed with hepatitis C.

That’s how he met Dr. Miller.

She gave him a date to come in and told him not to take any opioids for the 12 hours before his appointment. He didn’t take anything for two days, just to be safe. Miller gave him a half of a strip of Suboxone when he arrived.

Suboxone is an prescription opioid that’s used to treat opioid addiction. Buprenorphine, the active ingredient in Suboxone strips, sticks to the same receptors as other opioids. It can tamp down on cravings and suppress symptoms of withdrawal. Suboxone strips also contain naloxone, which is intended to make the drug more difficult to abuse.

“Within 15 seconds, I didn’t feel no withdrawals. I felt normal,” Wilson said.“I didn’t feel real good, but I didn’t feel bad.” He couldn’t remember the last time he’d felt like that without being on pills.

Wilson left the office that day armed with three strips and an order to come back in three days.

“That’s how I started,” he said.

It’s about an hour-long drive down winding country roads from Wilson’s house in Sallisaw to the hospital in Tahlequah. Wilson’s boss lets him take a half day off whenever he needs to make the drive. For awhile, that was several times a week. His boss didn’t blink an eye.

That’s surprisingly common here.

“I have so many young men who have bosses who are unbelievably understanding,” Miller said.

Breaking through generations of distrust

The Suboxone program here has about 40 patients. That’s not much, compared to the depth of need.

But health care providers here, as in much of the country, say there’s still a stigma to confessing addiction and getting help. In Cherokee Nation, that problem is exacerbated by a traumatic history of betrayal by the US government.

About 22 percent of American Indian households in Oklahoma lived below the poverty line in 2010, the most recent year of data available, compared to a 15 percent poverty rate nationally. The Trail of Tears — the forced removal of the Cherokee and other native peoples from their homelands under President Andrew Jackson — remains a deep, painful wound here.

“There’s stigma in behavioral health in rural communities, but then there’s also stigma around trusting the system,” said Joni Duffield, the administrator of the behavioral health program for Cherokee Nation.

Sometimes, that wariness comes from hard experience. Robert Fields, 32, sought treatment for his addiction to painkillers through the Veterans Affairs system after leaving the military. He said every time he owned up to his condition to a doctor, he was treated “like an addict.” He felt judged — until he started getting treatment from Holder in Cherokee Nation.

“She hasn’t treated this as anything other than a medical condition,” Fields said. “She’s the only one.”

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It’s Sam Bradshaw’s job to try to break through the community’s distrust.

He likens helping people from rural communities to nursing a tree back to health, then putting it back into a forest of sick trees.

“They get well, they get better. Then they go back to the community, where there’s a culture of not talking about it and the culture of not trusting the system,” Bradshaw said.

Bradshaw and his colleagues in the behavioral health office are working to change that, one person at a time. They visit college fairs, tribal get-togethers, and town meetings to talk about drug and alcohol abuse with young people. They train doctors to better recognize the signs of addiction.

They’ve helped push for practical steps, too, such as installing drop boxes where patients can safely discard of unused opioids and prescription drugs in police stations across Cherokee Nation.

The public health program, known as the Partnership for Strategic Success, is funded by a $1 million federal grant to Cherokee Nation.

“We’re doing this because we don’t want our next generation to have an opioid epidemic,” Duffield said. “We’re doing this because we’re committed to the future of our tribe.”

A drop box at a police station in Talequah, Okla., where residents can deposit unused opioids and prescription drugs.

Pushing for more patients, but with caution

Back at the hospital, Miller and Holder aim to expand the Suboxone program; they plan to apply for federal approval from the Substance Abuse and Mental Health Services Administration to handle up to 100 Suboxone patients apiece, up from their current limit of 30 patients each.

But they still have hurdles to jump.

They can’t run a needle exchange program to curb cases of hepatitis C among individuals with opioid use disorders. The state of Oklahoma has criminalized drug paraphernalia, making needle exchanges impossible to open.

It’s also been difficult to recruit doctors. Tahlequah, population 16,369, has one main drag with an art gallery, a saddle shop, and a smattering of coffee places. It doesn’t have the big-city appeal that Tulsa might — nor do Suboxone patients make for easy cases.

And even if both doctors are given the green light to take on more patients, it’s not clear whether the pharmacy or relatively small health care staffs will be able to handle the additional cases.

“The challenge for Indian Country is the infrastructure support to help combat those issues,” said Carmen Clelland, the associate director of the tribal support unit at the Centers for Disease Control and Prevention.

If that’s not enough, the doctors have to combat local and national questions about the whole idea of medication-assisted treatment. It’s been criticized as simply swapping one drug for another; some physicians argue that abstinence is the only acceptable goal.

Miller finds that suggestion preposterous.

“If I have a diabetic patient who has gained 5 pounds, I don’t tell them I’m stopping their insulin until they get their act together,” she said.

Curtis talks about staying clean.

Small victories and an uncertain future

Wilson is nearing the end of his hepatitis C treatment. When that wraps up, Dr. Miller will begin to taper him off Suboxone.

His wife, Tracy, readily admits she has her doubts. She is glad to see Wilson feeling better, certainly, she said. But she’s been through too much of a roller coaster — spent too many sleepless nights with him, heard too many of his promises to get clean, seen him relapse too many times — to consider anything a surefire fix.

Wilson, though, is confident it’ll work.

“I feel better now than I’ve ever felt in my life,” Wilson said. “I have a lot of respect for [Miller] because she’s helped me do something I couldn’t have done on my own.”

Wilson doesn’t talk to his mother anymore, or anyone he believes is still doing drugs. Instead of sleeping in and shooting up, he gets up early enough to have a cup of coffee with Tracy before she goes into work. On her birthday in October, he had enough money to send her for a manicure and to get her hair cut and colored. He calls his sister every morning, around 6:30 a.m. He’s hoping to start his own construction business next year.

“I can get up every morning and I don’t feel bad,” he said. “I don’t have no regrets.”