It s time for a new approach and a new dedication to solving our mental illness, substance abuse, and addiction epidemics.

Dear Iowans, Our state is hurting. Tens of thousands of us are suffering from the ravages of mental illness or substance abuse and addiction diseases that are tearing families apart and taking a devastating toll on our cities, towns, and communities. The scope of these epidemics is widespread, and cares little for the background, income level, education, or race of its victims. More than 120,000 Iowans suffer from serious mental health issues, while studies show that one in six of us experienced significant childhood trauma. i This makes those individuals six times more likely to be diagnosed with depression, 2.5 times more likely to be chronically absent at work, and 2.3 times more likely to have serious financial problems. ii Meanwhile, state treatment admissions for opioid abuse nearly quadrupled from 2005 to 2016, iii while the number of opioid-related deaths has risen by almost 250 percent. iv Deaths related to heroin jumped by nine times over a 15-year period. v These crises are striking our spouses, children, friends, neighbors, and co-workers. And too few of them are getting the help they need. We must take urgent action to increase treatment capacity and resources to ensure all Iowans who need professional medical assistance can get it. We need to boost the number of mental health and substance abuse professionals that can best treat these diseases and care for patients. It is critical that we expand efforts to identify and treat children and teenagers suffering from mental illness or substance abuse so they have the chance to recover at an early age and avoid falling behind. And above all else, we must remove the stigma associated with these diseases so every suffering Iowan seeks out the treatment they need and is firmly supported by their friends, families, and communities, instead of being unacceptably viewed with shame and disappointment as too many are today. To accomplish all this, we re going to create a new statewide Office of Mental Health and Addiction Policy to spearhead and focus our efforts, while going after the prescription drugmakers who created the opioid epidemic through their greed to ensure they help clean up the mess they created. These initiatives won t come cheaply, but we can t afford not to pursue them. Even beyond the urgent need to save lives and help affected Iowans recover, allowing these epidemics to continue to explode will make the cost to our public health and public safety infrastructure astronomically more expensive in the future. And the truth is, many of these priorities will save us further money in the long term by reducing the burdens that individuals suffering from mental illness or substance abuse place on our resources. Too many victims of these epidemics are locked up because we have nowhere else for them to go and our criminal justice system is ill-equipped to handle them properly. Yet this comes at an immense cost to taxpayers. By shifting our focus to treating the root causes of these problems instead of acting punitively, we ll save money. It costs five times as much to incarcerate an individual than to give them the treatment they need to get back on their feet, vi while studies have shown that for every dollar we invest in treatment, we can save up to $12 in criminal justice and healthcare costs to society. vii 1

It s time for a new approach and a new dedication to solving our mental illness, substance abuse, and addiction epidemics. It won t be easy, and our state has been set back by the disastrous decisions of a Branstad-Reynolds administration that has had little interest in effective solutions. We rank last in the nation for state mental health beds and 47 th for overall beds, viii yet this administration short-sightedly closed half the state facilities designated for mental health treatment with no plan in place to make up the lost capacity. ix We have underfunded mental health treatment at both the state and local levels, and it s taking a heartbreaking toll everywhere from the lives of those who are at risk to our criminal justice system which is being overburdened by individuals who should be in treatment instead of jail. Due in part to this broken system, 433 Iowans are projected to lose their lives to suicide this year six times the number of homicides and it is the second leading cause of death for those aged 15-34. x We cannot wait any longer to get back on track in working to end these epidemics that are destroying our families and communities. This plan will be a starting point in that journey, and I hope you ll join me in working together to save lives. Sincerely, Dr. Andy McGuire 2

Sound Minds, Healthy Bodies: A plan to Combat Iowa s Mental Health, Substance Abuse, and Addiction Epidemics 1. Increase treatment capacity and ensure Iowans have sufficient treatment options... 4 A. Boost the number of beds available for mental health treatment... 4 B. Lift the dollar cap on the mental health property tax levy so jurisdictions can increase resources if they choose... 5 C. Create regional Restoration Centers at which individuals struggling with mental health or substance abuse can receive treatment on demand... 6 D. Prioritize the expansion of capacity for medium-length treatment facilities... 6 E. Ensure effective treatment is available in jails and correctional facilities... 7 2. Attract and retain more mental health providers... 7 A. Short Term: Make greater use of general practitioners, mid-level mental health professionals, and telemedicine to expand availability of mental health resources to more communities... 8 B. Long Term: Incentivize mental health professionals to come to or remain in Iowa through tuition incentives or loan forgiveness... 8 3. Expand and emphasize support for children and teenagers... 9 A. Fund Mental Health and Substance Abuse coordinators at the school district level... 9 B. Better train educators and teachers to recognize and respond to the signs of mental health or substance abuse issues... 10 4. Remove the stigma from mental illness and substance abuse and addiction... 10 A. Expand alternatives to incarceration and get more people into treatment instead of jail... 10 B. Better train law enforcement to handle individuals suffering from mental health issues... 11 5. Create a new statewide Office of Mental Health and Addiction Policy... 12 A. Conduct a comprehensive survey of our state s mental health and substance abuse resources and recovery efforts... 12 B. Foster better communication and synergy between all elements of our response... 12 6. Go after the drugmakers who created the opioid epidemic and hold them accountable... 13 7. Secure and protect key funding sources to combat the mental health, substance abuse, and addiction crises... 14 3

Mission: Save lives and strengthen families by rebuilding Iowa s broken mental health, substance abuse, and addiction treatment systems 1. Increase treatment capacity and ensure Iowans have sufficient treatment options Any plan to put Iowa on the path toward ending our mental health, substance abuse, and addiction crises must start with ensuring we have the capacity and resources required to get every Iowan in need of help the treatment they need. We are up against dangerous and relentless diseases that require dedicated and focused care from professionals. Yet we are failing miserably at providing access to such care to Iowans throughout our state. We must take immediate measures to increase resources and treatment capacity so we can work to get as many Iowans as possible on a sustainable road to recovery. A. Boost the number of beds available for mental health treatment Our state is suffering from a tragic and crippling shortage of psychiatric treatment beds. This shortfall has been building for years, but it was made worse by the Branstad-Reynolds administration s irresponsible decision to close two of the four remaining state facilities designated for mental health treatment without any plan in place to make up for the lost capacity. xi This left Iowa with only 64 state hospital beds available for those suffering from mental illness dead last in the country. xii Across Iowa, including private facilities, we can count on only roughly 720 psychiatric beds in total, xiii to serve the 127,000 of us suffering from mental illness. As the Des Moines Register editorialized, if the governor is trying to ensure Iowa does a worse job of providing [psychiatric care] than any other state, he s met his objective. xiv Iowa Department of Human Services Data Our capacity is not nearly enough. When beds are not available locally when patients need help, it doesn t just harm those unable to secure such treatment it also hinders treatment for those who are fortunate enough to secure a spot. Wait times of up to five days have become common, while some patients have been stuck in emergency rooms for lack of anywhere else to go. xv Too many Iowans are 4

being sent to facilities out of state or hours away from their communities, making patients less likely to seek treatment and greatly increasing public costs. Sheriff s deputies are often called upon to transport such patients, imposing a significant drain on public safety resources that should be spent doing their actual jobs, instead of having to form a link in our current treatment infrastructure. And patients respond to treatment best when surrounded by their own support networks and friends and family, not marooned in a strange place far from home. We urgently need more psychiatric beds so that Iowans can receive help in settings where they will respond best to treatment. That must include regaining the capacity in state beds we lost due to the Branstad-Reynolds administration s irresponsible decision. And it must include beds set aside for children and adolescents so those at a critical age can receive needed care. We also need to work with our state s critical access hospitals to explore ways to open up additional beds in these facilities to mental health or substance abuse patients. Critical access hospitals by definition serve underserved areas, and many have already been assisting in efforts to staunch the mental health crisis by accepting such patients. But we need to use all the bed space we can get to treat those suffering, and that includes excess capacity in these facilities. To ensure their fiscal health and continued service in underserved communities, these hospitals receive higher reimbursement rates from Medicare and Medicaid, but in return their inpatient bed space is capped in order for them to maintain their designation and they are subject to additional rules regulating the average length of stay for certain patients. We need to explore ways to capture any unused bed space in these hospitals for mental health and substance abuse patients in a manner that keeps them within the boundaries of federal requirements. B. Lift the dollar cap on the mental health property tax levy so jurisdictions can increase resources if they choose Counties in Iowa fund mental health services at the local level through the mental health property tax levy. These funds go to critical mental health resources, including directly supporting community mental health resources in each region. Unfortunately, this system is broken. In 1995, the Iowa legislature passed legislation that capped the dollar amount each county could raise through this levy. xvi This process was then modified to distribute funding on a per capita basis through legislation passed in 2012, but the overall dollar cap was effectively left intact at $125.8 million statewide. xvii While reforms were made this past legislative session to even out inter-county disparities in the way funding was raised under the state s regional mental health care model, the overall dollar cap was again left largely intact, preventing additional resources from being obtained to fight this crisis. xviii It makes no sense for our state s 14 mental health care regions to have requirements imposed on them by legislators in Des Moines determining how they can fund treatment and care, and it s even more absurd for those resources to be capped by a law passed over 20 years ago without effective growth in the interim. Polk County, for instance, was forced to run a $7 million deficit on its mental health services because the amount it s allowed to take in is capped from a time when it had nearly a third fewer residents to care for. xix We need to give individual regions and counties local control to fund mental health care as they best see fit, and lift the dollar cap on this levy which has starved our efforts to end this crisis of badly needed resources. It is often Iowans at the county level whether public health workers, first responders, or law 5

enforcement professionals who are dealing with this crisis on the ground every day, and they deserve to have the freedom at the local level to take action to increase their resources. By raising funding, we will help solve our shortage of psychiatric beds by making more resources available to place individuals in need of help in private beds incentivizing providers to grow or come to Iowa with the knowledge that caring for those in need of mental health care can be a sustainable business model. C. Create regional Restoration Centers at which individuals struggling with mental health or substance abuse can receive treatment on demand Currently, those seeking help for mental illness or substance abuse and addiction in Iowa have too few options where they can go to receive treatment on demand at any time of day. This is a disastrous missing link in our treatment infrastructure that prevents individuals from getting help and starting on the path toward recovery while increasing the burdens on resources further down the chain. When an Iowan is suffering from these terrible diseases, there are often short windows in which they are willing to seek treatment. If resources aren t available at those times if they re forced to wait days for an open psychiatric bed or to see a professional that chance can be lost as they spiral further into mental illness or addiction. We need to make sure that any Iowan can receive treatment on demand whenever they are ready at a location within a reasonable distance of their community. San Antonio, Texas has pioneered an effective model that we should adopt here in Iowa that provides guaranteed treatment options for those seeking help through a 24/7 Restoration Center. xx This center offers walk-in or referral access to those in need of psychiatric or substance abuse care, including immediate medical attention, beds for short term stays, and public health professionals who can meet with patients and connect them with the medium- and longer-term resources they need to embark on their path to recovery. xxi If an individual is taken to a hospital with psychiatric or substance abuse issues, or they encounter law enforcement while in need of help without having committed a crime, those entities can take them to the Restoration Center instead of taking up space in emergency rooms or local jails, neither of which are ideally equipped to treat such patients. Similarly, local non-profits working with such patients will have an additional resource to get individuals help. We need to create similar centers in Iowa so we can fill in this missing link for individuals in need, improve recovery outcomes, and reduce the strain on law enforcement and hospitals dealing with this crisis. By creating a network of Recovery Centers in each region throughout the state, we can ensure that all Iowans have a place to go to get help whenever they need it. D. Prioritize the expansion of capacity for medium-length treatment facilities There are countless individuals in Iowa struggling with mental illness or substance abuse and addiction who do not need to be taking up bed space at hospitals or short-term facilities, but also do not need long-term residential care. We have too few facilities and programs to treat these patients, who often need to be monitored periodically, yet do not require the round the clock care provided at an emergency room or acute care facility. As a result, patients are getting stuck in acute care facilities with nowhere to go when they re ready to move on. In one extreme case, Polk County was forced to spend almost $500,000 on care for one local man to have the psychiatric unit at Broadlawns Medical Center house him for over a year past when he should have been released because there was nowhere to place him. xxii One psychiatrist at Broadlawns estimated that roughly a quarter of the public hospital s beds were at any point occupied by patients who no longer needed to be there, yet were not yet ready to be released entirely to their own devices. xxiii 6

This not only damages the recovery process for patients ready to move on to the next stage of care, but creates a bottleneck at intensive acute care facilities where new individuals in need of help have no space available to them because there is nowhere to move the existing patients. And often private insurance or Medicaid only covers a fraction of the cost of caring for these individuals when acute care is no longer deemed medically necessary, meaning that hospitals or treatment facilities are covering the remainder out of their own pockets leading to massive losses and creating a deterrent for them to accept future patients who they worry could bankrupt them. In 2015, Broadlawns was forced to deny admission to 345 individuals in need of mental health treatment due to a lack of space. xxiv Our system is clearly failing. We must increase transitional care options and programs for individuals to continue their recovery after they leave full-time, acute care without being turned out onto the street with no aid. E. Ensure effective treatment is available in jails and correctional facilities Iowa s mental health, substance abuse, and addiction crises have harmed countless lives and torn apart too many families. Their effects have landed thousands of Iowans in jail or prison, and any effective plan to combat these epidemics must address that population. Officials with the Polk County Sheriff s Office estimate that between 40 and 60 percent of inmates at their facilities suffer from mental illness. xxv 70% of inmates statewide struggle with substance abuse. xxvi For these Iowans, a stay in a correctional facility too often plunges them deeper into the throes of mental illness or addiction, leading them with long odds of being able to responsibly integrate back into society after they ve served their time. If we don t treat these individuals, they will have little hope of rebuilding their lives and many will continue to place heavy burdens on our public health, law enforcement, and correctional systems. Polk County has been taking a proactive approach to this challenge through a program that allows inmates to remain on psychiatric medication while they are incarcerated at no cost, while additionally covering such medication for 90 days after they are released. xxvii We need to work with localities throughout Iowa to expand this program to additional regions as well as in our state prisons, so that when incarcerated individuals emerge from jail or prison, they do so in sound health with an even shot at holding down a job and contributing to society. Rhode Island has also pioneered a program to boost the effectiveness and reach of substance abuse and addiction treatment in correctional facilities by ensuring every inmate has access to the three major opioid treatment regimens methadone, Vivitrol, and buprenorphine. xxviii Currently, the vast majority of inmates in Iowa jails and prisons have access to at most one of these options and many do not receive any substance abuse treatment at all. As a result, addiction can often worsen while an individual is incarcerated, leaving them at high risk of re-offending when released. We should be treating these Iowans, not letting them languish. Each of these medication-assisted treatment regimens varies in their effectiveness for each individual, and in order to be maximally effective in reducing dependency, inmates must be able to partake in whatever option works best for them. xxix We should implement this program here at home, so we can reduce recidivism rates and give those who have served their time a chance to rebuild their lives and get back on their feet. 2. Attract and retain more mental health providers One of the greatest challenges we face in ending our mental health crisis is ensuring Iowans in all corners of our state have access to qualified psychiatric and public health professionals who can treat 7

mental illness and have prescription powers. Iowa ranks 47th in the country in psychiatrist availability and 44th in mental health workforce availability. xxx Overall, nearly 1.7 million Iowans live in areas that suffer from a qualified shortage of mental health professionals, and we are meeting only 60% of need. xxxi That s unacceptable, and people who need help are getting left behind. Legislation passed in 2016 to allow licensed clinical psychologists to prescribe mental health treatment medication with additional training was an important step in the right direction. xxxii But we urgently need comprehensive solutions that will tackle the effects of this shortage in both the short and long terms. In particular, we need to expand coverage options in rural areas with far too few providers, and place a special focus on those trained in both mental health and substance abuse as those illnesses are so often linked. A. Short Term: Make greater use of general practitioners, mid-level mental health professionals, and telemedicine to expand availability of mental health resources to more communities We need to do as much as we can as quickly as we can to expand options and access in underserved communities. Existing medical professionals even those that are not psychiatrists by training have a large role to play in combatting this crisis. Many communities in Iowa lack access to trained psychiatrists. But they do have other medical professionals such as general practitioners or nurse practitioners who have the authority to prescribe medication. With additional training on mental illness, many of these professionals can serve as a short term, local solution to increase prescriber access in areas of need. If necessary, they can then work with trained psychiatrists patching in from elsewhere in the state through telemedicine to ensure the needs of patients are being met. Mid-level mental health professionals can also play a key role in tandem with non-psychiatric doctors. Many mid-level mental health professionals are highly knowledgeable and able to serve patients if needed, but lack prescribing powers. By partnering with general practitioners or nurse practitioners who do have such powers, they can collectively help meet patients needs even if trained psychiatrists are unavailable. These are not ideal solutions, and Iowa should not rely on them in the long term. But we must get underserved areas the support needed immediately. Every day, week, or month of delay means additional lives lost or damaged. By increasing synergy and adding partnerships between the medical professionals we do have, while offering additional training for those individuals, we can save lives and help Iowans recover now. B. Long Term: Incentivize mental health professionals to come to or remain in Iowa through tuition incentives or loan forgiveness The best way to ensure all Iowans have access to the mental health treatment they need is to increase the number of psychiatric professionals in all parts of our state. Here in Iowa we have a lot to offer, including a high quality of life with a low cost of living and wonderful towns in which to raise a family. As a medical professional myself, that s why I raised my own family here in Iowa where I was born and grew up. We should be an attractive option for trained psychiatrists and mental health professionals. We need to incentivize these professionals to come here and stay here. We should start by exploring tuition incentives or loan forgiveness programs for those who graduate from Iowa training programs or medical schools and commit to serving our underserved communities for a period of at least five years. 8

Once these individuals become engaged in our communities, many of them are going to want to stay. And such programs will save money in the long term; while these incentives will come with costs, securing greater mental health coverage and treatment will allow mental illness to be treated and addressed earlier, resulting in fewer individuals needing serious treatment later on and drastically reducing the burden to our public health and law enforcement infrastructure. At the same time, we need to take a close look at our regulatory system to make sure that we are not driving away mental health professionals due to onerous regulations, requirements, or liabilities. While we must always ensure our licensed professionals provide quality services in which patients are safe and receive good care, we cannot afford to have unnecessary regulations that cause psychiatrists, psychologists, treatment facilities, or other providers to look elsewhere when setting up or joining a practice or operation. 3. Expand and emphasize support for children and teenagers Mental illness often begins at an early age. Roughly half of those suffering from mental health issues begin experiencing symptoms by age 14. xxxiii A heartbreaking 13 percent of children between the ages of eight and 15 experience mental illness that causes significant impairment on a daily basis. xxxiv That increases to 21 percent of those aged 13 to 18. xxxv Yet less than half of these children and teenagers receive the help they need, xxxvi and we are doing far too little in Iowa to reach these individuals at an early age and get them into treatment that will strike back at their disease. This must change. We need to expand mental health services for children and teenagers because no Iowan should be suffering without professional help at such a critical age. When children are afflicted with mental illness, it impedes their progress in school, reduces their chances of going to college or receiving quality training for a career, and impacts their emotional and psychological development. One of our key goals must always be to give every Iowa child a strong chance at opportunity and success, and mental health treatment is a vital plank in that effort. Furthermore, by treating these individuals now, we can attack mental illness at its source when it is easier to mitigate, rather than spending much greater resources on Iowans as adults suffering from years of untreated mental health issues. Solving this disease in children early will have a drastic effect on our entire mental health treatment infrastructure and reduce costs in the long term. A. Fund Mental Health and Substance Abuse coordinators at the school district level We need to reach children and teenagers where they are, and that s in school. Some young Iowans suffering from mental illness may lack a strong home environment with parents dedicated to getting them into treatment, while others may simply not be aware of the warning signs. But by expanding efforts to work with children in school, we can get them help when they need it most. We re going to create and fund dedicated Mental Health and Substance Abuse Coordinators in each school district that can work with school nurses, teachers, and administrators to treat children displaying the warning signs of mental illness. Our school nurses do a heroic job working every day to provide care to students for a wide variety of ailments and medical issues. But they simply don t have the capacity to take on additional duties outside of the challenging job they already have. These coordinators can provide the additional support students dealing with mental health or substance abuse issues need, including initial treatment and counseling in school as well as connecting them to the outside and longer-term resources required to fully recover. We simply can t afford to let these students go on unsupported any longer. 9

B. Better train educators and teachers to recognize and respond to the signs of mental health or substance abuse issues Educators and teachers can be a primary early warning system when a student is suffering from problems with mental health or substance abuse. They re willing and eager to play that role, and many already do. We must give them every tool possible so they are trained and prepared to recognize the signs of these issues and take appropriate action to get students help. Initiating mental health training requirements in all teacher preparation programs and adding to our Mandatory Reporting licensure programs would help ensure that more information about mental health is offered to the appropriate professionals working with our children. Teachers see students every day and know them best. They ve built the closest relationships with these children and teenagers, have earned their trust, and deeply care about them. They can and will be an enormously valuable resource in reducing mental illness and substance abuse and addiction among Iowa s youth. 4. Remove the stigma from mental illness and substance abuse and addiction Perhaps our biggest obstacle to getting every Iowan proper treatment and care for mental illness or substance abuse and addiction is not funding. It s not the budget mismanagement of Gov. Reynolds or our shortage of providers and prescribers, although each has caused great damage. It s the devastating stigma that has been associated with these diseases for too long that keeps us from addressing these issues as the true public health crises they are. Mental illness and addiction are each a disease, just like any other. Yet too often, we think of them as character flaws or moral failures on the parts of the individuals afflicted. When an Iowan is diagnosed with cancer or Alzheimer s, we rally around that person and make sure they are supported emotionally and logistically. Our communities pitch in to deliver meals to their family, help look after their children, and take up collections to assist with medical expenses. It s an inspiring example of the strength of our communities and towns. When an individual is suffering from substance abuse, however, or attempts to commit suicide due to mental illness, too many of us turn our backs. We regard these afflictions as shameful or a sign of weakness. As a result, many who need help the most fail to receive the support they need, both worsening their descent into mental illness or addiction and reducing the chances that they will seek help for an issue they may not realize is not their fault. This is wrong, it s heartbreaking, and it costs lives. We urgently need to end this stigma and change how our society views mental illness, substance abuse, and addiction in order for us to combat these crises. Similarly, we must approach this as a public health issue at the policy level, instead of a law enforcement crisis to be solved by locking people up. In too many parts of our state, our jails are the most common treatment facilities for those with mental illness and addiction problems. By adopting treatment focused, non-punitive attitudes in the legal system toward those struggling with mental health, substance abuse, and addiction issues, we can improve outcomes and save resources that can instead go toward fighting criminals. A. Expand alternatives to incarceration and get more people into treatment instead of jail 10

For years, we have addressed our mental health and substance abuse crises as public safety issues combatted with law enforcement and through our criminal justice system. As a result, we lock up countless individuals each year who committed non-violent, minor offenses spurred by addiction or mental illness. There is little reason to jail many of these people they pose minimal danger to the public at large and their problems worsen when incarcerated while lacking access to the treatment they need. They overburden our correctional and public safety resources and clog up millions in taxpayer dollars; studies have shown that it is five times more expensive to incarcerate an individual than to get them treatment. xxxvii This model serves no one. It is expensive to maintain at a time when we can t spare any available resource in fighting this epidemic. And it makes us less safe as our law enforcement and correctional infrastructure has to devote too much time to people who shouldn t be there, rather than the hardened criminals we need to get off our streets. We need to think differently. Six years ago, the city of Seattle ran into these same issues and unveiled a new program that would relieve these burdens while getting those who had minor brushes with law enforcement the treatment and help they needed. The Law Enforcement Assisted Diversion [LEAD] program was designed to offer an alternative to an arrest, trip through the court system, and incarceration for low-level, non-violent offenders with no existing felony convictions. xxxviii Instead of taking these individuals to jail and pressing criminal charges, they were given the option to participate in a closely-monitored treatment and recovery program. xxxix With social workers assisting and counseling them along the way, charges would never be filed if they completed the program designed for them. xl The initiative produced clear results four years in, it reduced recidivism rates for participants by nearly 60 percent. xli Cities all over the country have since adopted this model. We should bring the LEAD program to Iowa to offer an alternative to incarceration for individuals who ll be better off with treatment rather than jail. Through forward-thinking solutions like this, we can achieve better public health outcomes for those in need of treatment, while keeping our communities safer by freeing law enforcement to focus on more dangerous crime. B. Better train law enforcement to handle individuals suffering from mental health issues Our law enforcement, first responders, and emergency personnel do heroic work on a daily basis to keep our communities safe. On top of that mission, they routinely tackle a myriad of issues that are outside their direct job descriptions. When Iowans have a problem, these professionals pitch in and help whenever needed, and they do it in addition to the daily challenges of their work. The response to Iowa s mental health crisis has disproportionately fallen on the shoulders of our law enforcement and emergency personnel, largely because we have failed to get the resources into place to deal with this struggle in a more effective and sustainable manner. The least we can do for law enforcement and affected individuals alike is to prepare our emergency personnel with the training needed to best handle situations involving mental illness. We need to prioritize enhanced training so every law enforcement officer is prepared to deal with individuals suffering from mental health problems in a manner that keeps officers safe and leads to the best possible outcomes for those they encounter. This must include training on how to recognize the signs of mental illness, how to defuse such situations without harm to either the officer or individual, and which resources are available locally so officers can get that individual the help they need. Law 11

enforcement deserves to have our full support for the jobs they do; without adequately preparing them for what they face, we re simply letting them and those suffering from mental illness down. 5. Create a new statewide Office of Mental Health and Addiction Policy Solving our mental illness and substance abuse and addiction crises is going to take an all hands on deck approach in which we must utilize every available resource we have to save lives and help Iowans recover. Our efforts must function at maximum efficiency and as a top priority for state and local governments. To spearhead this effort now and ensure that maintaining strong recovery and treatment infrastructure remains a focus in the future, we must create a central office to manage our response to this crisis and drive the policy changes we need. A new statewide Office of Mental Health and Addiction Policy will relieve the burdens on the overtasked Department of Health and Department of Human Services while ensuring that efforts to end our mental health and substance abuse crises never get lost in the shuffle of competing priorities. And by bringing the formerly disparate policy areas of mental illness and addiction under the same structure, we will increase the effectiveness of our efforts to solve both epidemics as they so often overlap and require similar solutions. A. Conduct a comprehensive survey of our state s mental health and substance abuse resources and recovery efforts We can t fully combat these epidemics if we lack adequate data to govern our response. Our state has been sorely lacking detailed and open information on a variety of key treatment and policy elements. One of the first things the new Office of Mental Health and Addiction Policy will do is conduct a comprehensive survey capturing the true picture of what is occurring on the ground and yielding critical data that will tell us exactly what we need to improve and the biggest areas of need. We ll release this data publicly, because all parts of our treatment infrastructure providers, non-profits, treatment facilities, or any other elements deserve to understand the full scope of what we re facing. Just as importantly, Iowans themselves have a right to see this data so they can hold public officials accountable for ensuring their communities have the resources they deserve. After this initial, comprehensive survey is complete, we ll conduct annual examinations of pieces of the data in detail, drilling down deeper on the most pressing needs and furthering our understanding of how best to combat these crises. An additional focus will be giving a voice to those suffering from mental illness, substance abuse, and addiction and soliciting their ideas and feedback on how we can better support Iowans and where we need to improve. The victims of this epidemic deserve to have a role in bringing about its end and we need to better involve them and keep them informed of our efforts. By promoting transparency, efficiency, and greater knowledge of what we re facing, we can better help Iowans receive quality treatment and save lives. B. Foster better communication and synergy between all elements of our response The only way we re going to solve these crises is through all elements of our response working together in close coordination to bring treatment and recovery services to all Iowans that need it. This means that all of us from state and local government to law enforcement, first responders, public health professionals, the medical community, teachers and educators, the non-profit community, and treatment facilities must be on the same page and functioning together as one unit to maximize resources and efficiency. This will only happen if we create close communication and synergy between these different groups. 12

One of the most important initiatives of the Office of Mental Health and Addiction Policy will be to make sure that everyone involved in recovery and treatment efforts receives every piece of information they need to function to their greatest capacity, and feels connected to our broader efforts. All involved Iowans and organizations deserve to be kept informed on what we re doing, the progress we re making, and how they can further those efforts. This will assist each group in tailoring its efforts to reach as many Iowans as possible. We also must give greater guidance to each of Iowa s mental health regions to ensure they share best practices to provide services to residents so we can improve the effectiveness of their resources. That includes holding regions accountable when they fall short. Beyond that, we also must do a better job of bringing everyday Iowans into this effort. When citizens understand the importance of the role they can play in the community and can visualize the broader impact they are making, they will be more likely to pitch in and help. Here in Iowa, we pride ourselves on banding together as a community to make life better for all of us. By educating our communities on the importance of ending these crises and the true tolls they are taking on our families, we can boost involvement and volunteerism that can have a positive impact on people s lives. 6. Go after the drugmakers who created the opioid epidemic and hold them accountable Substance abuse, largely involving opioids, has taken a devastating toll on our state, ravaging communities all across Iowa, tearing families apart and taking thousands of people from us too soon. The number of Iowa treatment admissions for opioid abuse nearly quadrupled from 2005 to 2016, xlii while the number of opioid-related deaths rose by almost 250 percent. xliii Deaths related to heroin an outbreak of the opioid crisis jumped by nine times over a 15-year period. xliv This epidemic didn t just happen on its own. In large part, it was caused by corporate greed and the pursuit of ever larger profits by a select group of prescription drugmakers who were determined to make money, regardless of the cost to our country. These drugmakers flooded Iowa and the nation with opioid-based prescription painkillers that led millions down the path toward addiction, pushing doctors to prescribe them in ever higher amounts so they could sell more product and rake in growing profits. Last year, 301 million prescription painkillers were sold in Iowa enough for every Iowan to have received nearly 100 each. xlv That mirrors the rise in such opioids nationally, as our country saw sales of prescription painkillers increase 300 percent since 1999. xlvi In 2015, 98 million Americans took prescription painkillers, and 13 million of them misused those drugs. xlvii For many, these prescription painkillers can serve as a gateway drug, creating chemical dependency that can only be alleviated by larger or more frequent doses. When those doses run out, those suffering from addiction sometimes turn to heroin or other opioids to stave off withdrawal. This epidemic often isn t about getting high it s about avoiding the grueling withdrawal process after becoming addicted to prescription painkillers spread by large drugmakers. The rise of Oxycontin offers a case study in just how pharmaceuticals got us addicted. Perdue Pharma, its manufacturer, has made at least $31 billion in profit off the drug, which is America s most widely used painkiller. xlviii But it did so on the back of false marketing claims that actually increased the risk of addiction for patients despite the fact that it knew full well what it was doing. xlix 13

Perdue marketed Oxycontin with the claim that it held its effects for up to 12 hours double the length of other painkillers on the market at the time. l This claim was later proven to be false and the drug would instead wear off for patients before this period ended. li When doctors sought to prescribe the drug on a shorter time frame for patients, Perdue pushed back, seeking to protect its advertising claims despite having evidence to the contrary. lii As a result, doctors began to instead prescribe larger doses. Yet patients would still be forced to go through brief periods of withdrawal when the drug wore off before the 12 hours were up, only to have that pain lessened when they took their next dose. liii This created the perfect conditions for addiction to take root. Now, after twenty years of Oxycontin on the market, studies have found that over half of those taking the drug are doing so in too large amounts. liv Over 7 million Americans fell victim to substance abuse through that single drug alone. lv And that s just one example Perdue Pharma is far from alone in their reckless pursuit of profits and willingness to destroy the lives of millions of Americans. States and municipalities across the country are fighting back. Mississippi, lvi Ohio, lvii Washington, lviii New Mexico, lix and Missouri lx have all filed lawsuits against prescription opioid makers to hold them accountable for their greed. The Department of Justice has already achieved a $35 million settlement with a drugmaker that littered Florida with prescription painkillers. lxi Overall, more than 100 total jurisdictions nationwide have joined in this effort by taking legal action. lxii Iowa must join them. These massive pharmaceutical companies have caused heartbreaking damage to communities all across our state. We ll work with the Attorney General s Office to file our own lawsuits to force them to take responsibility to clean up the mess they created. And we ll make sure that every dollar we recover will go directly to our plans to stop these epidemics. 7. Secure and protect key funding sources to combat the mental health, substance abuse, and addiction crises Taking the necessary steps to boost treatment options and bed space, increase resources and support for children and teenagers, and expand and strengthen our mental health and substance abuse treatment workforce unfortunately won t come cheap. We need to utilize every available funding source we have to stem these crises and help Iowans recover. And just as importantly, we need to protect those resources to make sure they are never siphoned off for competing budget priorities. Iowa s lawsuits against prescription drugmakers will be a key funding source of these efforts, and the settlements we secure will go a long way toward funding many parts of this plan. Giving our mental health regions true local control by empowering them to decide for themselves on the resources they devote to these crises by lifting the cap on the mental health property tax levy is another key step that will have a large impact in strengthening public health infrastructure. We must be creative in finding additional ways to increase the impact of the resources we have already, such as working with critical access hospitals to expand their ability to treat mental health patients. And we will always be proactive and vigilant in pursuing and securing any possible grant or funding opportunities that could be put to work fighting these epidemics, whether from the federal government, the private sector, non-profits, or foundations. Beyond those actions, many of the initiatives in this plan will save us money in the long run. By treating children and teenagers at an early age and putting them on a healthy path that keeps them in school, we will drastically lower future costs compared to the resources we would have to spend to get them assistance as adults with much more severe problems. By getting more Iowans into treatment instead of jail, we will sharply reduce our prison costs, as it costs five times as much to incarcerate an individual 14

than to treat them. lxiii And above all else, if we don t take action now to put a stop to the problems Iowans are facing, these epidemics will continue to explode, growing far beyond what our resources can handle in the future. If we don t solve this, thousands more lives will be lost or destroyed due to mental illness and addiction. The costs of inaction are far greater than the prudent investments we can and must make today. 15

List of Citations i Beyond ACES: Building hope & resiliency in Iowa. ACES 360 Iowa, 2016 ii Beyond ACES: Building hope & resiliency in Iowa. ACES 360 Iowa, 2016 iii Opioid Use in Iowa: An Update. Iowa Department of Public Health, March 2017 iv Opioid Use in Iowa: An Update. Iowa Department of Public Health, March 2017 v Five priorities to reduce opioid overdose deaths in Iowa. Des Moines Register, 10/4/17 vi Is drug addiction treatment worth its cost? National Institute on Drug Abuse vii Is drug addiction treatment worth its cost? National Institute on Drug Abuse viii Going, going gone: Trends and consequences of eliminating state psychiatric beds. Treatment Advocacy Center, 2016 ix Branstad seeks to close two mental institutes. Des Moines Register, 1/14/15 x SUICIDE: IOWA 2017 FACTS & FIGURES. American Foundation for Suicide Prevention xi Branstad seeks to close two mental institutes. Des Moines Register, 1/14/15 xii Going, going gone: Trends and consequences of eliminating state psychiatric beds. Treatment Advocacy Center, 2016 xiii WAITING FOR A BED. Journal Express, 5/4/17 xiv Editorial: Iowa ranks last for state psychiatric beds. Editorial Board, Des Moines Register, 6/11/16 xv WAITING FOR A BED. Journal Express, 5/4/17 xvi Let counties spend more on mental health, advocates ask legislators. Des Moines Register, 4/5/17 xvii Fiscal Note SF 504, 2017 Legislative Session xviii Fiscal Note SF 504, 2017 Legislative Session xix Let counties spend more on mental health, advocates ask legislators. Des Moines Register, 4/5/17 xx The San Antonio way: How one Texas city took on mental health as a community and became a national model. Boston Globe, 12/10/16 xxi The San Antonio way: How one Texas city took on mental health as a community and became a national model. Boston Globe, 12/10/16 xxii Mentally Ill Iowans Stranded For Months In Hospitals. Des Moines Register, 6/18/16 xxiii Mentally Ill Iowans Stranded For Months In Hospitals. Des Moines Register, 6/18/16 xxiv Mentally Ill Iowans Stranded For Months In Hospitals. Des Moines Register, 6/18/16 xxv Iowans are talking about mental illness, but who will act? Des Moines Register, 11/17/17 xxvi A Public Health Crisis. NAMI, April 2017 xxvii Iowans are talking about mental illness, but who will act? Des Moines Register, 11/17/17 xxviii One state takes a novel approach to opioid addiction: access to treatment for all inmates. STAT News, 8/3/17 xxix How effective is medication-assisted treatment for addiction? Here s the science. STAT News, 5/15/17 xxx Iowa Must Act To Alleviate Mental Health Care Deficit. NAMI xxxi Mental Health Care Health Professional Shortage Areas (HPSAs). Kaiser Family Foundation, 12/31/16 xxxii Iowa Becomes Fourth State to Allow Psychologists to Prescribe Medications. American Psychological Association, 5/27/16 xxxiii A Public Health Crisis. NAMI, April 2017 xxxiv A Public Health Crisis. NAMI, April 2017 xxxv A Public Health Crisis. NAMI, April 2017 xxxvi A Public Health Crisis. NAMI, April 2017 xxxvii Treatment or Incarceration? Treatment or Incarceration? Justice Policy Institute, 1/04 xxxviii LEAD program for low-level drug criminals sees success. Seattle Times, 4/8/15 xxxix LEAD program for low-level drug criminals sees success. Seattle Times, 4/8/15 xl LEAD program for low-level drug criminals sees success. Seattle Times, 4/8/15 xli LEAD program for low-level drug criminals sees success. Seattle Times, 4/8/15 xlii Opioid Use in Iowa: An Update. Iowa Department of Public Health, March 2017 xliii Opioid Use in Iowa: An Update. Iowa Department of Public Health, March 2017 xliv Five priorities to reduce opioid overdose deaths in Iowa. Des Moines Register, 10/4/17 xlv Opioid painkiller prescriptions are falling in Iowa, to about 90 pills per person annually. Des Moines Register, 10/16/17 xlvi Opioid Use in Iowa: An Update. Iowa Department of Public Health, March 2017 xlvii Prescription Drug Use and Misuse in the United States: Results from the 2015 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration, 9/16 xlviii YOU WANT A DESCRIPTION OF HELL? OXYCONTIN S 12-HOUR PROBLEM. Los Angeles Times, 5/5/16 xlix YOU WANT A DESCRIPTION OF HELL? OXYCONTIN S 12-HOUR PROBLEM. Los Angeles Times, 5/5/16 l YOU WANT A DESCRIPTION OF HELL? OXYCONTIN S 12-HOUR PROBLEM. Los Angeles Times, 5/5/16 li YOU WANT A DESCRIPTION OF HELL? OXYCONTIN S 12-HOUR PROBLEM. Los Angeles Times, 5/5/16 lii YOU WANT A DESCRIPTION OF HELL? OXYCONTIN S 12-HOUR PROBLEM. Los Angeles Times, 5/5/16 liii YOU WANT A DESCRIPTION OF HELL? OXYCONTIN S 12-HOUR PROBLEM. Los Angeles Times, 5/5/16 liv YOU WANT A DESCRIPTION OF HELL? OXYCONTIN S 12-HOUR PROBLEM. Los Angeles Times, 5/5/16 lv YOU WANT A DESCRIPTION OF HELL? OXYCONTIN S 12-HOUR PROBLEM. Los Angeles Times, 5/5/16 lvi Mississippi sets tone as opioid drugmakers face rising tide of lawsuits. Clarion Ledger, 6/10/17 lvii Ohio's opioid lawsuit against 5 pharma companies: 6 things to know. Cleveland Plain Dealer, 5/31/17 lviii AG FERGUSON SUES ONE OF THE NATION S LARGEST OPIOID MANUFACTURERS OVER STATE S OPIOID EPIDEMIC. Office of the Attorney General, 9/28/17 lix New Mexico sues opioid drug manufacturers, distributors. Reuters, 9/7/17 lx Missouri sues opioid manufacturers, joining two other U.S. states. Reuters, 6/21/17 16