In 1998, forty-six state attorneys general settled with the tobacco industry. The Master Settlement Agreement was worth $246 billion over twenty-five years — the largest civil litigation settlement in American history at that time.

Tribes were not at the table.

The settlement went to states. Over nineteen years, $425 billion in tobacco revenue flowed in — $148 billion from the settlement, $277 billion from tobacco taxes. The states spent 2.6 percent of it on tobacco prevention and cessation. The rest went to general funds, budget gaps, and whatever else needed paying for that year.

Cherokee Nation Principal Chief Chuck Hoskin Jr. remembers. “There will never be another era,” he said, “in which there’s some industry that does damage to the Cherokee Nation, damage to the Cherokee people, where we will be bystanders looking for state legislatures, state attorneys general to get us justice.”

In 2017, Cherokee Nation became the first tribal nation in the United States to sue opioid manufacturers. Not the first to join a lawsuit. The first to file one.

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In the fourteen counties that make up Cherokee Nation’s jurisdictional territory, more than 1,000 people died from opioid overdoses between 2020 and 2024. Nationally, more than 900,000 Americans have died from opioid-related causes since 1999. Native Americans have the highest overdose death rate of any racial or ethnic group — and the CDC estimates that number may be undercounted by 34 percent.

The epidemic moved in three waves. Prescription pain pills first. Then heroin. Then fentanyl and synthetic opioids, which hit tribal communities hardest during COVID-19, when isolation compounded addiction and healthcare infrastructure was already stretched past capacity. Of the 825 Tribal Health, Urban Indian, and Indian Health Service facilities in the country, only 217 offer behavioral healthcare. That’s one in four.

Cherokee Nation recovered approximately $150 million through settlements with opioid manufacturers. Across all of Indian Country, the total is $371 million for more than 300 tribes — with an eventual $1.3 billion committed. The national total across all settlements is nearly $58 billion.

$371 million for 300 tribes. $58 billion for everyone else.

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Here is what Cherokee Nation is building in Tahlequah, Oklahoma.

A 45,000-square-foot residential and intensive outpatient treatment campus. One hundred inpatient beds across five housing units. An outpatient hub with follow-up support. It opens in August 2026. It costs tribal citizens nothing.

The facility has a stickball court. Stickball — anetso — is one of the oldest team sports in North America, played for centuries before European contact. It is not recreation bolted onto a treatment plan. It is ceremony, community, and physical expression of cultural identity. It is medicine.

There is a garden on the grounds for growing selu — corn. Corn is not a metaphor in Cherokee culture. It is one of the Three Sisters, central to Cherokee agriculture, ceremony, and survival for thousands of years. Selu is also the Corn Mother in Cherokee origin stories — the one who fed the people from her own body. Growing corn on the grounds of a treatment center is not landscaping. It is theology.

There is a sweat lodge nearby. A meditation space. A gym. Large windows facing the rolling hills of northeastern Oklahoma. The building faces east, to greet the rising sun.

Cherokee language experts are still finalizing the name.

Juli Skinner, senior director of Cherokee Nation’s behavioral health center and a citizen of the Ponca Tribe, put it simply: “Culture is such a protective factor. Historical trauma has hit a lot of people — Native Americans, tribes — hard.”

Fifty to seventy Cherokee citizens need residential treatment every month. Until August, there is no tribally operated residential facility to send them to.

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Christine Minhee, the attorney who runs the Opioid Settlement Tracker, found that families of overdose victims have received less than 2 percent of the $58 billion. Advisory groups help determine spending for about half of the total, but have decision-making authority over less than one-fifth. Less than one dollar in seven is overseen by boards that reserve even a single seat for someone who has used drugs.

The tobacco template holds. The states got the money. The states spent the money on things that were not the thing. KFF Health News documented the pattern: from addiction treatment to toy robot ambulances, billions in opioid settlement funds spent by state and local governments in 2022 and 2023 on purposes the settlements were never designed to serve.

While the states reproduced the tobacco playbook, the tribes built something different. The Navajo Nation received $63 million — the largest share among tribes. Kim Russell, their health executive, said they are not building buildings. They are hiring staff: clinicians, epidemiologists, primary care doctors, coders and billers to keep the system running. She called it “nation-building.”

The Mi’kmaq Nation in Maine received just over $150,000. They spent $50,000 of it on a sweat lodge. Katie Espling, the Mi’kmaq health director, said patients had been asking for it for years but couldn’t access it without insurance coverage. The settlement made it possible. $50,000 for a healing practice that predates the pharmaceutical industry by millennia.

The settlement terms explicitly authorize spending on sweat lodges, smudging ceremonies, basketmaking programs, and tribal language instruction. The legal language calls them “traditional and cultural healing practices.” The communities that use them call them what they’ve always been.

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Ashley Caudle is a citizen of Cherokee Nation, from Stilwell, Oklahoma. “Addiction is not linear,” she said, “and it doesn’t affect just the addict. It affects the daughters and the brothers.”

Hoskin called the treatment center “part of an existential effort.”

That word is precise. The opioid epidemic did not just kill people. It attacked the connective tissue of community — the elders who carry language, the parents who carry tradition, the young people who carry both forward. Every overdose death is a broken link in a chain already under stress from boarding schools, forced relocation, and two centuries of federal policy designed to sever exactly those connections.

A treatment center that integrates stickball and corn and sweat lodges and eastern-facing windows is not a cultural flourish attached to Western medicine. It is an assertion that healing happens inside identity, not outside it. That the treatment for a crisis manufactured by pharmaceutical companies might include something those companies could never patent or sell.

The tobacco settlement taught Cherokee Nation what happens when you wait for someone else to fight for you. You get nothing, and the people who got everything spend 2.6 percent of it on the problem.

The opioid settlement taught them what happens when you file first. You get to build the thing yourself. And when you build it yourself, the building faces east.

// NEON BLOOD

Sources: ICT News · KGOU/KOSU · KFF Health News · CDC Tribal Overdose Data · Opioid Settlement Tracker · Truth Initiative / MSA · Campaign for Tobacco-Free Kids