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Strang J, Groshkova T, Uchtenhagen A, van den Brink W, Haasen C, Schechter MT, Lintzeris N, Bell J, Pirona A, Oviedo-Joekes E, Simon R, Metrebian N. Heroin on trial: systematic review and meta-analysis of randomised trials of diamorphine-prescribing as treatment for refractory heroin addiction†. Br J Psychiatry 2015; 207:5-14. [PMID: 26135571 DOI: 10.1192/bjp.bp.114.149195] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Supervised injectable heroin (SIH) treatment has emerged over the past 15 years as an intensive treatment for entrenched heroin users who have not responded to standard treatments such as oral methadone maintenance treatment (MMT) or residential rehabilitation. AIMS To synthesise published findings for treatment with SIH for refractory heroin-dependence through systematic review and meta-analysis, and to examine the political and scientific response to these findings. METHOD Randomised controlled trials (RCTs) of SIH treatment were identified through database searching, and random effects pooled efficacy was estimated for SIH treatment. Methodological quality was assessed according to criteria set out by the Cochrane Collaboration. RESULTS Six RCTs met the inclusion criteria for analysis. Across the trials, SIH treatment improved treatment outcome, i.e. greater reduction in the use of illicit 'street' heroin in patients receiving SIH treatment compared with control groups (most often receiving MMT). CONCLUSIONS SIH is found to be an effective way of treating heroin dependence refractory to standard treatment. SIH may be less safe than MMT and therefore requires more clinical attention to manage greater safety issues. This intensive intervention is for a patient population previously considered unresponsive to treatment. Inclusion of this low-volume, high-intensity treatment can now improve the impact of comprehensive healthcare provision.
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Affiliation(s)
- John Strang
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
| | - Teodora Groshkova
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
| | - Ambros Uchtenhagen
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
| | - Wim van den Brink
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
| | - Christian Haasen
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
| | - Martin T Schechter
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
| | - Nick Lintzeris
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
| | - James Bell
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
| | - Alessandro Pirona
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
| | - Eugenia Oviedo-Joekes
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
| | - Roland Simon
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
| | - Nicola Metrebian
- John Strang, MD, MBBS, FRCPsych, FRCP, Professor of the Addictions, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and South London and Maudsley NHS Foundation Trust, London, UK; Teodora Groshkova, PhD, Researcher, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK, and European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Ambros Uchtenhagen, MD, PhD, Emeritus Professor of Social Psychiatry, The University of Zürich, Switzerland; Wim van den Brink, MD, PhD, Professor of Psychiatry and Addiction, Amsterdam Institute for Addiction Research, The Netherlands; Christian Haasen, MD, PhD, Director, Centre for Interdisciplinary Addition Research, Department of Psychiatry, Hamburg, Germany; Martin T. Schechter, OBC, MD, PhD, FRSC, FCAHS, Professor and Director, School of Population and Public Health, The University of British Columbia, Canada; Nick Lintzeris, MBBS, PhD, FAChAM, Associate Professor, Faculty of Medicine, The University of Sydney, and Director, Drug and Alcohol Services, SESLHD, New South Wales, Australia; James Bell, MD, FRACP, FAChAM, South London and Maudsley NHS Foundation Trust, London, UK; Alessandro Pirona, MSc, PhD, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Eugenia Oviedo-Joekes, PhD, Associate Professor, School of Population and Public Health, University of British Columbia, Canada; Roland Simon, Head of Unit, Interventions, Best Practice and Scientific Partners, European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Lisbon, Portugal; Nicola Metrebian, PhD, Senior Research Fellow, National Addictions Centre, King's College London, Institute of Psychiatry, London, UK
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