The monthly ACT ATOD Research eBulletin is a concise summary of newly-published research findings and other research activities of particular relevance to ATOD and allied workers in the ACT.
Its contents cover research on demand reduction, harm reduction and supply reduction; prevention, treatment and law enforcement. ATODA's Research eBulletin is a resource for keeping up-to-date with the evidence base underpinning our ATOD policy and practice.
A recently published issue of the Illicit Drugs Reporting System (IDRS) Drug Trends Bulletin explored the extent and nature of knowledge of naloxone and take-home naloxone programs among people who inject drugs (PWID) in the ACT and interstate. The study is a follow-up to the rollout, over the last two years, of
, managed by CAHMA. The key findings of the study are as follows:
, IDRS Drug Trends Bulletin, National Drug and Alcohol Research Centre, University of New South Wales, Sydney,
Wiley, along with other publishing partners is presenting a collection of recent papers on the theme of 'Indigenous Australia'. The papers collected are from a broad range of journals in the fields of medicine, allied health, social sciences and environmental sciences. While from diverse fields of study, the papers share an interest in improving the lives of Australian Indigenous peoples.
Individual papers included in the collection will be freely available until 30 September 2015.
How effective is long-term treatment for people dependent on prescription opioids?
Researchers in the USA examined the outcomes of the Prescription Opioid Addiction Treatment Study (POATS), a multi-site clinical trial lasting up to 9 months, examining different treatment durations of buprenorphine-naloxone plus standard medical management for prescription opioid dependence, with participants randomised to receive or not receive additional opioid drug counselling. (Opioid agonist therapy refers to the therapeutic use of pharmaceutical opioids as substitutes for illicit opioids; methadone and buprenorphine are the opioid agonist therapies most commonly deployed.) They found that ‘At Month 42, much improvement was seen: 31.7% were abstinent from opioids and not on agonist therapy; 29.4% were receiving opioid agonist therapy, but met no symptom criteria for current opioid dependence; 7.5% were using illicit opioids while on agonist therapy; and the remaining 31.4% were using opioids without agonist therapy... Engagement in agonist therapy was associated with a greater likelihood of illicit-opioid abstinence. Eight percent (…) used heroin for the first time during follow-up; 10.1% reported first-time injection heroin use’. The researchers concluded that ‘Long-term outcomes for those dependent on prescription opioids demonstrated clear improvement from baseline. However, a subset exhibited a worsening course, by initiating heroin use and/or injection opioid use’.
Weiss, RD, Potter, JS, Griffin, ML, Provost, SE, Fitzmaurice, GM, McDermott, KA, Srisarajivakul, EN, Dodd, DR, Dreifuss, JA, McHugh, RK & Carroll, KM 2015, ‘Long-term outcomes from the National Drug Abuse Treatment Clinical Trials Network Prescription Opioid Addiction Treatment Study
’, Drug and Alcohol Dependence
, online ahead of print.
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To what extent does medication-assisted treatment of opioid use disorder contribute to opioid-abstinence rates?
A review undertaken in the USA to examine the evidence supporting medication-assisted treatment of the opioid use disorder found that the evidence ‘strongly supports the use of agonist therapies to reduce opioid use and to retain patients in treatment, with methadone maintenance remaining the gold standard of care. Combined buprenorphine/naloxone, however, also demonstrates significant efficacy and favorable safety and tolerability in multiple populations, including youth and prescription opioid-dependent individuals, as does buprenorphine monotherapy in pregnant women. The evidence for antagonist therapies is weak. Oral naltrexone [the best-known antagonist therapy] demonstrates poor adherence and increased mortality rates, although the early evidence looks more favorable for extended-release naltrexone, which has the advantages that it is not subject to misuse or diversion and that it does not present a risk of overdose on its own’. The reviewer discusses the currently unmet challenges in treating the opioid use disorder and directions for future research.
Connery, HS 2015, ‘Medication-assisted treatment of opioid use disorder: review of the evidence and future directions
’, Harvard Review of Psychiatry
, vol. 23, no. 2, pp. 63-75.
Comment: This review, in a prestigious journal, largely confirms earlier reports about the effectiveness of agonist treatment and the problematic nature of antagonist treatment.
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How frequent is the misuse of prescription opioids?
(note that the review covered the international literature, not just that of a single nation):
Opioid use in chronic pain treatment is complex, as patients may derive both benefit and harm. Identification of individuals currently using opioids in a problematic way is important given the substantial recent increases in prescription rates and consequent increases in morbidity and mortality. The present review provides updated and expanded information regarding rates of problematic opioid use in chronic pain. Because previous reviews have indicated substantial variability in this literature, several steps were taken to enhance precision and utility. First, problematic use was coded using explicitly defined terms, referring to different patterns of use (ie, misuse, abuse, and addiction). Second, average prevalence rates were calculated and weighted by sample size and study quality. Third, the influence of differences in study methodology was examined. In total, data from 38 studies were included. Rates of problematic use were quite broad, ranging from <1% to 81% across studies. Across most calculations, rates of misuse averaged between 21% and 29% (range, 95% confidence interval [CI]: 13%-38%). Rates of addiction averaged between 8% and 12% (range, 95% CI: 3%-17%). Abuse was reported in only a single study. Only 1 difference emerged when study methods were examined, where rates of addiction were lower in studies that identified prevalence assessment as a primary, rather than secondary, objective. Although significant variability remains in this literature, this review provides guidance regarding possible average rates of opioid misuse and addiction and also highlights areas in need of further clarification.
Vowles, KE, McEntee, ML, Julnes, PS, Frohe, T, Ney, JP & van der Goes, DN 2015, ‘Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis’, Pain
, vol. 156, no. 4, pp. 569-76, open access http://journals.lww.com/pain/Fulltext/2015/04000/Rates_of_opioid_misuse,_abuse,_and_addiction_in.3.aspx
To what extent is involvement in opioid replacement therapy associated with changes in mental health?
A systematic review examined 22 randomised controlled trials of various aspects of mental health during opioid replacement therapy (ORT). The reviewers found that ‘Mental health significantly improved for all groups receiving ORT in 14 studies in either some or all of the domains assessed. There was tentative evidence to suggest methadone is less effective at improving mental health than other types of ORT. Improvements occurred early in the treatment process and were not always sustained’. The reviewers concluded that ‘Mental health generally improves during ORT but this improvement may not continue beyond 12 months. Standardisation of tools is recommended following comparative assessment of the sensitivity and specificity of different measures’.
Fingleton, N, Matheson, C & Jaffray, M 2015, ‘Changes in mental health during opiate replacement therapy: a systematic review
’, Drugs: Education, Prevention, and Policy
, vol. 22, no. 1, pp. 1-18.
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What were the impacts of reducing the sentences for 'drug mules' in the UK?
In February 2012, new sentencing guidelines for drug offences became effective in all courts in England and Wales. An explicit aim was to reduce the length of sentences for drug ‘mules’ and so make them more proportionate(…) Overall, the guidelines have achieved their intended aim. The length of the average custodial sentence for drug trafficking fell following the introduction of the guidelines, largely due to taking defendants’ roles into account. Notably, three-quarters of those in ‘lesser’ roles received sentences less than four years, representing an important change. Nonetheless, around 10% of mules received very long sentences due to the continued use of drug weight in sentencing.
: The new guidelines represent an internationally important innovation in drug policy reform.
Fleetwood, J, Radcliffe, P & Stevens, A 2015, ‘Shorter sentences for drug mules: the early impact of the sentencing guidelines in England and Wales
’, Drugs: Education, Prevention, and Policy
, online ahead of print.
Comment: This is an encouraging example of incremental changes to drug policy and legislation that can create more proportional, less harsh, sentences for drug offences.
To what extent is MDMA associated with crime and violence?
Researchers in the United States used data from the National Epidemiologic Survey on Alcohol and Related Conditions to assess the association between the use of MDMA, also known as ‘ecstasy’, and violent and non-violent antisocial behaviour while controlling for socio-demographic variables; lifetime psychiatric, alcohol and drug use disorders; and family history of anti-social behaviour. They found that ‘MDMA users, both male and female, were involved in a number of crimes in acts of violence including drunk driving, shoplifting, theft, intimate partner violence, and fighting. Notably, female MDMA users were more antisocial than male non-MDMA users. Although adjusting the results for numerous confounds attenuated the relationships, MDMA users were still at significantly greater odds of engaging in violent and nonviolent crime than non-MDMA users. Although MDMA has been considered a facilitator of empathy and closeness, the current study suggests a dark side as MDMA is associated with a broad array of crimes and transgressions’.
Vaughn, MG, Salas-Wright, CP, DeLisi, M, Perron, BE & Cordova, D 2015, ‘Crime and violence among MDMA users in the United States’, AIMS Public Health
, vol. 2, no. 1, pp. 64-73, open access http://www.aimspress.com/aimsph/ch/reader/view_abstract.aspx?file_no=Public2014040&flag=1#sthash.sl72V20B.dpuf
Comment: This study reminds us that the chemical composition of a drug is just one of many factors that determine how people behave after consuming it. Cultural, psychological, social, situational, life experience, expectations and other factors all play a part.
How close is the association between young people drug use and criminal offending?
A prospective longitudinal study was carried out in the city of Edinburgh using a single age cohort who started secondary school in that city in 1998, when they were, on average, twelve years of age. The researcher found that ‘Early in the teenage years drug use was associated with a similar set of factors to offending. These include weak bonds to parents and teachers, and deviant lifestyle behaviours. However, later in the teenage years there were differences, e.g. drug use was associated with higher socioeconomic status and importance of school, and a number of factors which were associated with offending were not associated with drug use, e.g. parent-child conflict, gang membership and hanging around’. The researcher concluded that ‘the factors included here are more appropriate to understanding offending than drug use. Different risk factors are associated with drug use and offending in the older, but not younger teens. It is argued that later in the teenage years drug use should be understood and addressed differently to offending’.
Aston, EV 2015, ‘Are risk factors for drug use and offending similar during the teenage years?
’, International Journal of Drug Policy
, vol. 26, no. 4, pp. 396-403.
Comment: In thinking about the implications of this study it is useful to consider the contextual factors, e.g. to what extent does being raised in Edinburgh, rather than, say, Canberra, impact on the findings. Nonetheless, the study provides helpful guidance to people designing and evaluating prevention programs.
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What are people saying about the links between alcohol and family violence in Australia?
ATODA’s Research eBulletin focuses on research findings rather than on opinion and commentary. Sometimes, however, a commentary is published that deserves wide dissemination and consideration. An article published in the Weekend Australian
newspaper in March 2015, written by Ross Fitzgerald, Emeritus Professor in History and Politics at Griffith University, falls into this category. Fitzgerald is an authority on alcohol in Australia.
Fitzgerald writes ‘Domestic violence was firmly back on the agenda with the announcement by Tony Abbott of family violence campaigner, Rosie Batty, as the 2015 Australian of the Year. Abbott also announced the formation of a national domestic violence scheme that would be added to the COAG agenda. But a real commitment to significantly reducing domestic violence, rather than just keeping on pretending that we wish or want to, requires another bold step. We need to get serious about one of the major causes of domestic violence — alcohol abuse. In fact, the misuse of Australia’s favourite drug of choice is probably the major cause of the incidence and escalation of domestic violence. The truth is that we know how to reduce alcohol-related problems: increase the price; reduce the availability; and start properly regulating alcohol advertising and promotion. But the latter should not involve the booze industry regulating itself. In this context, self-regulation is to meaningful regulation as self-importance is to actual importance.’
‘Certainly there are factors other than alcohol involved in our massive rates of domestic violence. In particular we need to be aware of the strong relationship between economic disadvantage, social distress and structural inequality on one hand and domestic violence on the other. Unfortunately, as well as ignoring the strong causal connection between alcohol misuse and domestic violence, most politicians and media commentators often also underestimate these important economic and social factors.
‘One useful suggestion is that, from now on, all proposed economic policies should be accompanied by a detailed social impact assessment. The latter should form an integral part of all federal and state legislation.’
Fitzgerald, R 2015, ‘Alcohol abuse a major factor in domestic abuse problem
’, The Weekend Australian
, March 28-29, 2015, Commentary, 28 March 2015, p. 22.
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How cost-effective are alcohol interlocks as an injury prevention measure?
We estimated the injury prevention impact and cost savings associated with alcohol interlock installation in all new US vehicles.
We identified fatal and nonfatal injuries associated with drinking driver vehicle crashes from the Fatality Analysis Reporting System and National Automotive Sampling System’s General Estimates System data sets (2006-2010). We derived the estimated impact of universal interlock installation using an estimate of the proportion of alcohol-related crashes that were preventable in vehicles <1 year-old. We repeated this analysis for each subsequent year, assuming a 15-year implementation. We applied existing crash-induced injury cost metrics to approximate economic savings, and we used a sensitivity analysis to examine results with varying device effectiveness.
Over 15 years, 85% of crash fatalities (>59,000) and 84% to 88% of nonfatal injuries (>1.25 million) attributed to drinking drivers would be prevented, saving an estimated $342 billion in injury-related costs, with the greatest injury and cost benefit realised among recently legal drinking drivers. Cost savings outweighed installation costs after 3 years, with the policy remaining cost effective provided device effectiveness remained above approximately 25%.
Alcohol interlock installation in all new vehicles is likely a cost-effective primary prevention policy that will substantially reduce alcohol-involved crash fatalities and injuries, especially among young vulnerable drivers.
Carter, PM, Flannagan, CAC, Bingham, CR, Cunningham, RM & Rupp, JD 2015, ‘Modeling the injury prevention impact of mandatory alcohol ignition interlock installation in all new US vehicles
’, American Journal of Public Health
, online ahead of print.
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To what extent could increases in alcohol excise taxes reduce the rate of fatal alcohol-related motor vehicle crashes?
In August 2009, the USA state of Illinois raised its excise on beer by 4.6 cents per gallon, on wine by 66 cents per gallon and on distilled spirits by $4.05 per gallon. If the full increase was passed on to consumers, a glass of beer would have increased by just 0.4 cents, a glass of wine by 0.5 cents and a single serving of spirits by 4.8 cents.
We examined the effects of a 2009 increase in alcohol taxes in Illinois on alcohol-related fatal motor vehicle crashes.
We used an interrupted time-series design, with intrastate and cross-state comparisons and measurement derived from driver alcohol test results, for 104 months before and 28 months after enactment. Our analyses used autoregressive moving average and generalised linear mixed Poisson models. We examined both population-wide effects and stratifications by alcohol level, age, gender, and race.
Fatal alcohol-related motor vehicle crashes declined 9.9 per month after the tax increase, a 26% reduction. The effect was similar for alcohol-impaired drivers with positive alcohol levels lower than 0.15 grams per deciliter [i.e. .15g%] (-22%) and drivers with very high alcohol levels of 0.15 or more (-25%). Drivers younger than 30 years showed larger declines (-37%) than those aged 30 years and older (-23%), but gender and race stratifications did not significantly differ.
Increases in alcohol excise taxes, such as the 2009 Illinois act, could save thousands of lives yearly across the United States as part of a comprehensive strategy to reduce alcohol-impaired driving.
Wagenaar, AC, Livingston, MD & Staras, SS 2015, ‘Effects of a 2009 Illinois alcohol tax increase on fatal motor vehicle crashes’
, American Journal of Public Health
, online ahead of print.
Comment: For some years, public health advocates have been calling on successive Federal governments to rationalise, and increase, alcohol taxation in Australia. The Illinois experience highlights the significant public health benefits that would occur if those changes were implemented.
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What types of tobacco control interventions are most effective in reducing socioeconomic inequalities in smoking?
Researchers based in the United Kingdom searched the international literature for reviews and primary research articles published between January 2006 and November 2010 that examined the socioeconomic impact of six tobacco control interventions in adults: price increases, smoke-free policies, advertising bans, mass media campaigns, warning labels, smoking cessation support and community-based programmes combining several interventions. They included English-language articles from countries at an advanced stage of the tobacco epidemic that examined the differential impact of tobacco control interventions by socioeconomic status, or the effectiveness of interventions among disadvantaged socioeconomic groups.
The reviewers found ‘strong evidence that increases in tobacco price have a pro-equity effect on socioeconomic disparities in smoking. Evidence on the equity impact of other interventions is inconclusive, with the exception of non-targeted smoking cessation programmes which have a negative equity impact due to higher quit rates among more advantaged smokers’. Their conclusions were that ‘Increased tobacco price via tax is the intervention with the greatest potential to reduce socioeconomic inequalities in smoking. Other measures studied appear unlikely to reduce inequalities in smoking without specific efforts to reach disadvantaged smokers. There is a need for more research evaluating the equity impact of tobacco control measures, and development of more effective approaches for reducing tobacco use in disadvantaged groups and communities’.
Hill, S, Amos, A, Clifford, D & Platt, S 2014, ‘Impact of tobacco control interventions on socioeconomic inequalities in smoking: review of the evidence
’, Tobacco Control
, vol. 23, no. e2, pp. e89-e97.
Comment: This is further good news, as tobacco control advocates have long been concerned that some intervention, while reducing the prevalence of tobacco use on average, may not deliver good outcomes for socio-economically-disadvantaged populations.
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How effective are opioid antagonists such as naltrexone in aiding tobacco smoking cessation?
A meta-analysis, using data from clinical trials in the Cochrane Tobacco Addiction Group Specialized Register and MEDLINE, sought to evaluate the efficacy of opioid antagonists in promoting long-term smoking cessation. Opioid antagonists are drugs such as naltrexone that block the opioid receptors in the brain. Outcomes measures of the study included smoking abstinence at long-term follow-up; abstinence at end of treatment; and effects on withdrawal, craving and smoking consumption. The study included eight trials with a total of 1,213 participants. Half the trials examined the benefit of adding naltrexone versus placebo to nicotine replacement therapy (NRT). The researchers found ‘There was no significant difference between naltrexone and placebo alone…or as an adjunct to NRT…Findings for naltrexone effects on withdrawal, craving and reduced smoking were equivocal’. They concluded that ‘The findings indicate no beneficial effect of naltrexone alone or as an adjunct to NRT on short-term or long-term smoking abstinence. While further trials may narrow the confidence limits, they are unlikely to appreciably alter the conclusion’.
David, SP, Chu, IM, Lancaster, T, Stead, LF, Evins, AE & Prochaska, JJ 2014, ‘Systematic review and meta-analysis of opioid antagonists for smoking cessation’, BMJ Open
, vol. 4, no. 3, p. e004393, open access http://bmjopen.bmj.com/content/4/3/e004393.full
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How safe and effective is a cannabis extract for treating cannabis dependence or withdrawal?
Although approximately ten percent of people who ever try cannabis develop some degree of dependence on the drug (particularly those who commence at a young age and those who are heavy users), there are currently no approved pharmacotherapies for treating dependence or withdrawal. Accordingly, Australian researchers have undertaken the first clinical trial of the cannabis extract nabiximols (Sativex) (which is approved in Australia for the treatment of spasticity related to multiple sclerosis) as an agonist substitution therapy for cannabis withdrawal. (Agonist substitution means providing the same or a closely related drug, in a safer form, as part of drug treatment.) Nabiximols has approximately equal proportions of the cannabinoids tetrahydrocannabinol (THC) and cannabidiol (CBD). They conducted a two-site, double-blinded randomised clinical inpatient trial with a 28 day follow-up, in NSW. It involved 51 cannabis-dependent treatment seekers. They received a six-day treatment of nabiximols or placebo, along with standardised psychosocial interventions, during a nine-day admission. The researchers found that ‘In a treatment-seeking cohort, nabiximols attenuated [i.e. reduced] cannabis withdrawal symptoms and improved patient retention in treatment. However, placebo was as effective as nabiximols in promoting long-term reductions in cannabis use following medication cessation. The data support further evaluation of nabiximols for management of cannabis dependence and withdrawal in treatment-seeking populations.’
Allsop, DJ, et al
. 2014, ‘Nabiximols as an agonist replacement therapy during cannabis withdrawal: a randomized clinical trial
’, JAMA Psychiatry
, vol. 71, no. 3, pp. 281-91.
Comment: This is useful new information about pharmacotherapy support in the management of cannabis withdrawal. The lack of impact on long-term abstinence is not a surprise, as withdrawal management alone cannot be expected to have an impact in the longer term.
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How can community health workers who have personal experience of drug injecting contribute to the well-being of other people who inject drugs?
This study reflected the widespread observation that ‘Although people who inject drugs (PWIDs) have increased healthcare needs, their poor access and utilisation of mainstream primary healthcare services is well documented. To address this situation, community health workers (CHWs) who have personal experience of drug injecting in addition to healthcare training or qualifications are sometimes utilised. However, the role peer workers play as members of clinical primary healthcare teams in Australia and how they manage the healthcare needs of PWID, has been poorly documented.’ The study set out to fill this information gap. The researchers used qualitative research methods to study the work of community health workers. Data were collected using participant observation of community health workers in a PWID-targeted primary healthcare centre. The researchers reached the conclusion that ‘This research explicates how CHWs serve as an interface between PWID clients and conventional healthcare providers. CHWs deployment of IDU-specific language, membership knowledge, values and behaviours, enable them to interact in ways that foster transparent communication and client participation in healthcare consultations. The incorporation of community health workers into clinical healthcare teams working with IDU populations is a possible means for overcoming barriers to healthcare, such as mistrust and fear of stigma and discrimination, because CHWs are able to serve as an interface between PWID and other healthcare providers.’
Morgan, K, Lee, J & Sebar, B 2015, ‘Community health workers: a bridge to healthcare for people who inject drugs’, International Journal of Drug Policy, vol. 26, no. 4, pp. 380-7.
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Buchanan, J 2015, ‘Fifteen benefits from the “War on Drugs”‘, LinkedIn, https://www.linkedin.com/pulse/fifteen-benefits-from-war-drugs-julian-buchanan.
Filtness, AJ, Sheehan, M, Fleiter, J, Armstrong, K & Freeman, J 2015, Options for rehabilitation in interlock programs, Austroads Ltd, Sydney, https://www.onlinepublications.austroads.com.au/items/AP-R484-15.
Harper, I, Anderson, P, McCluskey, S & O’Bryan, M 2015, Competition policy review: final report March 2015, The Review, [Canberra], http://competitionpolicyreview.gov.au/final-report/.
Legislative Assembly for the Australian Capital Territory, Standing Committee on Health, Ageing, Community and Social Services 2015, Inquiry into exposure draft of the Drugs of Dependence (Cannabis Use for Medical Purposes) Amendment Bill 2014 and related discussion paper; submission received and oral evidence provided, Legislative Assembly for the ACT, Canberra, http://www.parliament.act.gov.au/in-committees/standing_committees/Health,-Ageing,-Community-and-Social-Services/inquiry-into-exposure-draft-of-the-drugs-of-dependence-cannabis-use-for-medical-purposes-amendment-bill-2014-and-related-discussion-paper?inquiry=624651.
Legislative Assembly for the Australian Capital Territory, Standing Committee on Justice and Community Safety 2015, Inquiry into Sentencing, Legislative Assembly for the ACT, Canberra, http://www.parliament.act.gov.au/__data/assets/pdf_file/0019/707212/JACS-Ctee-report-for-Inquiry-into-Sentencing-FINAL.pdf.
National Health and Medical Research Council 2015, NHMRC CEO Statement: electronic cigarettes (e-cigarettes), NHMRC, Canberra https://www.nhmrc.gov.au/guidelines-publications/ds13.
Parliament of the Commonwealth of Australia, Senate Legal and Constitutional Affairs Legislation Committee 2015, Inquiry into the Regulator of Medicinal Cannabis Bill 2014; submissions received, Parliament of the Commonwealth of Australia, Canberra, http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Legal_and_Constitutional_Affairs/Medicinal_Cannabis_Bill/Submissions.
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