02/20/19 Doug McVay

Century of Lies
Doug McVay
Drug War Facts

This week: US Senators look at pain management, opioid policies, and the search for alternatives like cannabis.

Audio file



February 20, 2019

DEAN BECKER: The failure of drug war is glaringly obvious to judges, cops, wardens, prosecutors, and millions more now calling for decriminalization, legalization, the end of prohibition. Let us investigate the Century Of Lies.

DOUG MCVAY: Hello, and welcome to Century of Lies. I'm your host Doug McVay, editor of DrugWarFacts.org.

On February Twelfth, the US Senate Committee on Health, Education, Labor, and Pensions held a hearing entitled “Managing Pain During the Opioid Crisis.” We’re going to hear some audio from that hearing today. Witnesses appearing at this hearing included:

Cindy Steinberg, National Director of Policy and Advocacy for the US Pain Foundation and Policy Council Chair for the Massachusetts Pain Initiative;
Halena Gazelka, MD, Assistant Professor of Anesthesiology and Perioperative Medicine at the Mayo Clinic College of Medicine, where she's Director of the Mayo Clinic Inpatient Pain Service and Chair of the Mayo Clinic Opioid Stewardship Program;
Andrew Coop, PhD, Professor and Associate Dean for Academic Affairs at the University of Maryland School of Pharmacy; and
Anuradha Rao-Patel, MD, Lead Medical Director for Blue Cross and Blue Shield of North Carolina.

Let’s go to the questioning from members of the Committee. First up, Senator Patty Murray, Democrat from Washington State.

SENATOR PATTY MURRAY: You know, throughout this Committee's bipartisan work on the opioid misuse crisis, I've heard from people who supported our legislative efforts and were very grateful.

But I also heard from some people with disabilities who experience pain and fear that restricting access to treatment could affect independent living, merely because they were unable to manage their pain.

So, Doctor Gazelka, maybe you can take this on. Have we struck the right balance in our work to misuse, but also making sure that treatments are available, which can be really vital for people with disabilities?

PROFESSOR HALENA GAZELKA, MD: That's a very good question, and I worry that we've gotten ahead of ourselves with wanting to restrict opioids. A lot of people are now, a lot of providers are now scared to provide opioids to patients they've been prescribing them to for many years.

But that doesn't necessarily mean that those patients have come in contact with a pain provider who can help them manage their pain, but with other means.

Most opioids in the United States that are prescribed chronically are prescribed by primary care providers, many of them who don't have any education in managing chronic pain. They don't have time to go into the detail that it takes to talk to patients about other options. They don't have access to pain providers.

And I think in some ways, I mean, we've done what needed to be done, which is to drastically reduce opioid prescribing, I think, but I worry that we're getting ahead of ourselves with having available other options.

SENATOR PATTY MURRAY: Okeh. Thank you. I know people experience pain in a lot of different ways, but one other thing I'm really concerned about is how bias in the health care system can affect a patient's treatment for pain.

Despite the fact that women experience pain at higher rates than men, they are more likely than men to receive sedatives or be diagnosed with a mental health condition when they seek treatment for pain.

And when it comes to cardiac care, women are less likely to have their heart attack symptoms recognized, or to receive painkillers after a cardiac surgery, and it's just, you know, when patients are listened to, the results can be debilitating, even fatal. So Doctor Gazelka, maybe I can ask you, have you seen female patients being treated differently than male patients?

PROFESSOR HALENA GAZELKA, MD: I have a patient who has not only given me permission to share her story, but has encouraged me to do so.

Sixty-year-old lady in 2017 went to her local provider in a small town in Minnesota with abdominal pain. She'd been very active running before this. As the year progressed, she was -- became less functional. Her primary care provider did not know what else to do for her, other than ordering a CT scan of her abdomen and ruling out any difficulty there.

She started presenting to the emergency room locally. After multiple presentations, the emergency room physician sat her down and said, Mrs. B, you have chronic pain. You're going to need to go home and figure out how to manage this.

She was frustrated, so came two hours to the Mayo Clinic Emergency Room and eventually ended up on my schedule in the pain clinic.

Now, talking about bias, I admit that when I saw that on the schedule and I read her history, I just felt a little irritated that morning, having to go into the room, but I stood outside of her room and I told myself, you're going to listen to her like this is the first time she's told her story.

And I went in and I listened to her. And I ordered an MRI, that showed that she had a metastatic lung cancer eating through her rib and the nerve that innervated that area in her abdomen. It had been present for at least a year, and ignored because people felt that she was seeking opioids.

Bias is a significant problem in all areas of medicine. It's a problem in research, it's a problem when we see patients, and it contributes significantly, I think, to the stigma that surrounds the treatment not only of chronic pain but of addiction and of mental health disorders. I think it's a significant issue.

SENATOR PATTY MURRAY: I'm not sure how we address that, but being aware of it is certainly a critical part of it.

PROFESSOR HALENA GAZELKA, MD: I think awareness, and I think education, both for patients and providers, the public.

SENATOR PATTY MURRAY: And, I understand people of color, the same biases.

PROFESSOR HALENA GAZELKA, MD: Yes. There are definitely studies that show that, yes.

SENATOR PATTY MURRAY: Okeh. Ms. Steinberg, I wanted to ask you, can you share your experience in providing a healthcare provider, who helped you manage your pain, and your thoughts on how Congress can help make sure that providers have the tools they need to support patients who live with pain?

CINDY STEINBERG: Yeah, I think it's a great question, because, I've often asked myself, after five years, why did it take me so long to find somebody, and what was special about this doctor that finally helped me?

And it wasn't anything miraculous, and that's I think an important message today, which is, he empathized with me. He believed me. A lot of people with pain don't get believed, because it's an invisible disability.

He said I will work with you to help you find things to manage your pain, but understand that there is no cure now for chronic pain. You probably have chronic pain and you're going to need to learn to live with this. But I will partner with you.

He was honest, he was empathetic, as I said, and he worked with me to find things that helped me. We often say in pain management now, if you do a program of several different things, and what I do is, I take medication, I limit the amount of time I'm up. Everybody has different limitations on their activities with pain.

I do a water based therapy, physical therapy program, and land based program. So if each thing takes down your pain fifteen or twenty percent, that adds up to maybe a fifty or sixty percent reduction in pain. You can live that way.

But, it's a matter of having doctors have the time to do the coordinated care. Our system is so fragmented now that people go from doctor to doctor, nothing is coordinated. They try one thing, it doesn't work, they go to another person because they're desperate.

But if we had coordinated care. Think about cardiac rehab. Heart disease has been a huge cost for us. Right? But we focused on cardiac rehab and said, we are going to have a rehab program that puts everything together. And we've had great success with that.

Pain needs something like that. We need that kind of approach. Where there's an integrated care center, doctors have time to provide that care, and you can try different things and have somebody helping you, you're not isolated.

It would go a long way to staving a lot of the wasted costs from trying different procedures and different needles and different injections. This is what happens to people with pain. So that's my suggestion. It is not miraculous. I think we can do this, if we rethink and realign insurance reimbursement, and think about models of care that are creative that way.


DOUG MCVAY: That was questioning by Senator Patty Murray during a hearing by the Senate Health, Education, Labor, and Pensions Committee on the subject of "Managing Pain During the Opioid Crisis." You’re listening to Century of Lies. I’m your host Doug McVay.

Now, let’s hear from the Chair of the HELP Committee, Senator Lamar Alexander, Republican from Tennessee.

SENATOR LAMAR ALEXANDER: Let me go back to you, recognizing I've only got five minutes, Ms. Steinberg. We have 300,000 primary care doctors in the country, they're the access point for most of us to whatever else we need.

How do we empower them to do a better job, as you just described?

CINDY STEINBERG: So, that is a great question, because I've been working in policy in Massachusetts for at least eleven years now, and I've worked with lawmakers to try some innovative things, and we just passed a law, something that I worked on, which was, patients are being dropped from care right now.

You've heard that doctors are afraid to take care of people with pain. And the bulk of people with pain end up, because we have so many millions, being taken care of by primary care physicians, who don't get much training in it.

So, we try --

SENATOR LAMAR ALEXANDER: I don't want to cut you off but I've got several questions in my five minutes.

CINDY STEINBERG: Okeh. So, we try to program where primary care doctors can call pain management specialists for consultation free of charge to them. So the state is going to pay for specially trained teams of pain management specialists who can consult with the doctors, so the doctor feels more comfortable handling that patient, they have a network of alternative providers, that really is helpful.

SENATOR LAMAR ALEXANDER: Doctor Gazelka, does the Mayo Clinic have such a system to connect with primary care doctors around Minnesota or other states?

PROFESSOR HALENA GAZELKA, MD: We do have a system within our electronic medical record. We allow for e-consults, where a physician or provider can contact a specialty physician and ask for advice to treat that patient, and ask if a referral might be appropriate.

SENATOR LAMAR ALEXANDER: Doctor Coop, the hearing, this hearing, for an obvious reason, it's called human nature, you set out one direction, and it's the right direction, but you know for sure that something's going to happen that can cause -- in the other direction you didn't anticipate. And that's what we're worrying about here today.

Let's say, I'm, I have a loved one who's about to have a serious surgery. How do I think about opioid prescriptions in a state like Tennessee, where the state has said, with our encouragement, three days per prescription. How should we think about opioids, is it something you don't use at all?

I notice that Blue Cross in Tennessee won't reimburse Oxycontin, although I don't think that may be true for other opioids. But, how should one think about that, looking at it from the point of view of your own family, and someone headed toward a painful surgery?

PROFESSOR ANDREW COOP, PHD: My own family takes opioids, and I'm fully supportive of them taking them. When, if somebody needs opioids, they should get them. I really don't think -- one of the issues is the pendulum has swung way too back, to limiting and people suffering from pain.

We need to get to the middle ground, where opioids are used in limited quantities, but we also add all the other approaches that we --

SENATOR LAMAR ALEXANDER: What is a limited quantity? Three days, or three weeks?

PROFESSOR ANDREW COOP, PHD: I'm not a physician. I can't answer that. I'm sorry.

SENATOR LAMAR ALEXANDER: Doctor Gazelka, what's a limited quantity?

PROFESSOR HALENA GAZELKA, MD: That varies, by the patient and the procedure.

SENATOR LAMAR ALEXANDER: Well, what would a range be?

PROFESSOR HALENA GAZELKA, MD: Between, I think three days is very reasonable for emergency room presentations. That's what we've instituted at Mayo, and actually throughout the state of Minnesota with other healthcare organizations cooperating.

But I think for a knee surgery, we know, from research, that it's about 16 days of opioids that a patient takes. What is appropriate is to educate the patient, and perhaps with the participation of a pharmacist.

Educate the patient that you should take this for the shortest amount of time possible. The risk for maintaining long term opioid use increases dramatically at about ten days of use.

SENATOR LAMAR ALEXANDER: Doctor Coop, I have about a minute left. What are the most promising non-addictive painkiller treatments or medicines coming down the road? And you can mention your own.

PROFESSOR ANDREW COOP, PHD: My own would not be approved. My own would not be approved. It does indeed cause less dependence and tolerance, but it is reinforcing. So, that's why I say the FDA needs to fully address all these drugs.

My drug should not be approved. It would be the worst thing to put onto the market. I'm working on the next generation.

The drugs that are coming, I mention cannabinoids. I really do, and I know that's a controversial topic, but, there is great potential --

SENATOR LAMAR ALEXANDER: Why is there controversy?

PROFESSOR ANDREW COOP, PHD: Certain states have legalized, the federal government has not legalized. The studies out there --


PROFESSOR ANDREW COOP, PHD: The studies out there have potential, but, the studies have been done with no systematic approach. We need systematic approaches --

SENATOR LAMAR ALEXANDER: You're talking about medical marijuana, is that -- ?

PROFESSOR ANDREW COOP, PHD: Medical marijuana. Sorry, yes. Medical marijuana.

SENATOR LAMAR ALEXANDER: We're laymen, most of us, women ...

PROFESSOR ANDREW COOP, PHD: Sorry. I'm really sorry. Medical marijuana, yes. I think that has great potential.

SENATOR LAMAR ALEXANDER: Thank you very much.

DOUG MCVAY: That was questioning by Senator Lamar Alexander during a hearing by the Senate HELP Committee on the subject of Managing Pain During the Opioid Crisis.

The hearing witnesses were:
Cindy Steinberg;
Halena Gazelka, MD;
Andrew Coop, PhD; and
Anuradha Rao-Patel, MD.

You’re listening to Century of Lies. I’m your host Doug McVay, editor of DrugWarFacts.org.

Now let’s hear a round of questioning by Senator Bill Cassidy, MD, Republican from Louisiana. It's worth noting that during her medical training, Doctor Rao-Patel, who’s one of the witnesses, was a resident under Doctor Cassidy.


SENATOR BILL CASSIDY, MD: Thank you. First, Ms. Steinberg, you're sitting back there, but I remember, and this will set up my next question, I remember having, when I was a first year in Congress, having a slipped disc in my neck, with a radiating pain down my radian -- my honor distribution, and it was so incredibly painful.

I was imprisoned by the pain and all day long I just waited for my every six hour dose of Motrin, and or, and I staggered it with my Tylenol, taking something just when I went to bed.

And for three or four months, that's all I did. And it just sapped my emotional energy. Now, I was eventually helped by epidural injections, and, and this sets up my next question, Doctor Gazelka.

When I looked at the research on epidural, and for people who are not in medicine, they put a needle right there, they injected it, and it would give me instant release -- relief that would then wear away.

I looked up the data, it said it was no good. The data says, you know, epidural has no long term benefit in the management of chronic pain.

But after my third one, it just went away, and never came back. Now, then I looked at the CDC guidelines for management of chronic pain, and they say, going back to Senator Collins' question, that there's really just no evidence of use of opioids long term versus no opioids versus et cetera et cetera et cetera.

So it seems like we have a paucity of evidence, and that which empirically worked in me, you know, n is equal to one, doesn't have the evidence to support it.

Now, briefly comment on that, because then I'm going to go to my former student. Doctor Rao-Patel, to ask if Blue Cross's covering things which have no evidence but nonetheless empirically do work in some. So, quickly.

PROFESSOR HALENA GAZELKA, MD: Well, so, Doctor Cassidy, I do not have to explain to you that you can find studies almost to back up whatever you're looking to back up.

You had acute pain. Epidurals very effectively manage acute pain, radicular pain. Probably for patients who have spinal stenosis or other types of chronic radicular pain, they may not be as effective. I could tell you that anecdotally, from my practice.

Do we use them? Yes, because they are helpful to them, sometimes patients don't have other options available. But, definitely for acute pain, those are helpful.

SENATOR BILL CASSIDY, MD: Now, of course, mine lasted three months. Now eventually what my neurosurgeon friend told me is that just part of your nerve will die, although I still have a little bit of something, it tingles right there, and then after that death, that's a great way to look at it, I would feel better.

So, by the way, I also once read in Mad Magazine as a kid, give me statistics and I can prove that Rhode Island is bigger than Texas.


SENATOR BILL CASSIDY, MD: So, I feel your point. But Doctor Rao-Patel, will Blue Cross pay for that, which evidence suggests does not work, number one?

Number two, Doctor Gazelka mentioned all these wonderful things that can be used in lieu of opioids, in the, say, post-surgical setting, but then my physician friends tell me, hey, you're on a bundled payment, or you're on capitated paymet, and the insurance company won't give you that bump up for the more expensive drug, or the more expensive procedure. And I see Doctor Gazelka over there vigorously nodding her head yes.

So, tell us, since ultimately it comes to your decision as the UR [Utilization Review] manager for Blue Cross. How does that handle?

ANURADHA RAO-PATEL, MD: So, along with her comment, there are studies that show that for acute pain, injections like epidural steroid injections work.

Again, there are multiple kinds of injections for spinal pain, depending on where the pain generator is. And those are things that Blue Cross Blue Shield does cover.

Several of the things that we've discussed, like physical therapy, occupational therapy, water therapy, chiropractic care, epidural steroid injections, [inaudible] injections, those are all a multitude of things that we cover as a plan without any type of prior authorization.

So, if a provider feels that this is the appropriate intervention for the pain, for the patient, for their pain, they can go ahead and do the procedure, they don't even have to contact us.

SENATOR BILL CASSIDY, MD: Now, let me ask, though, because clearly given a prescription for opioids would be cheaper than a whole panoply of that which might be less likely to induce, and it seems like that sends -- that's the rub, right? If you're getting X number of dollars to manage patients, do you, how do you employ that which is significantly more expensive, even though long term there is a benefit?

ANURADHA RAO-PATEL, MD: Well, I mean, our approach at Blue Cross is, you know, again, we've participated with multi stakeholders at our state level, including the medical board and specialty societies on appropriate management and treatment of pain. And our approach has always been a multimodal approach.

SENATOR BILL CASSIDY, MD: So then let me ask, as I'm almost out of time, go back to the question of a bundled payment, and I don't know if Blue Cross uses bundled payment but I can imagine some place either you do or you plan to, and again my pain management physician said, listen, put surgically, we can do this or that, but it's more expensive than just giving them a prescription or giving them an injection of an opioid.

So, how do we manage that? How do we approach, as policymakers, bundled payments, when we know that it may increase the cost to do something which would decrease the use of opioids?

ANURADHA RAO-PATEL, MD: Again, the reason that we bundle payments, for example, is to be more cost efficient overall. So, again, we're, again, not trying to limit the options that providers have in managing pain, but we're encouraging them to use a multimodal approach in terms of management.

SENATOR BILL CASSIDY, MD: But I'm not sure that answers my question, because if your cost basis is just giving a prescription for opioids, but the alternative is this, and he's politely tapping his thing to tell me to shut up. So that will be a question for the record. Thank you.

SENATOR LAMAR ALEXANDER: Well, maybe you could provide some -- Senator Murray would like to know the answer, so we'll give -- if you -- we'll extend the discussion for Senator Cassidy and ask you if you have any comment on what he just said.

ANURADHA RAO-PATEL, MD: Yeah, again, like I said, the things that, for example, that I'm aware of that we bundle at Blue Cross in terms of payment are, for example, post-surgery, let's say a patient has a knee replacement or a hip replacement. They're, the perioperative period, the preoperative period, the perioperative period, and the post-operative period is bundled in a payment in terms of management of that patient.

I would -- it's more of a payment question that I would -- I could get back to you on and specifically what we bundle in terms of interventional pain management procedures. But there are instances where we do bundle payments in order to contain the cost.

SENATOR LAMAR ALEXANDER: Thank you, Doctor Cassidy, I think she said she wants to submit some homework to you. It's terrific to have a United States Senator who has a former resident student as a witness.

ANURADHA RAO-PATEL, MD: Yeah, I feel like I'm in his clinic right now, so ...

DOUG MCVAY: That was questioning by Senator Bill Cassidy, MD, during a hearing of the Senate HELP Committee on the subject of “Managing Pain During the Opioid Crisis.” Now, let’s hear questioning by Senator Doug Jones, Democrat from Alabama.

SENATOR DOUG JONES: Senator would be fine.

SENATOR LAMAR ALEXANDER: That's all right. Senator Jones. Well, you have a doctorate from law school.

SENATOR DOUG JONES: That's right. Thank you, Mister Chairman and ranking member, thank you all for being here today.

One brief comment, I appreciate the comments about tele-health and tele-medicine. We are continuing to have our rural hospitals and providers leave our rural area, and I've always thought that tele-medicine and tele-health is one way to try to keep that.

It is only however as good as our rural broadband, and access to the internet, and that is something that we are -- my office is continuing to push for, and I would, any help on that area, to try to get broadband in those areas, would be great.

I do want to follow up, though, with an area, and I, you know, a lot of times when we ask these questions, people think we're going at it with an agenda, and sometimes we are and sometimes we're not. This is not one of those.

But Senator Rosen asked about the research and development using medical marijuana and cannabis, and Doctor Coop, you gave a very good answer, I appreciate that very much. But I'd also like to hear from the other three of you on this issue.

I do think it's an important topic, it is one that, in the public's mind, is growing throughout the country, and so, with each of our physicians as well as Ms. Steinberg there, if you would, we'll just start with you, Ms. Steinberg, if you could comment on the pros and the cons of what you see in the developing of medical marijuana, cannabis, the ability to use as an alternative, but also the research that would be required to go into it.

CINDY STEINBERG: Yes, and actually cannabis has helped a number of people living with pain. I mean, I -- it's another option, as we talk about, in the toolbox. It's helped a significant number of people, but it's not legal in a lot of places, and therefore even where it is legal, as Doctor Coop said, it's not standardized.

Doctors need to be the ones prescribing it, but they're not -- they don't know what they're doing with it. They're not trained with it, either. And so without having a real good research base, you know, we're just flying, you know, blind.

SENATOR DOUG JONES: What prohibits the research base?

CINDY STEINBERG: The fact that it's not legal.

SENATOR DOUG JONES: Okeh. Just wanted to get that in the record, that we're a scheduled -- it's a scheduled substance, so that it limits the amount of research considerably that can go on and deal with the pros and the cons. Yes. Yes. Okeh, thank you. Doctor Gazelka?

PROFESSOR HALENA GAZELKA, MD: I don't think we do know that marijuana is not addictive. I've certainly seen patients who have excessively used marijuana, not medical marijuana perhaps, but pot, and, it is believed to be an addictive substance.

And it is, you know, years, not that many years ago, we heard that opioids weren't addictive, and so I think we have to proceed with caution, as with anything else.

I think the inconsistency among the products that are produced, with the ratio of CBD to THC, et cetera, is an important component of this, that will factor in when it's being researched. But I think the impediment has been that it's a schedule two -- schedule one substance, rather, sorry, and it's not permissibly prescribed by providers.

But I do think that there may be some significant areas where this may be very useful. I have some palliative medicine patients using it for nausea, appetite, et cetera, and I think pain, I think it can be helpful.

SENATOR DOUG JONES: Right. Right, thank you. Yes ma'am.

ANURADHA RAO-PATEL, MD: So, I would agree with that. I think that there is -- I think due to limitations, such as the fact that it is illegal in some states as well as on the federal level, make research difficult.

I think a lot of times, I have seen patients of mine in the past who were taking opioids and, you know, if we did a urine drug screen on them they tested positive for marijuana, and they found that that seemed to help more than being prescribed an opioid or any type of adjunctive medicine to an opioid.

So I do think that there potentially, from a physician's standpoint, I think that there is some potential to the utility of medical marijuana for the management of chronic pain.

I'll say, putting on my other hat as an insurer hat, that we obviously only cover procedures and drugs that are FDA approved, so we would obviously need some clinical evidence and support to be able to cover those kinds of medications.

SENATOR DOUG JONES: Have any of you got any suggestions other than -- other than, short of removing it off of schedule one, which I guess you could do, and put some other weird restrictions, I guess. What we -- can we do, other, is there anything other than that that we can do to open up the ability to research the pros and the cons of medical use of cannabis? Or is that the impediment that we've got to try to figure out how to deal with? Doctor Coop, you?

PROFESSOR ANDREW COOP, PHD: I was going to punt this. I would say that this is a decision that the National Institute on Drug Abuse, with the experts, that could know all the confounding factors. It would be something that I think we should charge those guys with, coming up with what is the best way forward.



SENATOR DOUG JONES: Great. Well, thank you all for your answers, and thanks for being here. Thank you, Mister Chairman.

DOUG MCVAY: That was questioning by Senator Doug Jones, Democrat from Alabama, during a hearing of the Senate Health, Education, Labor, and Pensions Committee – the HELP Committee – on the subject of “Managing Pain During the Opioid Crisis.”

The Senators heard from:
Cindy Steinberg, National Director of Policy and Advocacy for the US Pain Foundation and Policy Council Chair for the Massachusetts Pain Initiative;
Halena Gazelka, MD, Assistant Professor of Anesthesiology and Perioperative Medicine at the Mayo Clinic College of Medicine, Director of the Mayo Clinic Inpatient Pain Service and Chair of the Mayo Clinic Opioid Stewardship Program;
Andrew Coop, PhD, Professor and Associate Dean for Academic Affairs at the University of Maryland School of Pharmacy; and
Anuradha Rao-Patel, MD, Lead Medical Director for Blue Cross and Blue Shield of North Carolina.

There’s no question that there’s a role for cannabis medicine when it comes to pain management.

The question which policymakers are wrestling with is whether marijuana should be available in its natural plant form as an over the counter herbal product, just like so many others on the grocery store and drug store shelves; or solely as a precisely formulated and patented combination of cannabinoids produced by a pharmaceutical corporation and sold only by prescription?

That question requires input from people with experience in cannabis medicine and cannabis research, experience no one on that panel has.

And for now, that's it. I want to thank you for joining us. You have been listening to Century of Lies. We're a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I’m your host Doug McVay, editor of DrugWarFacts.org.

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