TAZEWELL, Tenn. − Sheila Dummett had been shooting heroin for two years when a dirty needle landed her in the emergency room with severe sepsis that spread to the bone in her leg.
Sitting in her hospital bed, the 58-year-old weighed her options.
She could stay and treat the sepsis, but then she'd likely be arrested over a $700 fine related to drug charges and face withdrawal in a county jail with no treatment programs. Or she could go home and score heroin to ease her dope sickness. She chose the latter.
"I can't go to jail," she said. "They'll let you lay there and die before they help you."
Dummett lives in Claiborne County, a rural corner of northeast Tennessee known for its rolling hills and small towns tucked into valleys. But its beauty hides a harsh reality in a part of Appalachia ravaged by the opioid epidemic.
The county in 2023 had Tennessee's third highest fatal drug overdose rate, with 102 deaths per 100,000 residents — twice the state average and more than three times the national average.
Dummett has seen a dozen friends die in recent years, including three just in the past two months from heroin mixed with xylazine, a powerful horse tranquilizer. She said she's used naloxone to reverse opioid overdoses on more people than she can count.
"I've brought a lot of people back," she said.
Tennessee is set to receive a windfall of more than $1.2 billion over two decades from national settlements with companies that sold prescription painkillers, fueling a generation addicted to opioids. But experts fear much of the funds so far aren't reaching people like Dummett, who need it the most.
Between 2023 and 2025, Tennessee's 95 counties received a combined $86.8 million in opioid abatement funds meant for treatment, prevention and recovery.
But the state so far has struggled to track how local governments are actually spending the money, and their rollouts have been slow and uneven. Two years in, counties have spent only about half the funds, said Dr. Stephen Loyd, who chairs the state's Opioid Abatement Council, which is charged with allocating and tracking the funds.
Tennessee is not alone in grappling with how to track and publicly report opioid settlement dollars.
Across the country, states are working to distribute billions of dollars from national opioid settlements, with uneven results.
Some states, like North Carolina, are cited as models for transparency, with clear reporting requirements and public dashboards. Others, like Mississippi andIowa, have been criticized for slow spendingand inconsistent oversight, leaving large portions of settlement money unaccounted for or unused.
The challenge is especially felt in rural regions, where small local governments lack the resources to manage the large pots of funds and reporting requirements.
In Tennessee, the reporting process has been so confusing for counties that the abatement council paused its semiannual reports this year to develop a new format, with public reporting expected to resume next spring.
Loyd, an addiction expert who is himself in recovery from opioid use, said he's frustrated with the rollout.
"The frustration is not knowing what the money's being spent on and how it fits into the ecosystem that we're trying to build across the state," he said. "We're not meeting our mark, and that's the part that scares me."
Meanwhile, people like Dummett remain trapped in a cycle, wanting recovery but facing hurdles. For now, she said her best option is a clean needle exchange program at a local church.
Dollars for deaths
After record spikes during the COVID-19 pandemic, the nation is finally seeing a meaningful drop in overdose deaths.
Tennessee logged a projected 32% decrease last year, but the battle is far from over. In 2023, the state had the third highest overdose death rate in the country, behind only West Virginia and Delaware, according to theCenters for Disease Control and Prevention.
The nation now is in what experts call the "fourth wave" of the epidemic, as fentanyl is appearing in other drugs like methamphetamine and cocaine,sparking clusters of deadly overdoses.
Nationwide, more than $50 billion in settlement money is expected to flow over two decades to states and local governments thatsued companies like Purdue Pharma, and its owners the Sackler family, for flooding the market with opioids.
States and local governments are all handing the funds differently, and some have faced criticism for spending money onquestionable things like concerts and police gear.
In Mississippi, for example, the attorney general this month said the state would review its process for overseeing settlement dollarsafter cities and counties spent millionson general expenses without clear state guidance.
Tennessee uses a three-bucket approach: 15% is distributed as direct payments to local governments, 15% goes to the state's general fund and 70% goes into the Opioid Abatement Fund controlled by the abatement council, which then funnels it to counties and organizations in competitive grants. Local policymakers can decide how to spend their share of direct payments and abatement funds as long as it fits within an approved list of uses.
The county abatement payments began flowing in 2023, but oversight has proven difficult for the state's 15-member Opioid Abatement Council. By late 2024, almost one third of counties had reported not yet spending any of the funds, and with the state halting public reporting, it's even harder to know how much they're spending today.
Opioid Abatement Council Executive Director Mary Shelton said counties are struggling to report accurate spending and are uncertain about what uses are legally permitted. The result has been math mistakes and mounting confusion.
"There's no blame on the counties. We need to regroup and figure out the best way to report," she said. "More than anything they need education and consulting."
While local leaders hash out plans, others are on the front lines, hoping for funding.
Clean needles and prayers
On a quiet weekday evening in Claiborne County, Pastor Joseph Hoffman is in his office at Bethany Church packing bags for the weekly clean needle exchange. The bags are filled with sterile syringes, fentanyl and xylazine test strips and naloxone kits to reverse overdoses.
About 40 people show up each week, trading in used needles that could spread hepatitis, HIV or sepsis.
He said Bethany is the only church in the region offering this type of program. The state allows clean needle exchanges but programs outside of health departments are rare.
Hoffman knows there's a stigma that needle exchanges enable drug use, but he points to the studies showing they actually reduce harm. Through the program, the church has distributed more than 2,000 naloxone units and reversed nearly 400 overdoses, by his estimate.
"This is what it means to be a Christian," he said. "To meet people where they are."
Addiction has carved deep into Claiborne County, where poverty grips nearly one in five residents. First came the flood of pain pills in the late 1990s, then cheaper heroin, followed by deadly fentanyl. These days, Hoffman sees people with festering wounds, a hallmark of xylazine.
As both a pastor and nurse, he cleans injuries and prays with those who ask.
It's unclear how the county is spending its opioid settlement funds. The mayor didn't respond to requests for information.
Hoffman said officials are planning a round of community grants, and he hopes the church will get funds to expand its work.
"I feel that we could use the funding effectively," he said.
Cyndi Miller, 45, was one of many who trickled in that evening for supplies. She moved from Ohio earlier this year, hoping Claiborne would be a place to get clean, but she's still struggling. Addiction, she said, has shadowed her family for generations.
"It's been a chain reaction," she said. "My father was the first to put a needle in my brother's arm."
An endless cycle
Dummett is a regular at the church's clean needle program, which she said has kept her alive by helping her avoid new infections.
On a recent Tuesday evening, she scooped up a bag of supplies and limped to her car, her right leg still weakened from the untreated sepsis that nearly killed her.
Back at her two-bedroom house on a wooded country road, she settled into a recliner to prepare her next dose of heroin. Her sister, who also struggles with addiction, stayed behind a closed bedroom door. Outside, her dogs barked to be let in.
Dummett knows the powder in front of her likely contains fentanyl, but she hasn't tested it.
"When you're sick, you don't care," she said. "You just want to be over that sickness."
Her right arm is mapped with track marks and a swollen abscess where she missed a vein. She said she once worked as a restaurant cook and didn't start using until later in life. First it was meth, which was always around, and then heroin. Now she injects not to get high, but to stave off the sickness.
She hopes to get into rehab. But before she can do that, she has to come up with the $700 in court fines that hang over her. Only then, she said, can she return to the hospital and finish treating the sepsis without risking jail.
She hopes sharing her story will help someone else choose a different path.
"Hopefully it'll help somebody down the road," she said, eyes fixed on her arm as she held the needle.
Loyd, with the Opioid Abatement Council, said Dummett's situation reflects a system with no path forward.
The Claiborne County Jail once had a medication-assisted treatment program, he said, but officials later chose to discontinue it. Now Dummett is stuck in a cycle where she can't afford her fines, can't access treatment without resolving them and is getting sicker without medical care.
"There's no option for her that leads to getting better," he said. "She's trapped in the system, and it's a revolving door. There's no way out."
Into the epicenter
About two hours south of Claiborne, Roane County has also been battered by the opioid epidemic, but its leaders have taken a far more aggressive approach with its settlement dollars.
In 2023, the rural county of roughly 55,000 recorded the highest overdose death rate in Tennessee. Since then, deaths have nearly been cut in half, a turnaround significant enough to earn Roane an award from the Johns Hopkins School of Public Health for its use of opioid funds.
Dr. Tom Boduch, the county medical examiner and a physician here for more than three decades, has watched the crisis evolve since his early days as a general practitioner in the 1990s.
"The Purdue reps would come in and aggressively push these pills," he said. "They'd talk about the low addictive potential, but as a doctor I didn't believe it."
During the pandemic, he saw bodies, sometimes three or four a day. Now, those numbers have fallen sharply.
County Executive Wade Creswell credits a simple strategy: putting people on the ground. Roane's local abatement council funded three community navigators. One works in schools, another coordinates recovery plans inside the jail, and a third connects with patients at the hospital.
"It was like a lightbulb for everyone," Creswell said. "It just made total sense."
An uneven rollout
While some counties, like Roane, are making progress, others are struggling to keep pace.
To help with the statewide rollout, the Opioid Abatement Council this year partnered with the Substance Misuse and Addiction Resource for Tennessee (SMART) Initiative at the University of Tennessee. The group helps counties navigate the rules and understand where the funds can be used.
SMART Executive Director Jennifer Tourville said most county leaders want to spend the money responsibly, but many are overwhelmed.
"We get a lot of questions like, 'Can I buy ambulances?' or 'Can we pay for police gear?'" she said. "One county wanted to buy a body scanner for the jail. We have to explain that this is not what this was intended for."
To better understand how counties are using their opioid abatement dollars, The Tennessean, part of the USA TODAY Network, sought spending records from the 10 counties with the highest overdose death rates, largely concentrated in East Tennessee: Roane, Cocke, Claiborne, Morgan, Anderson, Polk, Knox, Campbell, Cumberland and Hickman.
Only half provided information. Among those that did, spending varied widely, from school-based drug awareness programs to free mental health counseling and treatment services for veterans.
Elsewhere in the state, some spending has drawn criticism from advocates.
Cheatham County sparked concern when it proposed using opioid dollars to help fund its jail expansion, which officials defended as permissible because the facility will offer treatment programs. And in November, Hamilton County approved using $195,000 in settlement funds to support local food banks serving SNAP recipients affected by the federal government shutdown.
Daniel Busch, chair of the FED UP! Coalition to End the Opioid Epidemic, a national group led by parents who lost children to addiction, said he worries more counties and states will start using opioid settlement dollars to fill unrelated funding gaps.
"Hamilton County is just the beginning of what we're going to see," he said.
Funding community efforts
Nationally, advocates warn that without clear tracking and accountability, states risk repeating mistakes with the major tobacco settlement funds, where much of the money was used for budget holes rather than anti-smoking efforts.
Linda Richter, with the nonprofit Partnership to End Addiction, said the struggle to spend and track opioid funds is a pattern across the country. The organization provides guidelines for states to invest the funds for prevention.
"There are states that are letting a lot of the money just sit there because they don't quite know what to do with it, which is very sad and disappointing, because it's such a fantastic opportunity to spend the money on things that can actually help improve the addiction crisis," she said.
She recommends communities do thorough assessments to determine their needs.
Tonya Garton lost her 20-year-old son, Quintenn Clark, to a fentanyl overdose in 2021. She wishes more of the opioid settlement money would reach her community in Cheatham County just outside of Nasvhille.
Clark, a former baseball player, began struggling with Xanax in high school, a struggle that eventually escalated to heroin. Today, his baseball-shaped gravestone looks out over his old high school in Ashland City, the county seat.
In his memory, the family created the Quintenn Clark Foundation to raise awareness about the dangers of drugs. So when Garton learned that Cheatham County planned to use its share of opioid funds on the local jail expansion, she was disheartened.
She believes the money should be used to educate young people.
"I understand their logic behind it, but that's not what that money was to be allotted for in my opinion," she said. "There are so many other avenues, jail is the last stop in all of this."
This article originally appeared on Nashville Tennessean:Opioid aid floods rural America, yet support falls short for many
