It has become a recurrent moment in Hillary Clinton's speeches as she campaigns for the presidency: softening her voice to a hush, she says she wants to end the "quiet epidemic" of Americans dying from overdoses of painkillers and other drugs.
Often, she remarks how surprised she is to find herself discussing the problem, which is now among the leading causes of injury death in the United States. Prescription painkiller overdoses alone kill an average of 44 people each day according to the federal government. Several of her rivals for the presidency have said they plan to do something about it if elected in November 2016.
In Clinton's case, she says she decided to put the issue high on her campaign agenda only after she started to meet affected voters in April. In stops hundreds of miles apart, people she talked to in coffeeshops and at campaign events repeatedly described the struggles their families and neighbors were facing with the addictive pills and other drugs, she says.
What she has not yet publicly discussed while campaigning are personal links she has to the epidemic: In 2011, overdoses of opioid painkillers killed two young men known to her and her husband, former President Bill Clinton.
Nor has she drawn attention to the ambitious work undertaken since those deaths by her family's main charity - the Bill, Hillary & Chelsea Clinton Foundation - to slow the death toll.
In 2014, a year before becoming a candidate, Clinton described the foundation's efforts at length in an hour-long speech on drug abuse at a mental health conference. She focused on the foundation's plan to make naloxone, a drug that can rapidly reverse the effects of an opioid overdose, more widely available.
"We have to get serious and creative about stemming the tide of drug overdoses and dependency," she told an audience of thousands of health workers, calling it an "evolving epidemic."
Since then, Clinton has emerged as the favorite to become the Democratic Party's presidential nominee. How work the foundation has done might shape her forthcoming policy proposals is unclear - spokesmen for Clinton declined to answer questions about her approach to the epidemic, instead referring Reuters to the 2014 speech.
Each time Clinton has raised drug abuse at her public stops, she has chosen, for now at least, not to mention her family's investment in the issue. Instead, she credits her concern about the epidemic almost entirely to the voters she has recently met.
Standing in a small bookshop last month in Exeter, New Hampshire, she told a gathering of supporters that she probably would not be discussing people misusing drugs and related mental health issues if she had been there only a few months earlier "because I hadn't heard a lot about them, I hadn't gotten my chance to listen to people."
Since then, her campaign staff have held discussions with local organizations helping people with drug abuse, police and lawmakers in New Hampshire and Iowa, asking them what they want to see included in Clinton's policies.
Sudden deaths shocked Clintons
Bill Clinton has said it was the sudden deaths in 2011 of two young men he and his wife knew that shook him from what he called his "total ignorance" about the drugs' dangers. The U.S. Centers for Disease Control declared prescription painkiller overdoses an epidemic that same year. (Graphic on drug overdose deaths: http://reut.rs/1IlnEzj)
They have killed more than 22,000 people annually in recent years, according to CDC data. Nearly 2 million Americans were addicted to painkillers in 2013, the CDC says, and thousands of people arrive at hospitals each day after misusing the drugs, which can produce euphoric highs but can also disrupt the parts of the brain that control breathing.
Health experts say the epidemic is unusually sweeping, and has grown to affect so many voters that it is increasingly difficult for politicians to overlook: the powerful drugs are taken by men and women, blacks and whites, the young and the old, urban and rural, rich and poor.
One of the young men who accidentally overdosed was a neighbor of the Clintons in the wealthy hamlet of Chappaqua in New York, the Clintons have said. The other, 28-year-old Benjamin Gupta, was an intern at the U.S. State Department while Clinton was secretary of state and a son of a close family friend, the businessman Vinod Gupta. He took oxycodone a friend had given him, drank some alcohol, and later stopped breathing in his sleep, according to an interview his father and Bill Clinton gave CNN in 2012. Both Clintons gave eulogies at the funeral.
He was "unbelievably bright, attractive, charismatic, going to law school - really the whole world in front of him," Hillary Clinton said in her speech on mental health last year.
The deaths so shocked Bill Clinton that he decided to put the Clinton Foundation to work on the matter, both he and Hillary Clinton have said.
In 2013, around the same time as Hillary Clinton joined the foundation's board of directors after leaving her job at the State Department, the foundation declared its goal to halve the number of deaths from prescription drug overdoses.
Vinod Gupta pledged $1 million to the program. Both Clintons are "very passionate" about the effort, Gupta wrote in an email to Reuters. "20,000 deaths in one year is like 50 jumbo jets crashing in one year."
Foundation staff began organizing conferences with experts on the epidemic and government officials, including senior officials from the U.S. Department of Health.
In a 2014 speech, Margaret Hamburg, then the U.S. Food and Drug Administration's commissioner, praised the foundation's efforts to widen access to the anti-overdose medicine naloxone. That year the FDA approved a new form of naloxone called Evzio. It comes in an injector kit and is the first approved form of the medicine in the United States that can be prescribed to people without medical training.
In January, the foundation and kaléo, the pharmaceutical company that makes Evzio, said they had reached an agreement for kaléo to make the medicine available more cheaply to colleges, community organizations and other groups. It normally sells for about $600 for two doses, according to recent wholesale price listings. Kaléo did not respond to questions about how many organizations had bought the discounted drug so far.
Naloxone a key tool
Public health experts say increasing the availability of naloxone is an important part of any approach to the epidemic, although more work also needs to be done to help treat underlying addictions and prevent misuse of the drugs.
"Naloxone is a drug that can make a real difference," Clinton said in her mental health speech last year, "and that's one of the reasons the Clinton Foundation is making the provision of that a priority."
Clinton had been invited to speak by Linda Rosenberg, the president of the National Council for Behavioral Health, a group that represents addiction treatment organizations. Rosenberg was impressed by how knowledgeable Clinton seemed on the issues.
"That was the first time she trotted out her speech around the opioid epidemic and she did a very nice job and obviously her staff had spent a lot of time on it," Rosenberg said in a telephone interview.
Asked about Clinton's expressions of surprise a year later at the scale of the epidemic, Rosenberg said she saw no contradiction.
"Voters wouldn't come up and talk to you about it 10 or 15 years ago," Rosenberg said. "I think that's the surprise here."