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Re: For review/approval: TPs for Thursday substance abuse event

From:ssolow@hillaryclinton.com To: ha16@hillaryclinton.com CC: kcosta@hillaryclinton.com, speechdrafts@hillaryclinton.com, speechwriters@hillaryclinton.com Date: 2015-09-30 11:54 Subject: Re: For review/approval: TPs for Thursday substance abuse event

Huma raises a great point. The topper does mention his school program, but you could add a little more. --Walsh apparently established a unit in the mayor's office, the Office on Recovery Services, dedicated to addiction and recovery. He also commissioned a big study last year to understand treatment capacity in the city. And the needle collection program this past spring. --Walsh is in recovery himself (not that she needs to note this), but has more credibility and legitimacy with the recovery community than any elected leader I've read about. *MEMORANDUM FOR HILLARY RODHAM CLINTON* Date: September 29, 2015 RE: Substance Abuse Policy Roll Out On Thursday, October 1st, YOU will be participating in an event in Boston with the Attorney General of Massachusetts, Maura Healey (recently elected in January 2015), who has already endorsed YOU, and the Mayor of Boston, Martin Walsh, who is close to making an endorsement. Walsh specifically requested this event. The three of YOU will participate in a community forum on a panel, with two other panelists selected by Walsh’s office. This Memorandum provides YOU with (1) background on substance abuse in Massachusetts, on AG Healey and Mayor Walsh’s recent activities in this area, and areas of overlap between their priorities and YOUR substance abuse initiative; (2) a refresher on the architecture of and rationale for YOUR substance abuse initiative; and (3) Q&A. *I. BACKGROUND on SUBSTANCE ABUSE MASSACHUSETTS and MAYOR WALSH & ATTORNEY GENERAL HEALEY* *Substance Abuse in Massachusetts* As in other parts of the country, misuse of prescription drugs—and drug addiction in general—is a significant problem in Massachusetts. Some statistics: · About 1 in 5 young people in Massachusetts have misused a prescription drug. · The state’s heroin epidemic claimed 1,000 lives in 2014. Heroin overdose fatalities are up 45% in Massachusetts since 2005. · In Boston, drug overdoses increased 76% between 2010 and 2012. Opioid and heroin use are perceived as the most significant problems. There are three recent state-wide developments in the area of substance abuse that are worth noting. First, this past summer, Massachusetts Governor Charlie Baker announced that he will establish 100 new addiction-treatment beds within a year. This underscores the continued problem with shortages of treatment capacity in the state. Second, in August 2014, Massachusetts passed a law under former Governor Deval Patrick that federal leaders in drug policy (including Senator Markey) say they are looking to as a model. The bill, which passed the Massachusetts legislature with bipartisan support, requires insurers to pay for up to 14 days of inpatient care for addiction treatment and detox, and forbids insurers from requiring prior authorization. It also includes new overdose reporting requirements, addiction specialists in some courts, and an authorization for the state commissioner of public health to classify a drug as dangerous for up to a year, and impose certain restrictions on it. Finally, this Thursday (the day of YOUR event), the Massachusetts Senate is expected to vote on a comprehensive opioid prevention bill, S.2010. The bill would require schools throughout the state to screen students in grades 7 to 10, for signs of addiction. (We considered including something similar in YOUR substance abuse initiative, but ultimately did not, because we worried about a proposal that sounded too much like mandatory drug testing in schools. That said, there is appeal to requiring universal assessments of school-aged children to see if they are using drugs or developing addictive behaviors. In 2011, the American Academy Pediatrics recommended that pediatricians provide substance abuse screenings (not tests) to adolescents during routine clinical visits). The proposed Massachusetts Senate bill also would encourage prescribers to prescribe alternatives to opioids for pain management, and allow patients to limit their own access to the addictive drugs. *Mayor Walsh* Mayor Walsh is a recovered alcoholic. When he ran for mayor two years ago (he had been a state representative from 1997 through 2013), he spoke often about his 18 years of recovery from alcoholism. His campaign included staff members and volunteers who were also in recovery, and he is strongly supported by the recovery community. In 2014, Mayor Walsh announced a collaboration between the City of Boston and the Blue Cross Blue Shield of Massachusetts Foundation to produce a study on the supply of treatment and recovery services in Boston for those with substance use disorders. The study, published in May 2015, is currently serving as a road map for the Mayor’s Office on Recovery Services (ORS)—an office that Walsh established, and which he claims is the first-ever municipal governmental unit dedicated to addiction and recovery services. The report found that Boston’s rate of substance abuse is roughly comparable to that in other regions in Massachusetts—11.3% of the population (based on respondents’ indication of having abused illicit drugs or alcohol in the past year). It also found that Boston has a better per-capita supply of treatment and recovery beds than other areas in the state, at 152 beds per 100,000 residents. However, these programs are at *97% capacity and the wait time is currently over 3 weeks*, due to the fact that so many people from outside of Boston use its services. The report found that at any given time, as many as half of the residential treatment beds in Boston are filled by people who live outside of the city. The report recommended augmenting the number of beds for detox and residential treatment in the city; creating a “more cohesive and integrated continuum of care” for people who leave in-patient treatment, to reduce relapse; creating a central source of information on available in-patient and out-patient services; and payment reform. In other news, Mayor Walsh launched a needle-collection program in Boston this past May. It included a new 24-hour hotline and a mobile app, which residents can use to report loose needles, and a team dedicated to discarding needles from streets, parks, and public places. Within 1 month, the team found 2,000 needles. NOTE that Mayor Walsh *opposes* legalization of marijuana for recreational use. The issue is expected to be put to a state referendum in Massachusetts in 2016, and Walsh has said he will lead a crusade against it. He sees marijuana as a dangerous “gateway” drug. Governor Baker and Attorney General Healey also oppose legalization of marijuana, but are less likely to lead a charge against it. Many pundits expect the referendum to pass, as strong majorities of voters approved measures that decriminalized possession of small amounts of marijuana in 2008, and authorized its medical use in 2012. *AG Healey* Attorney General Healey made combatting prescription drug abuse, the heroin epidemic, and drug addiction a key part of her candidacy for Attorney General in 2014 (note, she is the nation’s first openly gay AG). She emphasized: · Strengthening the state’s prescription drug monitoring program—increasing resources for it; making it interoperable with PDMPs of nearby states; and having it more integrated with electronic health records; · Better intelligence collection and law enforcement in drug-trafficking “hot spots”; · More resources for prescriber education; · Reforming the criminal justice system to focus on substance abuse and mental health treatment, over incarceration; · Education and early intervention. Since becoming AG, Healey has prosecuted cases relating to heroin trafficking and to people writing fake prescriptions, requested information from the manufacturer of Narcan about recent price spikes, sued an Andover-based center for charging patients fees for Suboxone (which would have been covered by MassHealth insurance), and is looking at strengthening the state’s prescription drug monitoring program. She has also created a team that is researching issues relating to insurance coverage and parity. *Innovative Pilot Program in Gloucester, Mass.* About 40 miles from Boston, in Gloucester, Mass., the police department began a pilot program this past June which has now gained national attention, and which Mayor Walsh has said he is considering implementing in Boston. The program—called “PAARI” (Police Assisted Addiction and Recovery Initiative) – allows any opioid addict to walk into the Gloucester police station, surrender their drugs and related paraphernalia, and not be arrested. Instead, individuals with substance use disorders are fast-tracked into a recovery program. Gloucester police officers, in conjunction with other local partners/volunteers, work to find recovery spots for anyone who comes forward—and to date, PAARI has partnered with 50 addiction recovery institutions across the country, and placed over 200 people into treatment. No one is turned away, regardless of their income, their insurance, or where they are from. And when an individual arrives at the station seeking help, they are assigned an “angel”—someone usually in recover themselves, to stand by their side and help them through the process. Chief of Police, Leonard Campanello, says that cities and towns across the country have expressed interested in replicating PAARI’s model. Apparently, 26 police departments are starting to implement a version of the program locally. *Related Recent Development in New Hampshire* On Tuesday September 29, Governor Hassan and state officials gathered to announce a new program in New Hampshire to *hand out free naloxone kits –the opioid antidote that can prevent an overdose from becoming fatal – to families and friends of people at risk of an overdose*. The New Hampshire legislature recently passed a bill to exempt people from criminal prosecution if they report an overdose and make it easier for the patient to take naloxone, and Governor Hassan is now building an awareness campaign. YOU could mention that you are aware of New Hampshire’s recent decision to expand access to naloxone, and that YOU want it to be more widely available in all states. *Areas of Overlap Between Walsh/Healey and YOUR Plan* · *Expanding treatment services and supporting people throughout recovery. *Governor Walsh seeks to expand the supply of treatment and recovery services in Boston—he commissioned a high-profile study on the city’s supply of in-patient beds last year, and he is implementing a plan to enhance them and shorten wait lists. YOUR plan similarly seeks to ensure there is an adequate supply of treatment facilities and providers in every state—as YOU note, only 10% of the people suffering from a substance use disorder receive treatment. Walsh also advocates for increased coordination between inpatient and outpatient programs in order to make sure people who have been treated do not relapse. This is also a high priority in your initiative. YOU recognize that recovery lasts a lifetime. · *Strengthening prescription drug monitoring programs.* AG Healey has focused on strengthening Massachusetts’ PDMP to make the program interoperable with nearby state programs, and to have it draw on electronic health records. Note that in Massachusetts, enrollment is mandatory for all prescribers, but utilization of the system is optional in many instances. The same is true in many other states, and YOUR initiative encourages states to make use of the program mandatory before writing a prescription. · *Exploring opportunities related to prevention and early intervention.* Both Mayor Walsh and AG Healey think preventative education and programming is imperative. In March, Mayor Walsh announced “Too Good for Drugs,” a new school-based drug prevention program designed to reduce the use of alcohol, tobacco, and illegal drugs. This pilot program will be installed in seventh grade courses to promote positive social skills and character. One of YOUR key goals is also prevention: as YOU have said, preventative education and early intervention programs—particularly those which focus on peer mentors, community role models, and after school activities—do work. · *Ensuring that all first responders carry Naloxone.* Mayor Walsh has called for all first responders in Boston to carry the opiate overdose reversal medication called naloxone (commonly known by its brand name, Narcan). All EMTs and paramedics from Boston EMS already carry the medication and have used it to successfully reverse countless overdoses, but Walsh’s proposal includes all members of the Boston Police and Fire Departments. This aligns with YOUR goal that naloxone be in the toolkit of all first responders Attorney General Healey has expressed concern about the cost of naloxone, and indicated interest in meeting with pharmaceutical companies and public health leaders to push for cheaper nasal naloxone products and to ensure first responders can restock supplies of the medicine. *II. REFRESHER ON YOUR SUBSTANCE ABUSE INITIATIVE* YOUR Initiative to Combat America’s Epidemic of Drug and Alcohol Addiction commits $10 billion over 10 years to enhancing access to treatment for persons with substance use disorders, as well as preventive education, resources for first responders, and other policy measures. The basic architecture of YOUR plan is as follows: · YOU set forth five national goals in the area of drug and alcohol addiction—a statement of principles and commitment for what YOU think this country needs to do to tackle the drug addiction epidemic. · Next, YOU call upon states to partner with the federal government by submitting proposals for how they will achieve locally the national goals you set. If a state submits a credible plan and it identifies how it will work with local government and nonprofit partners, it is eligible to receive funding from a new $7.5 billion fund (the largest component of YOUR $10 billion initiative). The state must also commit to match $1 for every $4 it receives from the federal government. · Finally, YOU identify several immediate actions that YOU would instruct or call upon the federal government to take and which do not require state collaboration. One is to increase the baseline Substance Abuse Prevention and Treatment Block Grant, currently funded at $1.8 billion a year and distributed to the states by SAMSHA, by 25% (costing $2.5 billion over 10 years). The five new goals YOU set for the nation, and call upon the states as well as the federal government to work to achieve, are: · *Treatment:* YOU articulate a national imperative that every person in America who suffers from drug or alcohol addiction have access to affordable, comprehensive treatment. The gaps in access to treatment are undeniable: SAMSHA estimates that there are 23 million Americans currently suffering from a substance use disorder, but only 10% of these people receive care. One of the most important messages we think YOU can and will convey on this topic—both in the op-ed and factsheet—is that YOU view addiction as chronic disease that affects the brain. And similar to how those with heart disease or diabetes need continuing courses of treatment to manage their chronic conditions, people suffering from substance use disorders need ongoing care and support. Depending on their condition, they may need ongoing regimes of medication assisted treatment (methadone or suboxone), mental health counseling, peer support, or other treatment. We have to ensure that there is an adequate supply of these treatment facilities and providers, and that treatment is covered or affordable. If we expect people suffering from drug and alcohol addiction to overcome their illness through one-off interventions—e.g., a multi-day hospital stay for detox—we will not make a meaningful difference in this epidemic. · *Prevention: *YOU state that every adolescent should receive some form of quality, locally tailored preventive education or programming—whether it be school-based or community based. Although the DARE education program, which involves police officers visiting schools and coaching students to “say no” to drugs, has been found by multiple studies to be unsuccessful at changing behavior, that does not mean we can give up on prevention. Some preventative education and early intervention programs—particularly those which focus on peer mentors, community role models, and after school activities—do work. DARE itself is undergoing a make-over, having instituted a new curriculum in 2009 called “Keepin’ it Real” based on some of the more recent evidence about what works. · *Naloxone*: YOU set a goal that naloxone, a rescue drug that can prevent overdoses from being fatal, be in the toolkit of all first responders. · *Prescribers*: YOU say we should require that every prescriber of a controlled substance have a minimum amount of training in addictive diseases, so that they are educated about the potency for the substances they are prescribing to lead to addiction. In the vast majority of states (one estimate is all but 4 states), there is *no* training requirement as a prerequisite to getting a state license to write prescriptions for controlled substances. YOU call on every state to impose such a training requirement—i.e., a rule that prescribers need 10 hours of ongoing education and training, every 3 years, in this area. YOU also state that doctors and pharmacists should be required to consult state prescription drug monitoring programs—which are in place in 49 states, but are not mandatory in most of them—before writing a prescription. These systems enable prescribers to see a patient’s drug use history and recognize whether he or she is at risk of addiction. · *Criminal Justice Reform*: YOU prioritize treatment and rehabilitation over incarceration for low-level and nonviolent drug offenders. And YOU would use the significant savings to the criminal justice system from the reduction in incarceration to, in part, fund YOUR $10 billion treatment initiative. To arrive at the policy framework in the factsheet, we consulted numerous public health professionals; advocates in the addiction and recovery community; elected officials’ staff; and other stakeholders. Some of our most informative discussions were with an expert from the Kennedy Forum, a Board Member from the American Society of Addiction Medicine, practitioners at Montefiore Hospital, an individual from the National Alliance for Mental Illness (NAMI), and the director of an advocacy organization called the Parity NOW Coalition. We also worked with the legislative directors for Senators Tim Kaine, Tammy Baldwin, Joe Manchin, Sheldon Whitehouse, and Congressman Butterfield. *III. Q&A* *Q: Aren’t you just throwing more federal money at the problem of drug and alcohol addiction*—*without making any meaningful differences in the way we deliver treatment, or in coverage under health insurance?* · My Initiative to End Drug and Alcohol Addiction is ambitious and it is bold: it commits $10 billion in new federal resources, over 10 years, to tackling our substance abuse epidemic. · It requires states to step up and partner with the federal government, and to figure out solutions on treatment, prevention, prescriber training, and criminal justice, that work for their specific populations. It doesn’t impose any top-down or one-size-fits all model because the needs are different across different regions, states, and communities. · And there are strong accountability components built into this Initiative. First, to receive federal funding, states have to put forth credible plans with meaningful roadmaps to how they will deliver on the national goals. Second, they have to commit $1 for every $4 from the federal government—which will impose quality control in how states spend the money. *Q: The DARE Education Program is widely seen as a failure. Why are you investing more federal dollars in prevention programming for teens when it doesn’t work?* · We have a national epidemic of drug and alcohol abuse on our hands, and the problem starts with our youth. One in four teenagers has abused a prescription drug. We cannot give up on preventive education and early intervention. We need to do everything we can to send the right message to our youth, and try to intervene early and change behaviors and attitudes, before dangerous patterns set in. · We also know that preventative education and programming can work when done correctly. There are proven, evidence-based solutions we can build on. The Substance Abuse and Mental Health Services Administration has a national registry of programs that have been clinically evaluated and found to work. LifeSkills Training, a program typically focused on middle-schoolers, is one such example. And other interventions—ones that focus on involving peer mentors, community role models, resilience building, and after-school and community service—can also work to change behavior and send the right message. · DARE itself has been undergoing an overhaul in recent years to update its curriculum according to evidence-based models. We cannot give up on prevention. *Q: Is this going to lead to an expensive new insurance mandate*—*i.e., an expensive new insurance benefit for people who are addicted to drugs to be able to take more drugs, like methadone?* · My Initiative does not involve any new insurance mandate. Instead, I call on every state to look at the gaps in access to treatment in their communities, and to come up with strategies for closing those gaps—for example, by expanding in-patient and out-patient treatment infrastructure, supporting recovery communication organizations, expanding provider training, and making other changes to their laws or policies. · On insurance coverage, my Initiative commits to implementing and enforcing the 2008 Mental Health Parity and Addiction Equity statute, which requires insurance plans to cover substance use disorders in the same way they cover most other medical conditions. The Initiative directs federal agencies to more aggressively inspect and where appropriate, bring enforcement actions against insurers that are not in compliance. And it commits to promulgating federal guidance to states and consumers on how to file complaints. *Q: What are you doing for veterans?* · There is no question that veterans are one of the populations most in need of better treatment and recovery support for their mental health illnesses, and for drug and alcohol addiction. These are individuals who bravely served our country, and we owe them the best possible healthcare upon their return. That includes comprehensive healthcare for mental health and substance use disorders. · So first, my plan will work with states to greatly build out the treatment infrastructure so that every single person in the state has access to comprehensive, affordable treatment for substance use disorders. That includes veterans, and it includes access to both in-patient supply and out-patient programs. In a state like New Hampshire, the only state in the continental U.S. where there is no full-service VA hospital, veterans need to find in-patient care for mental health or substance use disorders at other hospitals or residential facilities in the state, or outside the state. My initiative calls upon every state to come up with a credible plan for how it is going to build out its supply infrastructure to serve its population—including veterans. · Second, my plan would immediately promote better prescriber practices in Medicare and in the Veterans Administration. It would direct the Department of Veterans Affairs and Centers for Medicare & Medicaid Services to promulgate guidelines that identify treatments for pain management other than opioids, so that prescribers in the VA can consider those alternatives particularly for patients without chronic physical pain. This will help promote better practices from the outset—to avoid inadvertently fueling addiction. · I also think we need better patient education, and I am looking at policies that would guarantee that. *ATTACHMENTS* (1) Editorial, *Clinton Searching for the Key to Walsh’s Heart*, Boston Globe (Sep. 29, 2015) (2) YOUR Substance Abuse Initiative Factsheet (3) YOUR Substance Abuse Op-Ed Copyright 2015 Globe Newspaper Company All Rights Reserved The Boston Globe September 29, 2015 Tuesday *SECTION:* EDITORIAL OPINION; Opinion; Pg. A,9,2 *LENGTH:* 652 words *HEADLINE:* Clinton searching for the key to Walsh's heart *BYLINE:* By Joan Vennochi, Globe Columnist *BODY:* ABSTRACT The mayor's ambivalence underscores the practical political problem faced by Clinton these days. At this stage in her troubled presidential campaign, Hillary Clinton could certainly use support from a popular urban mayor with close ties to labor and the recovery community. And so she searches for the key to Boston Mayor Marty Walsh's heart. During this week's visit to Boston, Clinton is scheduled to discuss substance abuse issues with Walsh and Attorney General Maura Healey — two Massachusetts Democrats with high voter approval ratings. Clinton already has Healey's endorsement. But Walsh is uncommitted and said to be torn between Clinton and Vice President Joe Biden, who has not yet announced a decision about a presidential run. Right now, there's no plan for any private meeting between Clinton and Walsh. But a presidential campaign often accused of not being very smart was at least smart enough to find an issue that Walsh, a recovering alcoholic, cares deeply about. He still attends Alcoholics Anonymous meetings after two decades of sobriety. And the local recovery community provides not just moral support to Walsh, but political backing. So Walsh's personal interest in the subject of addiction coincides with Clinton's recently announced $10 billion plan to target drug and alcohol abuse. But it will take more than a "plan" to win him over. As one Walsh adviser put it, "The key to Marty Walsh is when he thinks you really do understand issues that affect people who are afraid their kids will never be able to buy a house." In other words, Walsh, a former labor leader, relates to the average citizen living from paycheck to paycheck, not to the Clinton Foundation world of multimillion-dollar foreign donors and sky-high speaking fees. According to another Walsh aide, the Thursday event was set up at the request of the Clinton campaign with the understanding that no mayoral endorsement should be expected. While Clinton is still seen as the party's likely nominee, her campaign remains mired in controversy over her decision to store e-mail on a private server during her tenure as secretary of state. Meanwhile, Walsh has a close personal relationship with Biden. Walsh's ambivalence underscores the practical political problem faced by Clinton these days. So far, all the passion on the Democratic side comes from the left, which has embraced Vermont Senator Bernie Sanders. On Clinton's side, emotion runs flat, leaving an opening for Biden. That's true in Massachusetts, too, despite strong past loyalties to Bill and Hillary Clinton. Indeed, during the 2008 presidential primary season, the Bay State was ground zero for a fierce fight between Hillary Clinton supporters and those backing Barack Obama. In that contest, Clinton had the late Mayor Thomas M. Menino in her corner. In his book published shortly before his death last October, Menino took some credit for helping Clinton pull off a come-from-behind victory over Obama in the 2008 New Hampshire primary. While it's questionable how much a Boston mayor can really do in New Hampshire, Menino did send his political army across the border. When Clinton next won the Massachusetts primary, again with help from Menino's organization, Menino declared, "This is still Clinton country. Our campaign wasn't about speeches. It was about work." After her loss to Obama, Clinton continued to cultivate a relationship with Menino. But now there's a new mayor in charge. For Walsh, the personal connection is all about a candidate's ability to understand the world he represents. It's a humble world filled with people struggling to overcome adversity — like the network of former drinkers and drug users, to which the mayor still belongs. That's not a political button to be pushed. It's his life, and whoever Walsh endorses will understand that. Joan Vennochi can be reached at vennochi@globe.com Follow her on Twitter @Joan_Vennochi. *LOAD-DATE:* September 29, 2015 On Wed, Sep 30, 2015 at 9:49 AM, Huma Abedin <ha16@hillaryclinton.com> wrote: > shouldnt she say more about walsh? that hes been a leader in highlighting > this issue etc? > > On Tue, Sep 29, 2015 at 2:12 PM, Kristina Costa <kcosta@hillaryclinton.com > > wrote: > >> Team, >> >> Attaching two pages of TPs for HRC's substance abuse event Thursday in >> Boston. She will not have a podium for this event, so keeping these short. >> They are based off the Laconia town hall TPs with some Boston-area flavor. >> >> Please send edits/comments/approvals by *10am Wednesday*, as I will be >> offline for most of Wednesday afternoon and want to make sure we get this >> buttoned up in time for the book. >> >> Thanks all! >> >> Kristina >> > >