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Addictions

Alberta and opioids II: Marshall Smith’s ambitious campaign

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Marshall Smith. Photo: PW

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Alberta’s system builder

The Alberta model, made in BC

“I, as you know, have been everywhere in this field, from eating out of garbage cans to this office,” Marshall Smith said. “So I have a deep respect for everybody who works along that continuum.”

We were sitting in the office at the Alberta Legislature reserved for chiefs of staff to Alberta premiers. That’s Smith’s current job. Premier Danielle Smith was probably nearby, though I didn’t see her on this trip. On a shelf behind Marshall Smith were two coffee mugs of different design, each bearing the inscription WAKE UP. SAVE LIVES. REPEAT.

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Anyway, Marshall Smith (all future uses of “Smith” in this post will refer to him, unless I specify the premier) was talking about the continuum from dumpsters to the centre of power. “Where you work on that continuum obviously colours the way that you enter this conversation,” he said. “When you are standing on a sidewalk with a person in front of you, the solutions to that person’s problem look very different than what you might do to plan a broader system of care, for a large population of people.”

This was his way of anticipating criticisms he faces as a leading strategist behind Alberta’s emerging strategy for handling a deadly progression in opioid doses. Since he entered Alberta’s government as a more junior staffer in the government of former premier Jason Kenney in 2019, Smith has been working to put a much greater emphasis on recovery from addiction than on “harm reduction,” whose valuable goal is to keep drug users alive whether they recover or not. This makes him a bête noire among harm-reduction advocates. (You can read a mild critique of his efforts here; or a real scorcher here).

What Smith was saying was, in effect, If you work on the street, you’re going to be all about harm reduction, and I respect that. But he is working on drug policy for a whole province, and perhaps beyond, so he needs a broader perspective. “I’m a system builder. So I don’t have the luxury of just focusing on one particular substance. I have to worry about the whole population. I have to worry about the disease burden of addiction and drug use more broadly.”

He sees much to worry about. “Over the last 30 years in Canada, successive governments have failed miserably to anticipate and adequately address the type of services — both from a capital investment and an operating investment — to help people do this.” By “this,” he means escaping addiction. “We have not cared about people with mental health and addiction issues. And we had the ability to not care because up until the last six or seven years, the evidence of them was hidden away.”

Smith first started thinking about this when he was in British Columbia, where he began his recovery from a history of drug use. In 2018, at the BC Centre for Substance Use, Smith co-wrote a report with Dr. Evan Wood that called for a large new investment in facilities and programs to help people recover from addiction. The report is no longer on the BCCSU website, but you can download a copy here.

“It was a 39-point strategy to transform the system in British Columbia,” Smith recalled. “The government of British Columbia wasn’t interested in that strategy. They wanted to go a particular direction.

“So that report is now known as the Alberta model.”


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Marshall Smith in the dining hall of the Lakeview Recovery Community, opening in July. Photo: PW

In its first page, the Wood/Smith report said “British Columbia has long suffered because of the lack of an effective system to support individuals in and pursuing recovery from substance use disorders.” The system’s “overwhelming focus” was on keeping people alive rather than helping them get better. Wood and Smith wanted that to change.

The need for major new investments in addiction recovery was essentially uncontroversial in B.C. Indeed governments there still periodically announce they are making such investments. But Smith was perpetually unsatisfied with the scale of that commitment.

A year after BC’s new NDP government could-shouldered his report, Smith began working in the UCP government of Alberta’s then-new premier, Jason Kenney.

“Obviously we started off very modestly,” Smith said. “I worked in an office down in the basement. Mental health and addiction wasn’t a big deal. It really was very much a group of cubicles.”

Today, Alberta’s department of mental health and addiction is the seventh-largest ministry in the provincial government.

“The ROSC transformation that is going on in Alberta is massive. It is one of the most massive whole-of-government system transformations that I’ve seen,” Smith said. The premier chairs a ROSC committee of cabinet with seven ministers.

I guess I’d better unpack that acronym. ROSC stands for “recovery-oriented system of care,” a term that appeared in the 2018 report Smith co-wrote.

So you get the premier and her ministers of mental health and addiction, Indigenous relations, advanced education, health, community and social services, public safety and the attorney general meeting regularly to coordinate recovery policy. The premier’s chief of staff is on the file constantly. As I mentioned on Monday, he devoted a full day to explaining this broad effort to me.

“We spend enormous amounts of time and energy,” Smith said. “All of us live and breathe this. Anybody out there that thinks that we’re just, from a conservative perspective,  just cavalierly doing this, that just couldn’t be more untrue. We we are in this completely and totally. We monitor almost everything that goes on in the system.”

What are they working on? Smith said the “recovery” part of that “recovery-oriented system of care” jargon-ball gets most of the attention, because it draws attention to the contrast between harm-reduction and abstinence-based recovery models. But Smith is a wonk, and if anything he is more interested in the “system of care” part. His goal is to ensure that every interaction an opioid user has with the modern government apparatus is designed to encourage recovery from dependency. Since people who use drugs tend to bump up against the state a lot, Alberta’s emerging system has a lot of moving parts. The goal is to hook the parts up more effectively.

One of the other men in Smith’s office, Dr. Nathaniel Day, chimed in. He’s been the lead strategist on substance use at Alberta Health Services. He’s an important Smith collaborator.

“Across Canada,” he said, “the system of care for people with addiction has been fragmented, poorly thought out — convenient.” He meant services had generally only been provided when, and where, it was easy for government to provide them. “If you look at opioid dependency treatment, if you lived in a suburban or rural community, it didn’t matter that you had an opioid use disorder. Tough. We had no services for you.”

Day designed the Virtual Opioid Dependency Program, which provides online consultations to patients anywhere in Alberta, and if needed, prescriptions to medications that can be filled at local pharmacies. For patients without coverage, the medication is free and if their local pharmacist has it in stock, available on the day of the call.

“We went in and said, enough is enough,” Day said. “What would be good enough for you and your family? And how do we take that to everybody?”

Which medication? “In this province, we’re huge fans of gold-standard opioid-replacement medications, and we use it a lot,” Smith said. “We have Sublocade, which is something that other provinces don’t have because it’s very expensive. It’s the injectable version of Suboxone. It’s a subcutaneous injection, it goes under the skin, it lasts for 30 days, where the oral is 24-hour. So that’s a thousand bucks a shot, and we pay for that.”

An obvious point about this is that these so-called opioid agonist treatments, or OATs, are big-time harm reduction. They greatly reduce both withdrawal symptoms and highs. One question that I still have, after watching everything Smith and the Alberta government are doing on drug recovery, is whether other provinces could afford to match it.


Running into those institutions

VODP is useful for people who are able to reach out for help from home. But other potential beneficiaries are distracted, or in distress. Very often they run into the police.

“So we took that technology” — the virtual access to physicians and treatment — “and we gave it to the 34 police agencies that we have in the province,” Smith said.

“We said to the officers, ‘If you encounter somebody who has an opioid-use disorder, you can get them started on opioid-use medication. You can, officer. Here’s the phone number to call. Put them on. We make the arrangements. They go to the pharmacy, right then and there. If they’re on the street, that can be done right in the back of a police car.

“If they are in custody at the cell block and they go into the cell block, we have put paramedics in every cell block in Alberta. So the first thing that happens to somebody when they’re arrested and they go into into municipal cells, they’re met by a paramedic that says, ‘Let’s talk about your substance use. Are you an opioid user? We can offer you immediate treatment right now. Right here. Would you like to do that?’ Through our police programs, we’re probably up to like 4,000 people who have taken us up on that.”

That’s what you can get done in a police cruiser or a holding pen. Lots of people go much further into the correctional system than that. So does Smith’s system of care.

“[Alberta’s] focus on corrections and police right now, admittedly, is the opposite of what some other jurisdictions are focusing on,” Smith said. If anything this was an understatement. A major argument for decriminalization and safe supply is that the last thing a drug user needs is the stigma of a criminal record. Other jurisdictions, Smith said, “are running away from those institutions when they should be running into those institutions.

“I’ll give you a very direct example why.

“We know, from the 2017 coroner’s report in Alberta that 40 percent of the people who died [of opioid-related causes] were in custody in the year prior to their death. That’s a really important piece of information, because it tells me I have a big chunk of population there that — if I can get at them, and if we can change the way that they experience this process — we can make a big dent in these numbers.”

A lot of people in the correctional system have substance-use disorder, even if that’s not what they’re in for. “We said, ‘Let’s really do a different way of thinking on this,’” Smith said. “Even though Corrections is a public-safety agency, we want the Ministry of Mental Health and Addiction to take over all Corrections health care.”

Perhaps four in five detainees, he said, “have alcoholism, addiction and mental-health issues. They’re all pooled up in one place and they’re not doing anything. They’ve got nothing but time on their hands. And I don’t have to build a new building? You’re kidding me! This is fantastic! Why wouldn’t I just put therapists in? So we now have treatment programs inside correctional centers.”

Of course a lot of places do programs for inmates. “But what they’re going to show you when you unpack that is, ‘Well, we give them this workbook,’” Smith said. “What they’re not doing is the deep transformative, therapy work that is necessary. And honestly, Paul, our Therapeutic Living Units are probably the best treatment programs we have in Alberta.”

With that, we piled into Smith’s SUV — Smith, Day and the third member of Smith’s team that day, a physician and consultant named Dr. Paul Sobey. A half-hour later we arrived at the Fort Saskatchewan Correctional Centre, northeast of Edmonton.

Here we visited the Therapeutic Living Unit, a full-time addiction-recovery program for 21 women who are housed separately from the general inmate population. That’s about 10% of the total population of women at Fort Saskatchewan. The program opened in February. Participants, who must apply, run through a 12-hour daily program of activity: morning check-in meetings, physical exercise, twice-daily smudge ceremonies reflecting the large Indigenous population in the correctional system, frequent meetings of Alcoholics Anonymous and Narcotics Anonymous as well as the more recently developed SMART Recovery system. Participants are rarely alone during daylight hours. The program is designed to last for months, which struck me as an unusually long time for a recovery program.

Four of the program’s participants sat on a sofa and talked about their experience in the program. “I’ve been wondering and wondering if a program like this was going to happen,” one said.

“It’s like an answered prayer, honestly,” said another. “So I would just encourage you to keep opening places like this.”

That’s the plan. “We’ve got 12 correctional centers in Alberta,” Smith told me before our road trip. “Our goal is to have Therapeutic Living Units [in all of them]. There will come a time where we have whole correctional centers that are working on this model, right? This requires massive intervention, not tinkering around the edges. This is generational change in the way that we do corrections in Alberta.”


Connections

All of the four young women we heard from said they’re nervous about what happens when they get out of detention. Old acquaintances can encourage a return to old habits. Which is part of the reason why Alberta is also building a network of live-in Recovery Communities, long-term residential rehab programs to reinforce the lessons learned in the TLUs — or to help other people begin recovery if they didn’t arrive via the correctional system.

Once the system is fully built in 2027, “every correctional centre will have a sister Recovery Community,” Smith said. “That’s why we’re building 11 of them around the province. Five of them are on First Nations, in partnership with the First Nations.”

Here’s where the system starts to look like a system. After all, in the broadest outlines nothing’s new here. People in prisons have long received addiction counselling, and the Alberta government and various private groups have long run rehabs. But for the longest time, these assorted parts of the system could barely talk to one another. So the chances of a seamless transition from the correctional system to recovery care were lousy. They’re still not great, because the system is still being built, but the goal is a seamless network of care.

“Services in 2018, 2019 were very disconnected,” Warren Driechel, the Edmonton Police Service deputy chief we met the other day, told me. The bureaucratic runaround that we all have to face can be brutal on people with high needs and impaired function. Say you want to get on AISH, an income-support program for people with a medical condition. To do that, you need a doctor’s appointment. To get one, you need identification. To get ID, you need an address.

Public officials are working to provide services that match that complexity.

In January 2021, the EPS launched a “HELP Unit” to refer people to social services instead of just arresting them.

In September 2023, the police replaced the old holding cells where intoxicated people could dry out and then get dumped back on the street with an Integrated Care Centre where they could connect with social services that operate right in the centre.

And in January 2024, after many of the tent encampments were dismantled, a new Navigation and Support Centre became the city’s hub for providing medical, legal and bureaucratic help for people who have often been bereft.

The Nav Centre has nine shelter beds in the back where people can rest, if needed, while on-site staff and volunteers process their files. (Pets are welcome, unlike in some of the city’s shelters.) The centre has the province’s only on-site Service Alberta photo-ID station. On the day I visited, the Nav Centre assisted 50 people, with 24 visiting the desk run by the Hope Mission, 10 being helped by staff from Radius Health, 12 by the provincial department of mental health and addiction.


Everything old is new

Our final stop was the Lakeview Recovery Community outside Gunn, northwest of Edmonton. When it opens in July, it’ll be the third or fourth in a network of such long-term residential programs. Lethbridge and Red Deer have been open for a while. The goal is to have 11 centres up and running across the province by 2027. Smith hopes that once the full network of centres is open, long wait times in Red Deer and Lethbridge will shrink, perhaps to the point where some beds will be available on-demand.

Each recovery community has its quirks. Lakeview will be for men only. Five of the centres will be on Indigenous land. The minimum stay will be four months, with some residents staying for up to a year. That’s a long stint for a rehab; in some private rehabs, it’s unusual to stay for even a month. In theory every day you spend with a combination of counselling, group therapy, twelve-step programs and medical care will increase your chances of success. No resident will pay for their stay at any recovery community. It’s covered by the government.

Work crews have been renovating the Lakeview site since 2022. It’s an impressive place, roomy and bright, with rooms where residents can meet visiting family, a huge kitchen where residents will learn cooking skills, and a dispensary for opioid agonist treatment. Residents will share bungalows while they’re in the program, five or six to a house.

But it didn’t just come into existence. What’s now Lakeview began its existence as the McCullough Centre for homeless World War II veterans. It had been operating for years as an addiction rehab centre when Jason Kenney’s government closed it in 2021. When the government announced the site’s eventual reopening barely a year later, observers were baffled. Closing the centre fit a narrative about a government that put the bottom line over Albertans’ wellbeing. Refurbishing and reopening it was.. harder to explain. Fitting it into a network of nearly a dozen such centres that will, themselves, be better connected to street-level services and to the corrections system… well, we’ll see, won’t we?

I’m conscious of ending this installment in my series on opioids in Alberta on an ambivalent note. I simply don’t know how this will turn out. My first article, earlier this week, was about the scale of the challenge. This one is about the scale of the response. It’s impressive. It’s getting attention across the country. Sobey, the physician who was the third member of our little party as we toured the region’s facilities, has a consulting firm whose aim is to design recovery-oriented systems of care to any government that wants to start the conversation. His phone pinged with an inquiry from another provincial government while we were visiting the Fort Saskatchewan prison. These ideas may come soon to a province near you.

What we don’t know yet is whether they’ll work, or how well. In the third and final installment in this series, I’ll discuss a few reasons to reserve judgment.

But what Alberta is trying is, in many ways, not heretical. Nobody thinks it’s great design to leave desperate people to wander helplessly thorugh a piecemeal hodge-podge of social services and treatment options, with police and corrections hovering over it all as an aloof menace. Smith, his boss the premier, and several government departments are trying to build a better system.

There is room for many devils in the details. But if federalism is supposed to be a laboratory for testing different approaches to thorny problems, Alberta is testing this approach ambitiously. Watching Marshall Smith, I found myself wondering what other intractable governance problems could benefit from the sustained attention of an empowered senior staffer, a supportive head of government, and ministers and public servants working in close coordination.

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Addictions

Claims about ‘safer supply’ diversion aren’t disinformation

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News release from Break The Needle

This month, police in London, Ont., admitted to what critics have said all along: safer supply diversion is happening at alarming levels

Last spring, Canada’s minister of mental health and addictions claimed critics’ concerns about “safer supply” diversion — the illegal selling and trading of taxpayer-funded addictive drugs — were based on lies.

“For Pierre Poilievre to state untrue information about safer supply, and try to create barriers to accessing harm reduction services that are saving lives amid this ongoing crisis, is incredibly irresponsible and dehumanizing to people who use drugs,” read a statement by then-minister Carolyn Bennett’s office.

Fast forward a year, and it’s clear which side was telling the truth.

This month, police in London, Ont., admitted to what critics said all along: diversion of pharmaceutically supplied opioids to the streets is happening at alarming levels. London is home to Canada’s longest-running safer supply program, which dates back to 2016 and was significantly expanded in 2020.

The London Police Service released data that shows a staggering 3,000 per cent increase in the seizure of hydromorphone tablets — the opioid predominantly given out by safer supply programs — over the last five years. In 2019, London police seized just under 1,000 tablets. By 2020, that number had tripled. In 2023, they seized 30,000 hydromorphone tablets.

For context, hydromorphone is as potent as heroin and just two or three of these pills, if snorted, can cause an overdose in an inexperienced opioid user.

Earlier this month, the city’s deputy police chief, Paul Bastien, told CBC’s London Morning, “We recognize the value that safe supply plays as part of that harm reduction piece, but diversion is an important issue that is affecting community safety. I won’t say that everyone’s doing it, but some of the tablets from safe supply are being diverted for that purpose.”

“Criminal groups are fairly adept at exploiting policy changes that are well intended. But unforeseen consequences sometimes arise and this appears to be, at least in part, one of them,” he continued.

A reasonable person may assume that, given this alarming new evidence, proponents of safer supply would change their tune about widespread diversion being “fake news.” Unfortunately, they haven’t.

Some activists are now claiming on social media that London’s spike in hydromorphone seizures was not caused by safer supply, but rather by a high-profile theft of 245,000 hydromorphone tablets from an Ontario pharmacy. Yet the spike in seizures began years before this theft and, according to multiple addiction physicians, the street price of hydromorphone collapsed in the city well before 2023, suggesting an earlier influx of diverted supply.

However, these mental contortions aren’t surprising. As more and more evidence of widespread diversion emerged over the past year, accusations of disinformation and misinformation haven’t stopped –– they have simply evolved. The narrative changed from “Diversion doesn’t exist” to “Fine, it exists, but only on a small scale” to, now, “Fine, diversion exists at scale, but imagine the alternative?”

This is the angle already emerging in British Columbia, where the province’s top doctor, Bonnie Henry, authored a damning report that acknowledges the regularity and harms of safer supply diversion, yet still concludes safer supply is “ethically defensible” and advocates for its expansion.

Like many safer supply activists, Henry often argues diversion isn’t a significant concern because most opioid deaths are caused by fentanyl.

While it’s true that most opioid deaths are attributable to fentanyl, hydromorphone is still incredibly dangerous. When diverted into the black market, it creates new addictions, often among young people, which culminate in fentanyl use.

Moreover, data indicate hydromorphone is implicated in an increasing share of drug-related deaths in young people in B.C. In 2019, there were no reported deaths involving hydromorphone. By 2022, that number jumped to 22 per cent. Similarly, a recent report by the Centre for Addiction and Mental Health in Ontario found the number of youth in the province who self-reported using prescription opioids for “non-medical” reasons jumped 71 per cent between 2021 and 2023.

Still, safer supply activists continue to insist, despite overwhelming evidence to the contrary, that widespread diversion isn’t happening.

In 2017, Collins Dictionary declared “fake news” the word of the year. Since then, the term –– along with sister terms “misinformation” and “disinformation” –– have taken on a disturbing new life.

While fake news, misinformation and disinformation are very real democratic threats, some politicians and activists realized they could delegitimize opponents’ arguments and unflattering media stories by simply proclaiming them fake. Now, we’re in the dizzyingly ironic position of real news, and real facts, being dismissed as misinfo and disinfo by self-declared guardians of the truth.

This is the exact problem journalists and concerned medical professionals continue to face when raising the alarm on so-called “safer supply.” Despite the abundance of solid reporting, emerging data, whistleblower warnings and first-hand accounts of widespread diversion, harm reduction activists and their allies in government don’t just recklessly dismiss the problem, they weaponize the language of fake news to discredit a reality they don’t like.

Communities across Canada, and addicts themselves, deserve better.

A guest post by
Sabrina Maddeaux
Bold opinions and analysis of the political and economic issues that matter.
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Addictions

‘Drug dens’: Poilievre calls out Trudeau’s misleadingly named ‘safe’ injection sites

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From LifeSiteNews

By Clare Marie Merkowsky

Pierre Poilievre haș again sounded off on the Trudeau government’s ‘safe’ injection sites and other drug measures, policies which have been followed by an uptick in drug overdoses wherever implemented.

Conservative Party leader Pierre Poilievre has condemned Prime Minister Justin Trudeau’s Liberal government and the mainstream media for concealing the failure of federally-subsidized “safe” injection sites for hard drug use.

During a July 12 press conference in Montreal, Quebec, Poilievre slammed politicians and mainstream media alike for masking the failure of the Trudeau government-led “supervised injection sites,” pointing out the misleading nature of the term “safe” often used when discussing these facilities, which allow addicts to abuse themselves by injecting deadly narcotics such as heroin.

“I know wacko politicians in the Liberals and the NDP [New Democratic Party] and their supporters in the media want to make it sound like there’s a constitutional obligation that we allow these drug dens anywhere they want to go up,” said Poilievre. “That is not true. That is the opposite of true.” 

Poilievre’s remarks were delivered in a kindergarten playground near Montreal’s first federally-subsidized injection site that opened on April 15.  

Poilievre promised that “there will not be a single taxpayer dollar from a Poilievre government going to drug dens.”  

“Every single penny will go to treatment and recovery services to bring our loved ones home drug-free,” he added. 

Poilievre further called out mainstream media reporters for repeating Trudeau’s claim that the drug sites are “safe” or “supervised.” 

“What will you do around safe injection sites across the country?” Globe & Mail reporter Eric Andrew-Gee questioned. 

“You guys repeat the same language you get from the radical Liberal-NDP activists and bureaucracy,” said Poilievre. “You call them safe. How can they be safe? Do you think it’s safe when a bullet comes flying out of one these sites to kill a mother in Toronto? Do you think that’s safe? Do you think it’s safe to have people using crack and heroin and cocaine next to a playground like this? Do you think that is safe? It’s not safe.”  

Poilievre’s mention of the Toronto mother is a reference to the 2023 shooting death of Karolina Huebner-Makurat, a 44-year-old mother of two. Police allege Huebner-Makurat was killed by a stray bullet fired by a man in a drug-related dispute with another man outside of an injection site in the city’s Leslieville neighborhood.

In addition to injection sites, the Trudeau government has also been involved in the distribution of drugs to addicts. In fact, Health Canada recently noted that the Trudeau government has budgeted over $27 million in funding for “safe supply” drug programs that have been linked to increased violence and overdose deaths across Canada. 

Safe supply” is the term used to refer to government-prescribed drugs given to addicts under the assumption that a more controlled batch of narcotics reduces the risk of overdose. Critics of the policy argue that giving addicts drugs only enables their behavior, puts the public at risk, disincentivizes recovery from addiction and has not reduced – and sometimes even increased – overdose deaths when implemented. 

The best example of the Trudeau government’s drug policy failures come from the province of British Columbia. Starting in 2023, the Trudeau government decriminalized the possession of up to 2.5 grams of hard drugs without criminal penalty.

Shortly thereafter, record numbers of overdose deaths and similar incidents occurred, leading to the province itself requesting that the Trudeau government recriminalize drugs in public spaces.

Nearly two weeks later, the Trudeau government announced it would “immediately” end the allowance of hard drug use in public, which critics see as tacit admission the policy was a disaster.

The effects of decriminalizing hard drugs have been the source of contention throughout the country, as evidenced in Aaron Gunn’s documentary, Canada is Dying, and in U.K. Telegraph journalist Steven Edginton’s mini-documentary,  Canada’s Woke Nightmare: A Warning to the West. 

Gunn, who has since become a Conservative Party candidate, previously noted that his film shows clearly the “general societal chaos and explosion of drug use in every major Canadian city” since lax policies were implemented.

“Overdose deaths are up 1,000 percent in the last 10 years,” he said in his film, adding that “every day in Vancouver four people are randomly attacked.”

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