151
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Affiliation(s)
- Payel Jhoom Roy
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Michael D Stein
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts
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152
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Legal and policy changes urgently needed to increase access to opioid agonist therapy in the United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 73:42-48. [PMID: 31336293 DOI: 10.1016/j.drugpo.2019.07.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/22/2019] [Accepted: 07/02/2019] [Indexed: 11/22/2022]
Abstract
The United States continues to face a public health crisis of opioid-related harm, the effects of which could be dramatically reduced through increased access to opioid agonist therapy with the medications methadone and buprenorphine. Despite overwhelming evidence of their efficacy, unduly restrictive federal, state, and local regulation significantly impedes access to these life-saving medications. We outline immediate, concrete steps that federal, state, and local governments can take to change law from barrier to facilitator of evidence-based treatment for opioid use disorder. These include removing onerous restrictions on the prescription and dispensing of buprenorphine and methadone for opioid agonist therapy, requiring insurance coverage of these medications, and mandating that they be provided in correctional settings and promoted by drug courts. Finally, we argue that jurisdictions should proactively offer opioid agonist therapy to individuals at high risk of overdose, remove barriers to establishing methadone treatment facilities, and address underlying social determinants and barriers to treatment. These changes have the ability to save thousands of lives annually.
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153
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Lagisetty PA, Bohnert A. Role of an Accurate Treatment Locator and Cash-Only Practices in Access to Buprenorphine for Opioid Use Disorders. Ann Intern Med 2019; 171:58-59. [PMID: 31158851 DOI: 10.7326/m19-1429] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Pooja A Lagisetty
- University of Michigan School of Medicine, Veterans Affairs (VA) Ann Arbor Healthcare System, and Institute of Health Policy and Innovation, Ann Arbor, Michigan (P.A.L.)
| | - Amy Bohnert
- Veterans Affairs Ann Arbor Healthcare System, Institute for Health Policy and Innovation, and University of Michigan School of Medicine, Ann Arbor, Michigan (A.B.)
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154
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Winograd RP, Wood CA, Stringfellow EJ, Presnall N, Duello A, Horn P, Rudder T. Implementation and evaluation of Missouri's Medication First treatment approach for opioid use disorder in publicly-funded substance use treatment programs. J Subst Abuse Treat 2019; 108:55-64. [PMID: 31277891 DOI: 10.1016/j.jsat.2019.06.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 06/07/2019] [Accepted: 06/21/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Leaders of Missouri's State Targeted Response to the opioid crisis (STR) grant have prioritized increasing access to treatment medications for opioid use disorder (MOUD) through a "Medication First" approach. This conceptual framework prioritizes rapid, sustained, low-barrier access to MOUD for optimal impact on decreased illicit drug use and mortality. Medication First principles and practices were facilitated through state-level structural changes and disseminated to participating community treatment programs via a multi-pronged, multi-disciplinary approach. In the first nine months of STR, 14 state-contracted treatment agencies operating 38 sites used STR funding to implement the Medication First model. METHODS We utilized state billing and service data to make comparisons before and during STR on the following outcomes: MOUD utilization, timely access to MOUD, amount of psychosocial services delivered, treatment retention at 1, 3, and 6 months, and monthly price of treatment. We conducted follow-up analyses examining differences across MOUD types (no medication, methadone, buprenorphine, oral naltrexone, mixed antagonist + agonist, and extended release naltrexone). RESULTS During STR, MOUD utilization increased (44.8% to 85.3%), timeliness of MOUD receipt improved (Median of 8 days vs. 0 days), there were fewer psychosocial services delivered, treatment retention improved at one, three, and six month timeframes, and the median cost per month was 21% lower than in the year prior to STR. All differences were driven by increased utilization of buprenorphine. CONCLUSIONS Findings suggest Medication First implementation through STR was successful in all targeted domains. Though much more work is needed to further reduce logistical, financial, and cultural barriers to improved access to maintenance MOUD, the steps taken through Missouri's STR grant show significant promise at making swift and drastic transformations to a system of care in response to a growing public health emergency.
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Affiliation(s)
- Rachel P Winograd
- Missouri Institute of Mental Health, University of Missouri St. Louis, 4633 World Parkway Circle Dr., St. Louis, MO 63134, United States.
| | - Claire A Wood
- Missouri Institute of Mental Health, University of Missouri St. Louis, 4633 World Parkway Circle Dr., St. Louis, MO 63134, United States
| | - Erin J Stringfellow
- Missouri Institute of Mental Health, University of Missouri St. Louis, 4633 World Parkway Circle Dr., St. Louis, MO 63134, United States
| | - Ned Presnall
- Department of Psychiatry, Washington University, 1 Brookings Dr, St. Louis, MO 63130, United States
| | - Alex Duello
- Missouri Institute of Mental Health, University of Missouri St. Louis, 4633 World Parkway Circle Dr., St. Louis, MO 63134, United States
| | - Phil Horn
- Missouri Institute of Mental Health, University of Missouri St. Louis, 4633 World Parkway Circle Dr., St. Louis, MO 63134, United States
| | - Tim Rudder
- Missouri Department of Mental Health, 1706 East Elm St., Jefferson City, MO 65101, United States
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155
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Haffajee RL, Lin LA, Bohnert ASB, Goldstick JE. Characteristics of US Counties With High Opioid Overdose Mortality and Low Capacity to Deliver Medications for Opioid Use Disorder. JAMA Netw Open 2019; 2:e196373. [PMID: 31251376 PMCID: PMC6604101 DOI: 10.1001/jamanetworkopen.2019.6373] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
IMPORTANCE Opioid overdose deaths in the United States continue to increase, reflecting a growing need to treat those with opioid use disorder (OUD). Little is known about counties with high rates of opioid overdose mortality but low availability of OUD treatment. OBJECTIVE To identify characteristics of US counties with persistently high rates of opioid overdose mortality and low capacity to deliver OUD medications. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study of data from 3142 US counties from January 1, 2015, to December 31, 2017, rates of opioid overdose mortality were compared with availability in 2017 of OUD medication providers (24 851 buprenorphine-waivered clinicians [physicians, nurse practitioners, and physician assistants], 1517 opioid treatment programs [providing methadone], and 5222 health care professionals who could prescribe extended-release naltrexone). Statistical analysis was performed from April 20, 2018, to May 8, 2019. EXPOSURES Demographic, workforce, lack of insurance, road density, urbanicity, opioid prescribing, and regional division county-level characteristics. MAIN OUTCOME AND MEASURES The outcome variable, "opioid high-risk county," was a binary indicator of a high (above national) rate of opioid overdose mortality with a low (below national) rate of provider availability to deliver OUD medication. Spatial logistic regression models were used to determine associations with being an opioid high-risk county. RESULTS Of 3142 counties, 751 (23.9%) had high rates of opioid overdose mortality. A total of 1457 counties (46.4%), and 946 of 1328 rural counties (71.2%), lacked a publicly available OUD medication provider in 2017. In adjusted models, compared with the West North Central division, counties in the East North Central, Mountain, and South Atlantic divisions had increased odds of being opioid high-risk counties (East North Central: odds ratio [OR], 2.21; 95% CI, 1.19-4.12; Mountain: OR, 4.15; 95% CI, 1.34-12.89; and South Atlantic: OR, 2.99; 95% CI, 1.26-7.11). A 1% increase in unemployment was associated with increased odds (OR, 1.09; 95% CI, 1.03-1.15) of a county being an opioid high-risk county. Counties with an additional 10 primary care clinicians per 100 000 population had a reduced risk of being opioid high-risk counties (OR, 0.89; 95% CI, 0.85-0.93), as did counties that were micropolitan (vs metropolitan) (OR, 0.67; 95% CI, 0.50-0.90) and those that had an additional 1% of the population younger than 25 years (OR, 0.95; 95% CI, 0.92-0.98). CONCLUSIONS AND RELEVANCE Counties with low availability of OUD medication providers and high rates of opioid overdose mortality were less likely to be micropolitan and have lower primary care clinician density, but were more likely to be in the East North Central, South Atlantic, or Mountain division and have higher rates of unemployment. Strategies to increase medication treatment must account for these factors.
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Affiliation(s)
- Rebecca L. Haffajee
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
| | - Lewei Allison Lin
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Amy S. B. Bohnert
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jason E. Goldstick
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
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156
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Winograd RP, Presnall N, Stringfellow E, Wood C, Horn P, Duello A, Green L, Rudder T. The case for a medication first approach to the treatment of opioid use disorder. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2019; 45:333-340. [DOI: 10.1080/00952990.2019.1605372] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Rachel P. Winograd
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Ned Presnall
- Clayton Behavioral, Washington University, St. Louis, USA
| | - Erin Stringfellow
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Claire Wood
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Phil Horn
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Alex Duello
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Lauren Green
- Missouri Institute of Mental Health, University of Missouri, St. Louis, USA
| | - Tim Rudder
- Missouri Department of Mental Health, Jefferson, Missouri, USA
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157
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Pendergrass SA, Crist RC, Jones LK, Hoch JR, Berrettini WH. The importance of buprenorphine research in the opioid crisis. Mol Psychiatry 2019; 24:626-632. [PMID: 30617273 DOI: 10.1038/s41380-018-0329-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 10/15/2018] [Accepted: 11/14/2018] [Indexed: 12/14/2022]
Abstract
With the urgency to treat patients more effectively for opioid use disorder in the midst of the opioid epidemic, a key area for precision medicine is to improve individualized medication-assisted treatment for opioid use disorder. The expansion of medication-assisted treatment is a key to reducing illicit opioid use, preventing opioid overdose deaths, and reducing the comorbidities and societal impacts of opioid use disorder. The most common medication for opioid use disorder will soon be buprenorphine. Research to date shows the successful impact of buprenorphine treatment, including the pharmacogenomics of buprenorphine response and treatment efficacy. Buprenorphine is also a promising treatment for depression and anxiety, and neonatal opioid withdrawal syndrome (NOWS). However, the rates of success with medication-assisted treatment for opioid use disorder, particularly at the beginning of treatment, still show many individuals relapsing to illicit opioid use. With the scope of the opioid crisis, there is an urgent need for expansion of buprenorphine treatment research to provide critical information for improving outcomes of opioid use disorder. Implementing the best strategies for opioid use disorder treatment is of dire urgency and will save lives.
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Affiliation(s)
- Sarah A Pendergrass
- Biomedical and Translational Informatics Department, Geisinger, Danville, PA, USA.
| | - Richard C Crist
- Center for Neurobiology and Behavior, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Laney K Jones
- Center for Pharmacy Innovation and Outcomes, Precision Health Center, Geisinger, Forty Fort, PA, USA
| | - Jason R Hoch
- Department of Psychiatry and Addiction Medicine, Neurosciences Institute, Geisinger, Danville, PA, USA
| | - Wade H Berrettini
- Center for Neurobiology and Behavior, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Geisinger, Danville, PA, USA
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158
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Fiscella K, Wakeman SE, Beletsky L. Buprenorphine Deregulation and Mainstreaming Treatment for Opioid Use Disorder: X the X Waiver. JAMA Psychiatry 2019; 76:229-230. [PMID: 30586140 DOI: 10.1001/jamapsychiatry.2018.3685] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kevin Fiscella
- Departments of Family Medicine and Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - Sarah E Wakeman
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Leo Beletsky
- School of Law and Bouvé College of Health Sciences, Northeastern University, Boston, Massachusetts.,University of California San Diego School of Medicine, La Jolla
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159
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Lowenstein M, Kilaru A, Perrone J, Hemmons J, Abdel-Rahman D, Meisel ZF, Delgado MK. Barriers and facilitators for emergency department initiation of buprenorphine: A physician survey. Am J Emerg Med 2019; 37:1787-1790. [PMID: 30803850 DOI: 10.1016/j.ajem.2019.02.025] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 02/16/2019] [Accepted: 02/18/2019] [Indexed: 10/27/2022] Open
Affiliation(s)
- Margaret Lowenstein
- National Clinician Scholars Program, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America; Department of Medicine, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, United States of America; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Austin Kilaru
- National Clinician Scholars Program, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America; Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America; Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jeanmarie Perrone
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America; Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America; Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Jessica Hemmons
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Dina Abdel-Rahman
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Zachary F Meisel
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America; Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America; Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - M Kit Delgado
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States of America; Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America; Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
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160
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Haffajee RL, French CA. Provider perceptions of system-level opioid prescribing and addiction treatment policies. Curr Opin Psychol 2019; 30:65-73. [PMID: 30856591 DOI: 10.1016/j.copsyc.2019.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 01/14/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Abstract
Stakeholders have implemented a multitude of system-level policies to address the U.S. opioid overdose epidemic. Because opioid prescribing partly fueled the crisis and because prescribing of medications for opioid addiction treatment is a key prevention strategy, it is critical to understand prescriber perceptions of policies in these domains. This article reviews prescriber awareness and opinions of the following system-level policies: opioid prescribing guidelines, prescription drug monitoring programs (PDMPs), medications for addiction treatment, and naloxone distribution programs. Most providers are aware of these policies, especially PDMPs, albeit a smaller proportion actively participate in their implementation. Low engagement in certain system-level policies is concerning and deserves attention, given that prescribers play an integral role in achieving optimal impact and mitigating the crisis.
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Affiliation(s)
- Rebecca L Haffajee
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, United States.
| | - Cecelia A French
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, United States
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161
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Pizer SD, Frakt AB, Sheetz K, Clancy C. Testing Novel Payment and Delivery Approaches Through the Veterans Health Administration's New Center for Innovation. Ann Intern Med 2019; 170:112-113. [PMID: 30583295 DOI: 10.7326/m18-2225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Steven D Pizer
- Boston University School of Public Health, Boston, Massachusetts (S.D.P.)
| | - Austin B Frakt
- VA Boston Healthcare System, Boston University School of Public Health, and Harvard T.H. Chan School of Public Health, Boston, Massachusetts (A.B.F.)
| | - Kyle Sheetz
- University of Michigan, Ann Arbor, Michigan (K.S.)
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162
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Larney S, Hall W. A major expansion of opioid agonist treatment is needed to reduce overdose deaths in the USA. LANCET PUBLIC HEALTH 2019; 4:e77-e78. [PMID: 30655230 DOI: 10.1016/s2468-2667(19)30001-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 12/19/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Sarah Larney
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Wayne Hall
- Centre for Youth Substance Abuse Research, University of Queensland, Brisbane, QLD 4072, Australia; National Addiction Centre, Kings College London, London, UK.
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163
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The Future of the Behavioral Health Workforce: Optimism and Opportunity. Am J Prev Med 2018; 54:S187-S189. [PMID: 29779540 DOI: 10.1016/j.amepre.2018.03.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2018] [Revised: 02/13/2018] [Accepted: 03/06/2018] [Indexed: 11/24/2022]
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