Archive for the ‘Addicts behaving badly’ Category

Drug Arrest for Doctor

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Last week, news outlets in my area were all aflutter about a physician in a small town who was arrested for prescription medication fraud. It was alleged that he prescribed opioid pain pills to seven of his wife’s friends and acquaintances, none of whom were his patients, so that they could pick up the pills and deliver them to the doctor and his wife.

I’m not giving the name of the doctor, his wife, or the other people arrested, though you can get those if you click on the link below. I figure all of them are getting enough bad press without me piling on too. Besides, this bizarre situation has addiction written all over it. [1]

The SBI investigated this case for four months and finally arrested the eight involved people last week.

The doctor’s wife was a teacher, and she was accused of convincing coworkers at her school to become involved in the illegal activity. These people were teachers, teacher’s assistants, or administrative aides at the school. The illegal prescriptions were filled from late 2012 until early 2014, and totaled around 200 prescriptions and 25,000 doses of hydrocodone. According to the news reports, some of the people filling the prescriptions were using some of the pills, and delivering some back to the doctor and his wife. Others say they thought they were helping people get access to pain pills by using their names.

If this news report turns out to be true, I have a hard time believing the doctor and his wife would take such a risk unless one or both are addicted to opioids. No one is immune to addiction, as we know. And I doubt the people filling the prescriptions would participate in this mess unless they were getting something out of it, too. Claiming to have filled phony prescriptions just to help someone out…I call bullshit on that. These people could also be pill abusers or addicts, or maybe were getting paid to pick up the pills, but I can’t imagine anyone would do this highly illegal thing without some sort of remuneration.

This was a big news story because people were shocked that this drug ring (allegedly) involved a doctor and schoolteachers. But as we know, addiction is an equal opportunity destroyer. For too long, society has imagined that drug addicts are people lying in the gutter with a needle hanging out of their arm. In reality, opioid addicts today look like our next door neighbors.

I reacted to the story with sadness, and with curiosity. I was sad because I think it’s highly likely all the people who were arrested suffer from addiction, and are in need of treatment. But maybe they’ll get lucky, and will be mandated to treatment instead of jail.

I was curious because I wonder why the doctor prescribed only hydrocodone. Why not advance to a more powerful opioid, if you are going to break the law anyway? If you know what you are doing is illegal, why not splurge, and prescribe Dilaudid, or OxyContin? Or maybe he’s smart, thinking that higher powered opioids would call more attention to the scheme. But surely he knew this could not remain secret, with seven other people involved.

This story may illustrate, again, that we don’t do our best thinking in the midst of addiction.

1. http://www.wtvm.com/story/25968161/dr-orrin-walker-abby-walker-rss-bostian-elementary-drug-scheme

Misuse of Suboxone: What Should We Do?

I’ve been discouraged by the number of people who write to this blog indicating that they abuse Suboxone by snorting or injecting. I know that’s a small number of people, compared to the thousands that have used Suboxone to get their lives back, and who are in excellent recovery, but it still depresses me.

What should the addiction medicine community do? What should the government do, if anything? What about law enforcement?

In this country, most law enforcement people see abuse of Suboxone the same as any other street drug. For them, it’s usually black and white. If it’s not prescribed for you, or if you’re using it in a way that’s not prescribed, it’s a crime for which you should be prosecuted.

Harm reduction proponents see the situation wholly differently. Since Suboxone is usually safer than other illicit opioids (note I said safer, not safe), even when it’s misused, why not allow the illicit use? In fact, why not hand out Suboxone tablets to anyone proven to be an opioid addict? If the addict snorts or shoots Suboxone, at least he’s not shooting heroin, a much more dangerous drug. True, that person is susceptible to medical complications from injecting and snorting, but this would be true for any other opioid. And some studies indicate that most of the illicit Suboxone is bought by addicts either self-medicating in order to stay out of withdrawal, or giving the medication a try before making the financial commitment to go to a doctor’s office for a legitimate prescription.

In a purely scientific world, I would agree with the harm reductionists. But that’s not the world we live in. We should be sensitive and alert to political forces that would like to annihilate our present freedom to prescribe Suboxone from a doctor’s office. Doctors – and their patients – have to be good stewards of this freedom, by taking whatever measures are appropriate to keep Suboxone out of the hands of illicit users.

 So what can doctors do to reduce Suboxone diversion?

  • Tablet counts and film counts. When I get a new patient, I have in my monitoring agreement that I will occasionally call them to go to their pharmacy (Some patients drive up to forty minutes one way to see me, so it’s more convenient to go to their pharmacy than to my office. Most pharmacists are happy to help.) for medication counts. If the count is short, either the patient is taking more medication than prescribed, or diverting it. Decreased diversion is the drug manufacturer’s big selling point for the films, rather than the tablets. They say that since each box has a lot number, if a patient has sold or given away some of their films, they can’t just buy replacement films to replenish before their count, like can be done with tablets. The lot numbers have to match. I can see where in theory that can be true…but I can also think of some ways to easily get around that, which I won’t post here.
  • Urine drug screens to make sure buprenorphine is present in the urine. Screening should be done anyway, to check for other drug use. Doctors doing urine drug screens should, of course, have buprenorphine on their test panel. In the past this was an expensive test, but not at present. My on-site test kits cost less than $10 when bought in bulk, and test for buprenorphine, methadone, opiates, oxycodone, THC, cocaine, methamphetamine, and benzodiazepines. (I have individual test cassettes for other drugs, when indicated.) Obviously, if there’s no buprenorphine in the urine, we have a problem.
  • Check the prescription monitoring program in your state. If the patient is getting prescriptions for other opioids, like morphine or oxycodone, it’s possible the patient stops Suboxone and uses these opioids between doctor visits. The other possibility is that they sell these other opioids, also not an acceptable situation, since it fuels other addicts’ addictions.

What can patients do to help keep Suboxone away from illicit users?

  • Don’t share your medication. Even if someone you care about is in withdrawal, help him to get care from a legitimate source. Don’t endanger him and yourself by sharing medication. And of course…don’t sell your medication. Duh.
  • Make sure you keep your Suboxone in a lock box, or other safe place. Not only will this keep your medication away from children, but also from addicts looking for opioids. Many patients new to recovery haven’t yet cut off ties with all drug users, and other addict “friends” may be looking for medication.
  • If you know of a Suboxone patient who’s selling medication, tell their doctor. You don’t have to call the police to get them into legal hot water, but you should do all you can to stop the illegal sale of any prescription medication. After all, a patient selling Suboxone is endangering your right to get convenient, office-based treatment.
  • Family members: please call your loved one’s doctor if any part of their Suboxone prescription is being sold or given away to other people. Because of confidentiality, we may not even be able to confirm that your loved one is a patient, but we can always take information from you. We may do pill counts or other things to confirm what you are telling us, and then take action.

What are the possible consequences of continued diversion of Suboxone? Some authorities are talking about changing the DATA 2000 law. Others are clamoring for buprenorphine to be re-scheduled into a schedule II opioid, which would disqualify it under DATA 2000 for use in an office. It would still be available at an opioid treatment program. And many OTPs (opioid treatment programs) do now offer buprenorphine.

I advocate for continued availability of office-based buprenorphine treatment, but now I believe some patients should start at an OTP, and transfer to office-based program only if they do well. Some patients are so strongly addicted to other drugs that they don’t do well in office-based treatment.

I now work at a wonderful opioid treatment program that offers both buprenorphine and methadone upon admission. I’ve switched a few selected patients to my office-based practice. This means I see them and write a prescription for them to fill at a pharmacy, no longer chaining them to daily OTP dosing. I still see them at regular intervals, usually every one to two weeks. These patients can still contract with the OTP for individual counseling and drug testing. This allows the OTP to have a wider variety of treatment options for their patients, gives me a stable patient, and gives patients who are doing well more freedom and treatment at a lower cost. Win, win, win.

I hope more OTPs will begin to offer buprenorphine as a real option to methadone, so that patients who don’t do well in office-based programs can still be on buprenorphine. And I hope they direct the stable patients to office-based programs.

Smuggling Suboxone

I was intrigued by an article I saw on my internet homepage. It was titled: “When Children’s Scribbles Hide a Prison Drug”

http://www.nytimes.com/2011/05/27/us/27smuggle.html?_r=1&hpw

 This article describes unique ways Suboxone is being smuggled into jails. Law enforcement officials associated with both state and county jails from Maine and Massachusetts were interviewed. They say prisoners and their accomplices make Suboxone into a paste and smear it over the surfaces of papers sent to prisoners from their families. The article mentions the paste being spread over children’s coloring book pages, and under stamps. Suboxone films have been placed behind stamps or in envelope seams. Correctional officers now have to inspect material coming in the mail to prisoners much more closely.

 I had several thoughts. First, yet again, I’m struck by the creativity and cleverness of addicts. If only they could channel this energy in the right direction, amazingly good things could come to them, instead of the continued hardships brought by addiction.

 Then I felt sad that such actions described in the article would taint the reputation of a medication that has the potential to save lives, when used appropriately. Such illicit use of Suboxone gives ammunition to those who would prefer that office-based treatment with Suboxone didn’t exist.

 Then I wondered, how many of these prisoners have a legitimate prescription for Suboxone, but are denied their medication by prison officials? How many are legitimate patients of methadone clinics, also denied their medication while imprisoned, who know that Suboxone will alleviate some of the opioid withdrawal they are feeling? How many of these people are addicted to opioids, not in any kind of treatment, but who know Suboxone will treat their withdrawals?

At least one study supports the idea that many people use Suboxone illicitly not to get high, but to prevent withdrawal. Dr. Schuman-Olivier studied 78 opioid addicts entering treatment. Nearly half said they had used Suboxone illicitly prior to entering treatment. Of these people, 90% said they used to prevent withdrawal symptoms. These addicts also said they used Suboxone illicitly to treat pain and to ease depression.

Many law enforcement personnel and members of the legal community have strong biases against medication-assisted treatments. They don’t understand that addiction is a disease, and that methadone and buprenorphine are legitimate, evidence-based treatments. They have difficulty letting go of their idea that addiction is a choice that deserves blame, and have a punitive stance towards addicts. They have low opinions of addicts who are using drugs, but often have no better opinion of a recovering addict who has sought treatment and is doing well on replacement medications, like methadone or buprenorphine.

 But no matter what law enforcement personnel think they know, when they deny prescribed, life-saving medications, I believe they’re practicing medicine without a license.

The article mentions one woman who, with the aid of the Maine Civil Liberties Union, sued because her Suboxone treatment had not been continued while she was in jailed for a traffic violation. She settled out of court, but her lawyer made the excellent point that if inmates are denied their medications, they will try unlawful means to get it.

Other patients and their families have brought successful lawsuits against the jail facilities. In at least two cases, in the same Orange County, Florida jail, patient/prisoners were allowed to go through withdrawal for so long that they died. The estate of one person won a three million dollar judgment against the county. (1, 2)

I’m glad to see these lawsuits. I’ve heard appalling stories from many methadone patients, who were denied their medication while incarcerated. I’ve heard tales of jailers taunting these prisoners, when they became sick. There is no defense for such cruelty.

Orange County now works with local methadone clinics. If a prisoner is a current patient of a clinic, his clinic will send a week’s worth of medication in a locked box via courier. Nurses at the jail have the key to the box, and administer each day’s dose. The jail doctor consults with the medical director at the methadone clinic. Prisoners still have to pay out of pocket to get the medication, so the only cost to the jail is the time required for personnel to administer the medication. It’s certainly much cheaper than paying three million to the estate of a dead prisoner, not to mention much more humane.

I wish the county jails around the methadone clinic where I work would approach the problem of opioid addiction and treatment in a collaborative way. Sadly, only seven state prison systems offer medication-assisted treatment with methadone or buprenorphine.

Rikers Island, in New York City, gives us another example of how such a system could work. There, opioid-addicted prisoners charged with misdemeanors or low grade felonies can be enrolled in a program known as KEEP (Key Extended Entry Program). This program treats opioid addicts with methadone and counseling. Upon release from Rikers Island, these patients are referred to methadone treatment centers in the community. Seventy-six percent have followed through with their treatment, post-release. The results of this program show significant reduction in reincarceration and significant reduction in criminal activity. (3)

Drug courts trying to save money would be well-advised to look at the Rikers Island program. Studies have shown a cost savings of at least four dollars for every one dollar spent on methadone treatment. This money is saved because methadone patients require fewer days of hospitalization and other healthcare costs, and also because of reduction in criminal activity and incarceration costs. (3, 4)

I know from comments written to this blog that there are many more people abusing Suboxone than I previously imagined. For sure, some of the prisoners getting smuggled Suboxone are misusing it. But I don’t think the majority are using for anything other than prevention of withdrawal, since they are usually not offered any other effective treatment for this medical condition.

  1. “Outrageous: the death of Susan Bennett raises serious questions about the competence and quality of the jail’s nursing staff” Orlando Sentinel, editorial, March 27, 1998.
  2. Doris Bloodsworth, “Inmate begged for methadone” Orlando Sentinel July 12, 2001.
  3. Par`rino, Mark, “Methadone Treatment in Jail,” American Jails, Vol: 14, 2000, issue 2, pp 9-12.
  4. California Department of Drug and Alcohol Programs, 2004, California drug and alcohol treatment assessment (CALDATA) California Department of Alcohol and Drug Programs. California Drug and Alcohol Treatment Assessment (CALDATA), 1991-1993 [Computer File]. ICPSR02295-v2. Ann Arbor, MI: Inter-university Consortium for Political and Social Research [distributor], 2008-10-07. doi:10.3886/ICPSR02295

 

Drug Deals at the Methadone Clinic

Ideally, a drug deal should never happen at a methadone clinic.

This is a difficult topic, because it’s about a negative aspect of addiction treatment at methadone clinics. But nothing’s to be gained by ignoring the problem. We need to acknowledge problems of methadone clinics before we can improve them. People who are opposed to methadone as a treatment for opioid addiction often cite parking lot drug dealing as one of their reasons not to “believe” in methadone (as if it were a spiritual experience).

Methadone clinic administrators disagree on how to handle drug dealing and other problem behavior by patients at a clinic. Some administrators say that many addicts, to a greater or lesser degree, have sold drugs to finance their own habit. The buying and selling of drugs, fighting, and other problem behaviors are all part of addiction, and this behavior doesn’t change overnight. These administrators say that it’s unrealistic to expect patients not to deal drugs. After all, patients arrive in treatment with varying degrees of commitment to get well. Many such methadone clinic administrators don’t want to dismiss patients from the clinic for bad behavior, given the markedly increased risk of death for those who leave.

I don’t agree with that position. I think it infantilizes people with addiction to assume they aren’t capable of behaving in an acceptable manner. If you let patients know that drug dealing won’t be tolerated, it’s much less likely to occur. Tolerating drug dealing implies that clinic management is lazy, apathetic, or just don’t care about the patients who want to get well. Clinics should be safe places for patients who want to get well. It’s not acceptable for these patients to have to walk through a parking lot crowded with drug dealers. 

Clinic administrators can do several things to secure their premises. They can hire security guards to patrol the parking lots. This may or may not be necessary, depending on the physical arrangement of the clinic. Video cameras can be positioned inside the clinic and in the parking lot, for monitoring.

At one of the clinics where I work, I like how security is handled. We don’t need a security guard, because the program manager’s window overlooks the parking lot. He’s only steps from our exterior door, and quickly confronts our patients not only if they appear to doing a drug deal, but also if they loiter, throw trash, or smoke cigarettes. (We are a non-smoking facility).

Our program manager knows our patients are capable of behavioral change. Many of them have survived harrowing experiences, and had to develop coping skills to survive. They have abilities for which they are rarely given credit. Once we let them know what we expect, nearly all honor us and themselves by abiding with our guidelines. They also want a safe, clean treatment center. We get a little grumbling about the non-smoking rule, though.

This clinic’s “no loitering” policy, seemed harsh to me at first. The patients are asked not to talk to each other in the parking lot. Then the administrator explained that socializing in the parking lot allows a milieu where drug dealing can occur. If patients shared transportation, as often happens at more rural clinics, they need wait on each other inside, in the waiting room. The waiting room is in the middle of the clinic and well-monitored by two counselors. We ask patients not to talk about drugs or addiction “war stories.” Most of them understand that such talk often triggers cravings to use, and are able to refrain from such conversation.

It helps that our clinic is small, at just over 100 patients. When clinics are bigger, chaos and bad behavior is more likely to happen. That’s another reason I like working in smaller clinics, where I know all of the patients.

If patients are unable to abstain from drug dealing in our parking lot, they may not be well enough to be in this form of treatment. The safety of patients comes first; if one patient presents a risk to other patients’ well-being, we have to take whatever measures are necessary for the safety of all.

 Non-patient drug dealers often target drug treatment clinics, expecting to find easy customers. The police need to be called on these people

Usefulness of Prescription Monitoring Programs

I ranted recently about Florida’s Governor Scott’s bizarre decision to give the axe torpedo their prescription monitoring program (see March 8th, also March 6th). Now I’d like to post a link to a thoughtful piece about how prescription monitoring can have positive effects.

This link was found on Brandeis University’s Center of Excellence. These folks do research for public policy surrounding prescription monitoring, among other things. The first URL below is for their home page; the second is for the specific article that I thought was interesting.

 http://www.pmpexcellence.org

http://www.pmpexcellence.org/sites/all/pdfs/methadone_treatment_nff_%203_2_11.pdf

Suboxone: Miracle Drug or Manacle?

Yesterday in my office, I saw patients for whom I prescribe buprenorphine (better known under the brand name Suboxone). It was not my typically pleasant day. Usually, I see the positive changes occurring in the lives of my patients: they are getting families back, getting jobs or better jobs, getting health and dental care needs addressed, and overall feeling happier and more productive.

 But yesterday I had two patients who were bitter about being on Suboxone. Both were having great difficulty tapering off of Suboxone. Both had also been reading materials on the internet that described the hopelessness of ever tapering off this medication.

 This frustrates me for several reasons. First, not everything you read on the internet is correct. Second, people don’t appear in my clinic requesting Suboxone for no reason. All of my Suboxone patients were addicted to opioids before I ever prescribed Suboxone. Even assuming no patient ever gets off Suboxone, it’s still so much better than what they were doing before. Third, I’ve never said it’s easy to get off Suboxone. It can be done, but it’s still an opioid. When you stop opioids, you will have withdrawal. There’s no way around that. 

Overall, most people say withdrawal off Suboxone is easier than other opioids. But people and their biochemistries are different, and I accept that some people have a worse withdrawal than other people. I’ve had a few people say methadone withdrawal was easier than Suboxone withdrawal. I have to believe that’s their experience, but I think that’s unusual, and not the experience of most people. 

Some doctors think patients on maintenance medications, like methadone or Suboxone, should always stay on these medications, given what we know about the rates of relapse and even death for patients who leave these programs. And some patients have continued sub acute withdrawal symptoms for weeks or months off opioids, and just don’t feel right unless they are on maintenance medications. These people seem to do better if they stay on maintenance medication. 

And on the other hand, many people are able to taper off opioids and remain off of them, and lead happy, healthy lives. I keep thinking about two groups of recovering opioid addicts who do well off of all opioids, on no maintenance medications: members of 12-step recovery groups, and recovering medical professionals.

 Off the top of my head, I can think of a dozen recovering opioid addicts who are members of Alcoholics Anonymous or Narcotics Anonymous, and who aren’t on any maintenance medications. They feel fine, and have been abstinent from opioids for years. If you don’t believe me, go to an open Narcotics Anonymous meeting. Ask the recovering addicts there if they have been addicted to opioids in the past. Chances are that around a fourth of the people you talk to are recovering from opioid addiction. There may be a few people who are on methadone or Suboxone, but many are completely free from opioids.

 Look at doctors in recovery. Opioids were the drug of choice for many addicted doctors, and they are “real” addicts, having used remarkable amounts of opioids before getting into recovery. But doctors have one of the highest rates of drug-free recovery. This isn’t because we are so smart or special, or because we have Charlie Sheen’s tiger blood. It’s because we are held tightly accountable by our licensing boards. If we want to practice medicine, we have to participate in recovery. Licensing boards often hold our licenses hostage unless we do the work of recovery. This may mean three to six months of inpatient residential treatment, after a medical detoxification. It may mean four recovery meetings per week for the first five years of recovery, along with monthly random drug screen, and a monitoring contract for five years.  (1,2)

If every addict seeking recovery could have that degree of treatment and accountability, I suspect relapse rates would be uniformly low. Sadly, that’s just not possible for most opioid addicts, because of financial constraints, and because there’s less leverage with most people than with licensed professionals. 

Not all opioid- addicted doctors do great off opioids. Many have multiple relapses, and would probably be much healthier and happier if they got on maintenance medications like methadone or Suboxone, but isn’t allowed – at present – by the licensing boards in most states. Again, one type of treatment doesn’t work for everyone.

 My point is that it is possible for many people to get off Suboxone, and live a happy drug free life. And for other people, lifelong maintenance is probably the best and safest option. At present, we don’t have a way to predict who might do well off of Suboxone (or methadone). We do know that a taper should be slow, and probably takes four to six months for a taper to give best results.

 I believe in Suboxone. It’s saved many lives, just like methadone has. I wouldn’t prescribe it if I didn’t know it works. I think what I’ve been hearing and reading is a normal backlash against the unrealistic expectations many people had for Suboxone. It’s been called a miracle drug, but it’s not. It’s still an opioid, and there is still a withdrawal when it’s stopped. It’s a great medication for many people. It can allow many opioid addicts to get their lives back and enjoy a normal life, except for having to take a daily dose of Suboxone. But isn’t that still drastically better than active addiction? 

  1. Ganely, Oswald H, Pendergast, Warren J, Mattingly, Daniel E, Wilkerson, Michael W, “Outcome study of substance impaired physicians and physician assistants under contract with North Carolina Physicians Health Program for the period 1995-2000,” Journal of Addictive Diseases, Vol 24(1) 2005.
  2. McLellan, AT, Skipper, GS, Campbell, M, DuPont, RL, “Five Year outcomes in a cohort study of physicians treated for substance abuse disorders in the United States,” British Medical Journal,2008;337: a 2038.

Stop Buying and Selling Suboxone!

 It’s been longer than usual since my last post. That’s because I spent the last five days in Boca Raton, Florida, at the annual meeting of the American Academy of Addiction Psychiatry. I usually go to meetings of the American Society of Addiction Medicine, since I’ve been a member of that organization for seven or eight years. I’ve always thought of ASAM as more “medically -oriented” and AAAP as more “mentally-oriented” but this week I found that they’re similar. 

Anyway, I went to some great meetings and lectures.

 The most intriguing was “Buprenorphine 201.” In this meeting, we had a lecturer, but she functioned more as a moderator for many of the physicians as we exchanged ideas about how we prescribe buprenorphine for our addicted patients.

 One of the more interesting topics was if, when, and how to taper buprenorphine. Should physicians encourage patients who are doing well on buprenorphine to taper off of it at some point? All the research data shows high relapse rates for patients who taper off of it. But many patients insist on tapering, due to the stigma, cost, and inconvenience of being on this medication, so what’s the best way to do this?

 I heard several new ideas, like doing dose plateaus. This means that once you taper 25% of the total dose, stay on the new dose for a few months to make sure the patient has completely stabilized before pushing the dose down again. Then stay at that dose for months, and so on. Another doctor said to use clonidine to treat early withdrawal symptoms. Another doctor suggested using benztropine (Cogentin) to manage some of the symptoms of opioid withdrawal. This medication is usually given to help symptoms of Parkinson’s patients, and to help manage the side effects of anti-psychotic drugs.

 The two best ideas I heard were: 1-Taper the dose down to as low as possible, in the range of 2mg, and stay at that dose for a prolonged time, maybe months. The doctor and patient can decide to taper further after a very prolonged time. 2-Use the 2mg Suboxone film, and cut it to gradually lower the dose. 

We all agreed there is little research to guide us to decide when taper is appropriate, and how to do the taper. Much of what we decide depends on the characteristics of the patient and their desires.

 Several other things came out of this meeting. The most worrisome is the degree to which buprenorphine, brand name Suboxone, is being diverted to the black market. This is making the DEA rather cranky, and other law enforcement types are beginning to make noises, saying that Suboxone should be re-classified as a Schedule II controlled substance because of the frequency it’s seen on the black market. If that happens, it would be the end of the Suboxone program. The DATA 2000 law that made it permissible to treat opioid addiction in a doctor’s office says the drug must be scheduled III or IV. A schedule II drug wouldn’t be covered by DATA 2000.

 So let me say loud and clear: If you are buying Suboxone, selling Suboxone, or giving Suboxone to someone other than the person to whom it was prescribed… KNOCK IT OFF!!!

You could ruin a good program that offers opioid addicts an option that was illegal in this country until 2002.

 Let’s do all we can to keep this medication available for the addicts who want recovery.

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