“We want to be sure we have a balanced approach for folks who are having severe pain, but we also want to make sure we have treatment available for those who have actually developed an addiction.”
--Sarah Wakeman, MD, Substance Use Disorders Initiative medical director
Mass General/MGPO Opioid Task Force
Community health is one of the four pillars of Massachusetts General Hospital’s mission. Addressing the opioid epidemic in meaningful and effective ways is one of the hospital’s top clinical priorities. More than 2 million people nationwide suffer from substance use disorders related to prescription opioids. In 2015, more than four people died every day from overdosing on opioids in Massachusetts, which is one of the top-10 states for opioid prescriptions in the nation.
The increased prescription of opioids is one contributing factor to the opioid crisis, making it a critical area where the medical community can come together to find solutions. For this reason, Massachusetts General Hospital (MGH) and the Massachusetts General Physicians Organization (MGPO) launched the Mass General/MGPO Opioid Task Force in November 2015. Comprising doctors, nurses, researchers and other health care experts, the Mass General/MGPO Opioid Task Force is developing strategies to educate patients, clinicians and staff at Mass General and beyond.
New Mass General Guidelines for Safe and Responsible Opioid Prescription
In spring 2016, the Mass General/MGPO Opioid Task Force developed best practices for clinicians prescribing opioids for patients with acute or chronic pain. These guidelines are intended to assist clinicians in prescribing opioids safely when necessary, while improving patients’ treatment and care.
The task force has overseen the hospital-wide distribution and implementation of the guidelines and is developing training for all clinicians prescribing opioids. The guidelines help clinicians communicate openly with patients about the risks and concerns of opioids, while helping patients manage their pain effectively and responsibly. The guidelines ensure that clinicians’ prescription practices are in compliance with Massachusetts’ recent legislation to regulate opioids, the “Act Relative to Substance Use, Treatment, Education and Prevention.”
Mass General recognized as a leader in community health
Mass General was awarded the 2015 Foster G. McGaw Prize for Excellence in Community Service, in recognition of our strong commitment to improving community health and welfare. Mass General’s broad initiative to address the opioid crisis was recognized as an essential part of its ongoing mission to serve the community.
In addition to the guidelines, the Task Force is doing the following:
• Developing education and communication plans for patients and the hospital’s staff and clinicians
• Selecting clinical champions from each department to share and implement the strategies
• Working on effective interventions that will benefit patients, such as the wider availability of intranasal naloxone (Narcan)
• Collaborating with the Substance Use Disorder Initiative and the Pain Management Center
• Supporting take-back programs for unused and expired prescription medication
Substance Use Disorders (SUDs) Initiative
In 2013, Mass General created the Substance Use Disorders (SUDs) Initiative to dramatically improve the care of patients experiencing substance use disorders. The SUDs initiative brings together vital resources for hospitalized patients with substance use disorders, including better access to addiction treatment, smoother transitions between levels of patient care and post-care plans to reduce readmissions and relapses.
Mass General also has a special commitment to treatment and prevention in the communities of Chelsea, Revere and Charlestown through its Chelsea HealthCare Center, Revere CARES Coalition and Charlestown Substance Abuse Coalition.
Frequently Asked Questions
Sarah Wakeman, MD, and Eric Weil, MD, Co-Chairs of the Mass General/MGPO Opioid Task Force, answer important questions about the Task Force and Mass General’s related efforts to address the opioid crisis.
- Why has Mass General made opioid use disorders the highest clinical priority of its hospital-wide strategic plan?
Sarah Wakeman, MD: The mission statement of the hospital changed in 2007 to make community an explicit part of our mission, which is a big statement for a big hospital and academic medical center like Mass General. In its most recent strategic planning process, the hospital looked to the committees representing the four parts of the mission–-community, education, clinical care and research–-to help inform how it would focus its efforts going forward. For the first time in this last process, community was a part of that.
Every three years we do a community health needs assessment. The community committees looked to the communities to determine their biggest priority, and all three of our main communities — Charlestown, Chelsea and Revere -- identified substance use disorder or addiction as the main issue that mattered to them by a resounding majority. So whether that was because of public safety, concerns for health or concerns about loved ones, community members felt that was the single greatest issue.
That led the community subcommittee, as well as the population management clinical committee, to identify addiction or substance use disorder as the main clinical priority. The hospital embraced that as a part of the work moving forward with the strategic plan. It was really a response to what mattered to our community members as well as recognizing the health toll that addiction was taking on our populations as we provide medical care.
Eric Weil, MD: It’s important to realize that the hospital and the physicians in it don’t operate in a vacuum from the world outside. We recognized very much that there was and is an epidemic of substance use disorder. As an organization we felt it was both our responsibility and our obligation to help be a part of addressing that challenge.
- How did the Mass General/MGPO Opioid Task Force come about, and what are its main purpose and primary initiatives?
Dr. Weil: Since 2012, at least within primary care, there has been a lot of effort and attention around engagement with physicians and other members of our care teams on the safe and appropriate prescribing of opioid pain medications. We started in primary care because that’s where more of our patients interface with the health care system than almost anywhere else. Primary care also represented one of the larger prescribers of opioid pain medications. However, after focusing on primary care, we also acknowledged that it was quite important to focus on the entire healthcare system: the ambulatory arena, the inpatient arena and all of the providers in all of those places that are involved in prescribing and monitoring pain medications.
The Task Force began in the fall of 2015 in the setting of everything that [Dr. Wakeman] just spoke about in recognition of some mandates from the state and the realization that we really have a responsibility to be responsible stewards of health care, pain management and substance use disorders. The president of the hospital and the president of the physicians organization reached out to [us] and asked us to put together a consortium of clinicians from across the Mass General health care system to help think through the way to create a streamlined approach to the prescribing, management and education involving opioid pain medications. The task force includes physicians, nurses, pharmacists and social workers, really all of the internal stakeholders that are involved in prescribing.
Dr. Wakeman: It’s really being part of the solution. A lot of the narrative around the opioid crisis is that doctors have been a part of the problem and that changes in prescribing practices have been at least one component that’s helped drive the current crisis. From the very highest leadership at Mass General, it was clear that we wanted to be a part of the solution, to address the needs of our community and minimize any unnecessary exposure to these medications, which can be quite harmful. Yet we also want to ensure that we are compassionately caring for patients who have severe pain and need effective pain management. This is a very nuanced issue, and we wanted to approach it in a thoughtful and comprehensive way.
Dr. Weil: I totally agree, especially with that last point. The biggest concern that people have expressed over and over again is: is it possible, if you are beginning to be more proactive and thoughtful about the way in which you prescribe opioid pain medications, does that mean that you’re going to have more patients in pain? Part of the purpose of the Task Force really is to make sure we serve as a balancing force to make sure the pendulum doesn’t go all the way in the other direction and to avoid a situation in which we’re not thoughtfully and compassionately treating our patients.
Dr. Wakeman: I also think the Task Force working alongside the hospital’s other efforts around substance use disorders is essential. The other challenge with focusing purely on access to prescription medications is that you must simultaneously address addiction when it’s already developed: people aren’t going to get well just because it’s harder to find pain medication. We want to be sure we have a balanced approach for folks who are having severe pain, but we also want to make sure we have treatment available for those who have actually developed an addiction.
- Describe the importance of the best practice guidelines you helped develop for clinicians prescribing opioids and how they will make a difference for patients.
Dr. Wakeman: Partly, we want to support our prescribers. These are tough issues to navigate. There are a lot of external checks and balances and requirements through the new legislation that prescribers have to be sure they’re meeting. Having a balanced approach, as Eric mentioned, can be tough. We wanted to develop a framework and a toolbox so that our prescribers know the parameters within which to operate and understand the new requirements. We also want to help them develop a strategy for addressing what can be really difficult clinical situations and to ensure that all patients are getting the same type of excellent care regardless of the clinical context in which they’re encountering a provider.
Dr. Weil: I would say that part of the importance of developing our own best practice guidelines is that our clinicians now have a real sense of ownership regarding their content. There are lots of guidelines and checklists that have been created by many very reputable organizations, and those are important. But to be able to say that your colleagues created this internally within your organization increases the chances that it’s going to be embraced.
Dr. Wakeman: I think this will make a difference for patients in that they can be assured that all providers are going to be functioning within the same guidelines. There shouldn’t be a different experience if a patient goes to one provider versus another provider. Patient safety and experience is at the forefront of our intentions with these guidelines, to keep both our patients and communities safe and to ensure that we’re addressing their pain in a meaningful and comprehensive fashion.
- Describe the Task Force’s partnership with the Substance Use Disorder Initiative (SUDs). What is the role of the clinical champions in Mass General’s efforts to implement the new guidelines?
Dr. Wakeman: I think the partnership with the Substance Use Disorders (SUDs) Initiative has been crucial. I’m medical director of the SUDs Initiative, and I also practice as a primary care physician at one of our health centers. Working in partnership with Dr. Weil, part of my role on the Task Force has been ensuring that its work is very tightly linked to the work of the SUDs Initiative. With both of those efforts, the goal is excellent patient care, be it patients suffering from substance use disorder or those suffering from pain.
Dr. Weil: In a big organization it’s easy for really good, well-meaning people to work in silos, and so having people like Dr. Wakeman, who can cross between related programs, means that those programs won’t move in different directions. It really makes them both more effective.
Our hope for the clinical champions is that they have the capacity to implement the work through the lens of whatever their specialty is. What a urologist is going to need to do around the guidelines is probably quite different from what a dermatologist or a primary care physician is going to need to do. The general concepts are the same, but how you actually make it happen, and how you communicate with your own organization, is different. Our hope is that those clinical champions can take the work, understand it in the context of their own profession and then translate it appropriately.
- When should opioids be prescribed?
Dr. Wakeman: That’s a challenging question, but we would say in general opioids should be prescribed for severe pain that isn’t relieved by other interventions, such as other medications that perhaps have less risk than opioids, like anti-inflammatory medications. Some pain can be better managed with things like an injection to treat inflammation, or even acupuncture or physical therapy. I think opioids are a very effective medication. They can be life-saving and certainly improve quality of life for some patients, but they also carry risks. Prescribers have to be thoughtful about using them only in circumstances where the benefits outweigh the risks.
- Given the stigma surrounding opioid misuse, how do clinicians help patients openly communicate their substance use disorders?
Dr. Wakeman: A main goal of the Substance Use Disorder Initiative is really addressing the stigma surrounding addiction or substance use disorder. Part of that is beginning to help people see addiction as truly a chronic medical disease that isn’t any different from diabetes, hypertension, obesity or other mental illnesses like depression. Addiction is something that’s not the patient’s fault: it’s caused by a mix of genetics and environment or exposure. There’s treatment that’s effective, and most people will recover. We’ve done a lot of work around educating our medical staff, our patients and our communities about coming to see addiction this way, because we know that fear of stigma is one of the main reasons people don’t seek out treatment. Only one in 10 people with addiction get treatment in any given year.
I think talking about it openly helps reduce stigma: having everyone from the president of our hospital to the president of our physician’s organization on down talking about this as a chronic medical disease that’s treatable sends a strong message about culture change. We must then make sure that treatment is available. Part of the stigma that gets perpetuated is because of a lack of treatment, resulting in a feeling of helplessness both for patients and their loved ones and for clinicians, who want to take care of patients, but maybe feel like they don’t have the resources to offer. Clinicians really trying to step up and offer effective treatment at any encounter with a patient makes a big difference.
Dr. Weil: To be clear, however, we have a long way to go. I think that a lot of our clinical colleagues still have very significant conscious or unconscious preconceived notions about substance use disorders, pain medications and how patients approach receiving those medications. So part of the strategy of the Task Force is to make sure we’re really educating people on the approach to stigma and to thinking about patients with an illness as opposed to patients with a problem that they’ve chosen.
Dr. Wakeman: I think the other thing that having universal guidelines helps with is that if you standardize something, it’s no longer necessary to single a patient out. A patient isn’t going to get a toxicology screening because a clinician is suspicious of the individual, but instead it’s a standard part of clinical care for every patient as a safety check. That’s how we’ll make these guidelines universal.
Dr. Weil: It’s really great to be able to say to a patient, “This isn’t about you. This is what we do for everybody. Yes, I know that you’ve been on this medication for 10 years, and you live in a reputable community. There’s really no reason for us to believe anything about you any more or less than anybody else.” This is the approach we take for all of our patients in a very egalitarian, fair fashion.
- How will the wider availability of intranasal naloxone (Narcan) benefit patients?
Dr. Wakeman: I think that naloxone is life saving. No one should die from an opioid overdose when we have an effective antidote. We know that anyone can be at risk of an opioid overdose, not just someone with addiction or someone who is misusing a prescription, but even someone taking a prescription as prescribed.
Just like we don’t prescribe insulin to a patient with diabetes without talking to them about having something around in case their blood sugar goes too low, we shouldn’t be prescribing medications that as a side effect can cause an overdose unless we ensure that people have access to a medication that can reverse that. It is already saving lives, and we need to get it out into the community. Four or five people die every day across the state from an overdose. Anyone can save a life. Having this medication that can reverse an overdose in your medicine cabinet, in your purse or in your car can save a life anywhere.
Dr. Weil: Some might ask, “Isn’t that giving people who use heroin or opioids recreationally in some fashion the freedom to use more because they know they can reverse their overdoses?” That’s really not what we’ve seen, and it’s not what the evidence shows. It’s a tool with which we can save lives. As health care providers, our responsibility is to make tools available that can save people’s lives. There’s no reason for us not to do that.
Dr. Wakeman: The research shows that it doesn’t increase people’s use and if anything engaging with them around safety makes people more likely to get into treatment. We would never not recommend wearing a seatbelt because we think people would drive in a riskier fashion. We should be encouraging other ways to keep our patients safe.
- How has addiction treatment been incorporated into Mass General’s community health centers and other primary care practices?
Dr. Wakeman: A key part of our initiative has been integrating addiction treatment into the outpatient setting. As I mentioned this is a chronic treatable medical condition, just like diabetes or heart disease, and so patients should be receiving care for it at the same place they receive care for all their other chronic medical conditions. So what that’s looked like is increasing access to all of the life-saving and evidence-based types of treatment for addiction. That includes medications, which are proven to be incredibly effective in helping people sustain recovery. It includes making sure there’s counseling available. It’s also included hiring recovery coaches, which has really been a game changer. They function like community health workers in that they can go wherever the person is, and they can address any barriers that exist to recovery.
We want to bring together teams of champions in the health centers so that patients are getting the best care possible, with lots of minds thinking about their cases. This can be a very severe, very debilitating disease, and watching patients suffer with it without having support as a caretaker can be really challenging. One of the main reasons historically providers haven’t wanted to take care of patients with addictions is the feeling that they don’t have the support or tools to do that. Bringing together these multidisciplinary teams has enabled clinicians to provide this care in a way that’s effective for patients.
- How else is Mass General connecting with and nurturing patients on the road to recovery from opioid misuse?
Dr. Wakeman: We need to build a system that provides that support, the same as we would for any other illness. We’ve started hiring some of our former patients who now work as recovery coaches with the initiative. We must ensure that patients are getting the best treatment possible when they need it most, whether that’s in the emergency room, in our hospital or in our health centers. We must support them through recovery, recognizing that this is a chronic disease that needs long-term management, so that the care doesn’t stop after a week, after 30 days or after a year. This is something they need support with for the rest of their life.
Dr. Weil: I do think it’s worth emphasizing that as we’ve developed guidelines and our initiatives, we’ve never done it without engaging with the patients to some degree. We brought our guidelines to the patient and family advisory council, for example. When we’ve talked about safe disposal of opioid medications, we’ve thought about making sure that we have the appropriate patient information. We’ve put out tables in the main hospital hallway to make sure that we’re educating both staff and patients. A big piece of our strategy is making sure that the communities and patients we serve are engaged in that conversation, too.
Co-Chair, Mass General/MGPO Opioid Task Force
Substance Use Disorders Initiative medical director
Massachusetts General Hospital
Co-Chair, Mass General/MGPO Opioid Task Force
MGPO Associate Medical Director for Primary Care
Massachusetts General Hospital
Massachusetts General Hospital is committed to helping patients manage their pain compassionately and responsibly while enabling its clinicians and staff to be a part of the solution to the opioid crisis. Read news coverage of Mass General’s ongoing efforts to make a difference in the lives of affected patient.
Mass General’s Response to the Opioid Epidemic
In October 2014, Mass General established the Substance Use Disorders (SUDs) Initiative as a part of a new approach to treat substance use disorders. Opioid use disorders are the highest clinical priority of Mass General’s strategic plan. (June 2015)
Dangers of Fentanyl Discussed at Mass General with Senator Markey
On June 3, 2016, Senator Ed Markey spearheaded a roundtable discussion about the opioid crisis with leaders from government, first responders, Mass General president Peter L. Slavin, MD, and Sarah Wakeman, MD, medical director for Substance Use Disorders. (June 2016)
Mass General Honored for Excellence in Community Health
In recognition of its strong commitment to addressing health concerns within the community, such as the opioid crisis, Mass General has received the Foster G. McGaw Prize, one of the most prestigious honors in community health. (February 2016)
Mass General Initiative Aims for Addiction Treatment and Prevention
Mass General is committed to substance use disorder treatment and prevention, as reflected in the hospital’s ongoing support of one Chelsea patient’s recovery. (September 2014)
Mass General MGPO Opioid Task Force Tackles Epidemic
The Mass General/MGPO Opioid Task Force is committed to exploring ways in which Mass General can effectively respond to Massachusetts’ opioid crisis while at the same time improving the care of patients. (April 2016)
Mass General Awarded 2015 Foster G. McGaw Prize
Watch a video highlighting Mass General’s community health initiatives, which were recently recognized by the prestigious Foster C. McGaw prize. (May 2016)
Hospital’s New Opioid Policy Addresses Gap Highlighted by Ex-addict’s Harrowing Odyssey
Read how Mass General has made addressing opioid misuse a top clinical priority, and how it is helping patients like Seth Mnookin, who is recovering from a substance use disorder and managed painful kidney stones. (STAT, June 2016)
Mass General Rolls Out New Opioid Prescription Guidelines for Doctors
Watch a Fox 25 interview with Sarah Wakeman, MD, medical director for Substance Use Disorders, about Mass General’s new guidelines for clinicians addressing the opioid crisis. (Fox 25, July 2016)
Massachusetts General Hospital is committed to providing compassionate, evidence-based, responsible care to our patients experiencing pain. At the same time, we are dedicated to empowering our patients to have conversations with providers about their options for managing their pain.
What is an opioid?
An opioid is a prescription pain medicine used for severe pain not helped by other types of medications. When used carefully and with a health care provider's direct supervision, these medicines may help reduce pain.
Receptors in the body react to the opioids, determining the effect on the mind and body. Opioids can produce a feeling of euphoria, which in some cases can lead to recreational use and can ultimately result in addiction. Misuse of opioids can lead to overdose and can be fatal.
Mass General is committed to developing solutions to the opioid crises. The MGPO Opioid Task Force is a vital part of these efforts. We are helping to verify that clinicians prescribe medications safely by ensuring that they check the Massachusetts Prescription Monitoring Program (PMP) for each prescription as required by law.
Which medications are opioids?
Also known as narcotics, prescription medications such as Oxycodone and Hydrocodone are opioids. Heroine is an illegal opioid.
The following are common opioids:
• Codeine (only available in generic form)
• Fentanyl (Actiq ®, Fentora ®, Abstral®, Duragesic®, Onsolis®)
• Hydrocodone (Hysingla®, Zohydro ER ®)
• Hydrocodone/acetaminophen (Lorcet, Lortab ®, Norco ®, Vicodin, Zydone®)
• Hydromorphone (Dilaudid®, Exalgo®)
• Meperidine (Demerol®)
• Methadone (Dolophine®, Methadose®, Diskets®)
• Morphine (Astramorph™, Avinza®, Kadian®, MS Contin®, Oramorph® SR)
• Oxycodone (OxyContin®, Oxecta®, Roxicodone®, Xtampza® ER)
• Oxycodone and acetaminophen (Percocet®, Endocet®, Roxicet®)
• Oxycodone and naloxone (Targiniq ® ER)
Heroin is an illegal opioid that, because it is between two and four times stronger than morphine and takes quick effect, is highly addictive. The euphoria, or strong feeling of well-being and confidence, is short lived. The user is susceptible to overdose because the potency of the purchased heroin, frequently diluted with other dangerous substances, is not known. Withdrawal is very painful, and the impact on the human body is devastating.
What you can do about the opioid crisis
• Discuss pain management with your provider openly. Find out if there are alternatives to pain medication for treating your pain
• Follow your doctor’s instructions for taking opioids exactly. Never change the dose or the reason for taking the opioids unless you discuss it with your doctor
• Don’t sell, share or trade opioids
• Store your medication in a secure place known only to you, and dispose of your medication safely
• Only get your medications from one health care provider
Mass General/MGPO Opioid Task Force
If you are experiencing a medical emergency, dial 911.
At Mass General, our priority is helping patients manage their pain while empowering them to have meaningful conversations with their providers about treatment options. We are committed to supporting patients with opioid substance use disorders.
To address the opioid epidemic, the Mass General/MGPO Opioid Task Force has:
• Created guidelines with best practices for clinicians prescribing opioids for patients with acute or chronic pain
• Developed hospital-wide communication and education strategies for patients, hospital staff and providers
• Improved patient interventions, such as wider availability of intranasal naloxone (Narcan) to patients
• Collaborated with the Substance Use Disorders initiative and the Center for Pain Medicine
• Organized unused and expired prescription medication take-back programs
Substance Use Disorders Initiative
The Substance Use Disorders initiative comprises a team of clinicians and experts from across the hospital that provides addiction consult. Addiction treatment is offered in our community health centers. The staff at our health centers includes seven recovery coaches who have themselves known the challenges of addiction.
To assist our patients with substance use disorders, an addictions advanced practice nurse and social workers are ready to help in Mass General’s emergency department. In a pilot program, we are offering a special clinic for patients with substance use disorders needing treatment as they transition out of the emergency department or the hospital. The clinic provides short-term care and ultimately connects patients with resources and community services to ensure their continued path to recovery.
Grief Recovery After a Substance Passing (GRASP) is a compassionate recovery support group for those who have lost a loved one to substance abuse. The organization offers information, meetings and events for families and individuals with sharing and caring as a vital part of grief recovery.
As an important part of our mission at Massachusetts General Hospital, we help health care providers offer their patients safe, responsible and compassionate pain management while innovating new techniques and treatments for substance use disorders.
New Mass General Guidelines for Responsible and Safe Opioid Prescriptions
The Mass General/Massachusetts General Physicians Organization (MGPO) Opioid Task Force recently released new guidelines offering best practices for pain treatment and management in a variety of health care settings.
The guidelines include approaches for acute, chronic and pediatric pain and help ensure that clinicians prescribe opioids in compliance with Massachusetts’ recent legislation to regulate opioids, the “Act Relative to Substance Use, Treatment, Education and Prevention.”
The guidelines include the following recommendations:
• Opioids should only be prescribed when severe pain is not treatable by other methods
• When treating acute pain, prescribe only the amount of medication needed
• Utilize an approved screening tool to determine risk factors for patients who may be susceptible to problems with opioids
• Check the Massachusetts Prescription Monitoring Program (PMP) for each prescription
• Counsel patients to understand the possible risks of opioid treatment
• Communicate that opioids assist in pain management, but may not resolve pain
• Regularly observe and re-evaluate patients with chronic pain receiving long-term opioids
• Prescribe nasal naloxone for patients who may be in danger of overdosing
Across Mass General, clinical champions in each department have been selected for the hospital-wide implementation of the guidelines.
For Policy Makers
A Call to Community Service
Our community-based partners are vital to Massachusetts General Hospital’s efforts to address the opioid crisis. As a part of this important work, we have created a team of nurses, physicians, experts and other health care professionals representing disciplines across the hospital who are available to consult with providers treating patients with substance use disorders.
We have forged connections with providers in affected communities, hired recovery coaches who themselves are in some stage of recovery, and made new services for addiction prevention and treatment available in our health centers in Chelsea, Revere and Charlestown. In recognition of our efforts, Mass General was awarded the prestigious 2015 Foster G. McGaw Prize for Excellence in Community Service.
The Mass General/Massachusetts General Physicians Organization (MGPO) Opioid Task Force has developed best practice guidelines for the compassionate and responsible management of patient pain in a variety of health care settings. The guidelines offer recommendations for prescribing opioids for both chronic and acute pain.
Support our work in this important area by making a gift, or find out how you can collaborate by contacting us.
If you are experiencing a medical emergency, dial 911.
Jenna Berube, MPA
Senior Project Specialist
Strategic Communications and Physician Incentive Programs
MGPO (Massachusetts General Physicians Organization)
125 Nashua Street, 7th Floor
Boston, MA 02114
Center for Community Health Improvement
101 Merrimac Street, Suite 603
Boston, MA 02114
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