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Interface - Comunicação, Saúde, Educação

Print version ISSN 1414-3283On-line version ISSN 1807-5762

Interface (Botucatu) vol.22 no.66 Botucatu July/Sept. 2018

http://dx.doi.org/10.1590/1807-57622016.0940 

articles

Treatment for dependency from the perspective of people who use crack

Renata Barreto Fernandes de Almeida(a) 

Naíde Teodósio Valois Santos(b) 

Ana Maria de Brito(c) 

Keila Silene de Brito e Silva(d) 

Solange Aparecida Nappo(e) 

a Centro Universitário do Vale do Ipojuca. Rua Adjar da Silva Casé, 800, Indianópolis. Caruaru, PE, Brasil. 55024-740. renatabfa@hotmail.com

bc Departamento de Saúde Coletiva, Fundação Oswaldo Cruz Pernambuco. Recife, PE, Brasil. naide@cpqam. fiocruz.br; anabrito@cpqam.fiocruz.br

d Centro Acadêmico de Vitória, Universidade Federal de Pernambuco. Vitória de Santo Antão, PE, Brasil. keilabritoufpe@gmail.com

e Universidade Federal de São Paulo (Campus Diadema). Diadema, SP, Brasil. solangenappo@gmail.com


ABSTRACT

The aim of this study is to understand the essential aspects for a successful treatment for crack dependency, based on the speech of users. This is a descriptive study, using a qualitative approach. Interviews were conducted with 39 crack users who were assisted in a social protection program for drug users. In order to understand the narratives, the content analysis technique was used and the theoretical framework was based on Bardin. Aspects that were mentioned as important were undergoing voluntary treatment and spirituality, categories that can be grouped as individual aspects, as well as increasing the list of activities, supply of settings protected from drugs and professional qualification with socio-productive inclusion, as institutional aspects. These demands must be considered for a better understanding of what is needed for a successful treatment, and contemplated by public policies targeted at this issue.

Key words: Crack cocaine; Dependency; Treatment; Drug user

RESUMO

O artigo pretende compreender, a partir da fala dos usuários, quais os aspectos fundamentais para o sucesso no tratamento da dependência do crack. Trata-se de um estudo descritivo, com abordagem qualitativa, onde foram entrevistadas 39 pessoas que fazem uso de crack, atendidas num programa de proteção social para usuários de drogas. Para a compreensão das narrativas, foi utilizada a técnica de análise de conteúdo, com referencial teórico baseado em Bardin. Foram mencionados, como importantes aspectos, realizar tratamento voluntário e espiritualidade, categorias que podemos agrupar como aspectos individuais; como, também, ampliação do cardápio de atividades, oferta de espaço protegido da droga e qualificação profissional com inclusão socioprodutiva, como aspectos institucionais. Essas demandas precisam ser consideradas para um melhor entendimento das necessidades para o sucesso no tratamento, assim como serem contempladas pelas políticas públicas voltadas para o problema.

Palavras-Chave: Cocaína/crack; Dependência; Tratamento; Usuário de drogas

RESUMEN

El artículo pretende comprender, a partir de las palabras de los usuarios, cuáles son los aspectos fundamentales para el éxito en el tratamiento de la dependencia del crack. Se trata de un estudio descriptivo, con abordaje cualitativo, en donde fueron entrevistadas 39 personas que utilizan crack, atendidas en un programa de protección social para usuarios de drogas. Para la comprensión de las narrativas se utilizó la técnica de análisis de contenido con referencial teórico basado en Bardin. Se mencionaron como aspectos importantes la realización de tratamiento voluntario y la espiritualidad, categorías que podemos agrupar como aspectos individuales, como también la ampliación del menú de actividad, oferta de espacio protegido de la droga y calificación profesional con inclusión socio-productiva, como aspectos institucionales. Esas demandas deben considerarse para un mejor entendimiento de las necesidades para el éxito en el tratamiento, así como su inclusión por las políticas públicas enfocadas en el problema.

Palabras-clave: Cocaína/crack; Dependencia; Tratamiento; Usuario de drogas

Introduction

Drug consumption dates back to remote times and involves cultural, religious, economic, political and social issues. In different cultures, societies and eras, man always consumed licit or illicit drugs. In the majority of times, this did not constitute problems nor reasons for social alarm, as they were consumed with diverse purposes and understood as a cultural and human manifestation.1-3

As the years went by, it was possible to notice that both the type and the form of drug utilization started to vary. When a psychoactive substance is identified, different forms to reach the desired effects are discovered, and the substance becomes one more market product in our society. In recent decades, drug consumption has assumed worrying dimensions, with severe consequences to the individual, his family and community, negatively affecting different interfaces of daily life.4-6

The increase in drug use is not only associated with the culture of consumption and instant pleasure, but also with the vulnerability situation that has been experienced mainly by socially disadvantaged classes. It is considered that a large portion of society lives permanently threatened by the instability of their life conditions and by social exclusion. The status of social misery and lack of political support have made new survival strategies emerge, and this instability favors the ever-growing entrance of youths into the world of drug trafficking.4

Crack cocaine consumption emerged in Brazil at the end of the 1980s. This phenomenon suffered a quick expansion7, mainly among the population under major social vulnerability. According to Bastos and Bertoni8, the majority of users of crack cocaine and/or similar substances are young men with a low level of schooling who are living on the streets and do not have a permanent job or a regular income. Therefore, they form a socially vulnerable group.

According to Pulcherio9, crack cocaine is a drug with great power to make the person become dependent. It is largely associated with criminality, involvement in illicit acts to maintain consumption, like theft and robbery, and participation in drug trafficking.10-12 In spite of its severe consequences, the current knowledge about the use of this substance is still not sufficient, neither to provide efficient assistance for people in harmful drug use, nor to guide public prevention policies.

In view of the challenge of overcoming crack cocaine dependence, research has been developed to verify the efficacy of different therapeutic approaches. Due to the complexity of the harmful use of this drug, Kessler and Pechansky13 argue that treatment over long periods guarantees better results, and it should offer spaces protected from the substance. Pulcherio8 adds that, besides being long, treatment for crack cocaine dependence should have a multidisciplinary approach, considering clinical, familial, social and legal aspects. Pinho et al14 believe that the therapeutic proposal must be adequate to the user’s age, sex, ethnicity and culture, meeting the subject’s different needs.

Among the therapeutic approaches, Cognitive Behavioral Therapy focuses on the recovery of social skills, and its goal is abstinence.15 This approach produces good results in people who do not present severe consequences deriving from crack cocaine use. Relapse Prevention has provided motivational techniques to restructure cognitions and modify drug-use behaviors.16 With its well-structured techniques, it has been presenting good results in the treatment for dependence.15,17,18

Replacing the hegemonic models of treatment, which have a moral and legal character, the psychosocial approaches value the offer of hearing and embracement spaces for the phenomenon of drugs. In this perspective, offering assistance at public spaces for drug users without imposing abstinence or permanence in the service is a great challenge and an important tool in the treatment.19

Although crack cocaine stands out in scientific publications, it is still necessary to advance more in relation to the treatment for its dependence. Even with different therapeutic approaches, crack cocaine users are more likely to abandon the treatment and, therefore, are not successful. Some factors can be highlighted, such as problems with the law, poor coping skills, family history of mental disorder, associated alcohol use disorder, among others.20

On the other hand, studies that aim to assess the efficacy of different approaches have not investigated users’ demands in the treatment process. Thus, the present study aimed to understand, based on the users’ discourse, their fundamental needs for a successful treatment.

Methodology

This is a descriptive study with qualitative approach about aspects related to success in the treatment for crack cocaine dependence, according to the users’ view. It is part of the research “Vulnerability of crack cocaine users to HIV and other communicable diseases: a socio-behavioral and prevalence study in the state of Pernambuco”(f), developed by the Aggeu Magalhães Research Center and by the Oswaldo Cruz Foundation - Pernambuco, and funded by the Health Surveillance Department of the Ministry of Health (Notice 20/2013).

The qualitative methodology enables to give visibility to social reality, transforming it into a series of concrete and symbolical representations for the apprehension of the complexity of human behavior. According to Flick21, qualitative research has experienced an unprecedented period of growth and diversification ever since it became a consolidated and respected investigation proposal in different disciplines and contexts.

Knowledge about the social dynamics related to the culture of crack cocaine use22, as well as about aspects related to the treatment for dependence of this drug, is scarce. Therefore, it is pertinent to employ qualitative techniques to understand this context in depth.

To develop the study, semi-structured interviews were conducted with crack cocaine users assisted in the ATITUDE (Attitude) Program, a comprehensive care program of the Executive Drug Policy Department of the State of Pernambuco for drug users and their families. The Program is part of the state’s welfare policy and aims to respond to the social vulnerability situation of drug users and their families. It functions as a space for user embracement and support, without demanding that users participate in activities or adhere to the dependence treatment. Thus, it offers low demand services, which users attend voluntarily.

The Program has a set of actions of prevention, protection and assistance, focusing on situations of personal and social risk deriving from harmful drug use. Today, it is reference in the care provided for users of crack cocaine and other drugs in Pernambuco22.It prioritizes individuals who are in a situation of exposure to violence, who need to get away from their communities, and their family bonds are weakened or broken.

The regional nuclei of the ATITUDE Program, located in the cities of Recife, Jaboatão dos Guararapes and Cabo de Santo Agostinho in the Metropolitan Region, and Caruaru in the Agreste Region, have different modalities of social protection services: a Center for User Embracement and Support (temporary shelter), a Center for Intensive Embracement (institutional embracement), teams that approach homeless individuals and drug users on the streets to provide assistance, and rent benefit22. Thus, the ATITUDE Program enabled us to have access to crack cocaine users from different places in the state, in an environment that favors contact with the research subjects and data collection.

A total of 39 people were interviewed (men, women and transvestites), distributed across the four regional nuclei of the ATITUDE Program. All of them used crack cocaine and were participating in the Program at the Center for User Embracement and Support and at the Center for Intensive Embracement. The number of interviewees was considered sufficient for the analyses based on the saturation criterion, as we observed repetitions in the content of their reports. We verified, in the discourses, that the experiences related to fundamental needs for a successful treatment did not bring new contents to the analysis; therefore, the number of conducted interviews was considered sufficient.

According to Fontanella et al23, the use of saturation as a criterion is a conceptual tool that has been frequently employed in qualitative investigation reports in different areas in the field of Health. This strategy is operationally defined as the suspension of the inclusion of new participants when the obtained data start presenting, according to the researcher’s evaluation, redundancies or repetitions. The researcher then considers that data collection is no longer necessary.

The inclusion criteria were: the interviewees must be 18 years old or older, must have participated in the epidemiological inquiry Vulnerability of crack cocaine users to HIV and other communicable diseases: a socio-behavioral and prevalence study in the state of Pernambuco, and must sign a consent document.

Fieldwork started after the data collection procedures of the epidemiological inquiry. The interviews were conducted from March to August 2016, and the script approached aspects related to treatment for crack cocaine dependence. The interviews were recorded and subsequently transcribed in digital media.

All the interviews were conducted by the main author, and the transcriptions were performed by one single professional trained for this function. This reduced both the occurrence of variations in the form of conduction of the transcriptions and possible biases in the analysis process. Still concerning the procedure of transcription and validation of the interviews, the transcribed material was fully compared with the original audio version.

The content analysis technique was applied to the transcribed and revised material, and the theoretical framework was based on Bardin’s definitions24. To the author, the set of techniques that permeates qualitative analysis consists of making explicit and systematizing the content of messages in order to enable logical and justified deductions. To achieve this, the three stages recommended by the method were performed: pre-analysis, exploration of the material, and treatment of the results.

For the preparation of the material, the software NVivo version 10 was used. According to Gibbs25, the organization of the research material with the aid of a qualitative data analysis software “can make the analysis become much easier, as well as more accurate, reliable and transparent, but it will never do the reading and reflection for you” (p.136). With the support of the software, the transcribed material was stored and the data were organized and categorized. The categorization process enables to classify the signification elements. The technique consists in classifying different elements according to criteria that give meaning to them.24

Based on the categorization, interpretations were started, providing answers to the research question. Our aim was to understand the meanings of the studied context.26

To present fragments of the interviews in the results of the study, and as a way of maintaining anonymity, the interviewees were designated by names of gemstones.

Results and discussion

In our study, 39 people who use crack cocaine were interviewed (20 men, 12 women and 7 transvestites), aged between 20 and 46 years. They had been using crack cocaine for an average of 10 years (2 to 23 years of use).

Living on the streets in the cities where the regional nuclei of the ATITUDE Program are located (Recife, Jaboatão dos Guararapes, Cabo de Santo Agostinho and Caruaru) was a predominant characteristic among the interviewees. Six cities in the state of Pernambuco were also mentioned as their last dwelling places, three in the Metropolitan Region (Olinda, Paulista and Abreu e Lima) and three in the Agreste region (Bezerros, Garanhuns and Pesqueira). Of the 39 interviewees, the majority reported being of mixed ethnicity (black and white) or black, single and having a low level of schooling (did not start High School).

In the treatment of the results, we identified categories that can be grouped into two themes. The first refers to individual issues and concerned the way in which the user positions himself about the decision to undergo treatment, that is, the desire to undergo treatment, and spirituality. The second theme portrays institutional issues, which report the qualification of the therapeutic project and of the service’s technical team. The offer of diversified activities and a space protected from the drug, as well as professional qualification together with inclusion in the job market, were mentioned as important resources in the treatment.

The desire to undergo treatment: voluntariness and willpower

This category describes the extent to which the research participants consider important having the desire to undergo treatment. This desire proves to be essential for the treatment’s success, as exemplified by the discourses below:

He must have the willpower, because no treatment, no ATITUDE, no Support [ATITUDE’s service] can make a user quit. He must have the willpower, from the moment he is... that he feels he is away from drugs for a couple of months. You must face the reality out there. Here, inside the service, it’s ok, but when we cross the gate and step outside, abstinence knocks on our door. (Tiger’s eye, 20, female)

Willpower, this is what’ll count in your treatment. I’m gonna tell you this, you must focus, you must be willing to change, you must be aware that the drug you used wanted to destroy you, you must have the willpower. (Andalusite, 36, male)

[...] you must have the willpower to... because if you don’t, it’s nonsense... The person must want it, the person must... there are many nice people, you must work a lot to... because the person becomes ignorant. (Moonstone, 27, male)

It is possible to notice, in the narratives, the importance given to the decision of being in an institution and to the willingness to change their relationship with the drug, as well as maintaining their goals when they return to their social interactions. Regardless of the therapeutic approach or model, to the research participants, nothing matters if one lacks the desire to change, the desire to get out of harmful use, of compulsion. Thus, we can state that voluntariness and willpower are primordial aspects to be considered for the process to be positive, and they must be present at all stages of the treatment.

According to Ruiz and Marques27, compulsory hospitalization (ordered by Justice) or involuntary hospitalization (authorized by a physician) should be employed only when the individual is jeopardizing his life and other people’s. This measure should be monitored by a qualified multidisciplinary team that identifies the varied levels of dependence and the patient’s constitutional rights, and it must be integrated into other intervention proposals, at adequate places and with permanent inspections. To the authors, if these aspects are not respected, such interventions constitute violation of freedom and punishment, and are doomed to therapeutic failure.

Although some professionals defend compulsory or involuntary hospitalization as a strategy to successful interventions with crack cocaine users, Bastos and Bertoni8, in a study that described the profile of crack cocaine use in Brazil, have provided an important datum that makes us question this need: 78.9% of the interviewed users stated they want to undergo treatment, which reveals that these people are not, a priori, resistant to therapeutic approach. A similar result was verified in the socio-behavioral inquiry developed with crack cocaine users enrolled in the ATITUDE Program, in which 96.6% of the interviewees mentioned they want to undergo treatment28.

These data show that the majority of people who use crack cocaine have the desire and, a priori, want to experience a process of treatment voluntarily. To Coelho and Oliveira29, hospitalization against the individual’s will is not only aggressive; it is an inefficient form of treatment and constitutes a way of eliminating the socially undesired, that is, it is a hygienistic practice that violates human rights.

To calm the anguish: spirituality

In addition to voluntariness, expressed by the desire to undergo treatment, the need to strengthen spirituality was verbalized as another important aspect to facilitate the achievement of a successful treatment. Maintaining abstinence was highlighted and no specific religion was emphasized. This perception is revealed below:

I’ll tell you something. I think that the only objective to quit smoking crack is the presence of God. Yes... because there are some crack users, that if they drink, they feel like using crack, if they drink a glass of beer, they want to use it, like this friend of mine. He offered crack to me and it’s been 2 years since he used it for the last time. But why? He’s been going to church. If he stops, he falls again. If he stops, he falls to the same level. If he goes back to his friends, he relapses again. (Emerald, 21, male)

The spiritual dimension, to me, as quitting worked out and I spent more than two years without using crack, to me it was the only model that worked. To me. I don’t know to others; some people say they can quit. (Amethyst, 36, transvestite)

Some studies argue that religiosity is a factor of protection against harmful drug use or for the treatment of dependence.30-32 It is important to highlight that the interviewed people had different religions and some of them did not even consider themselves religious. They mentioned the encounter with something divine.

Sanchez and Nappo33, in a study carried out with former drug addicts who had used religious, non-medical resources to treat dependence, state that the positive result in the cure may be related to the interviewees’ faith in the power of their church. Arenari and Dutra34 discuss that religion has the potential for reversing trajectories of exclusion, mainly connected with drugs, due to its specific vocation for integrating individuals with high levels of social disengagement, unlike other systems, such as social networks and work. Thus, religion, religiosity or spirituality can be factors of protection and therapeutic resources against harmful drug use.

Despite this understanding, it is important to mention that the condemnatory discourse of some churches, according to which users will only be all right through religious conversion, do not help those who do not want or cannot treat themselves in this perspective.35

Against craving: diversified activities

The crack cocaine users who were interviewed stated that, during treatment, it is necessary to develop different therapeutic activities, ranging from those directed at reflection on dependence to those related to schooling and professional qualification, and also ludic and leisure activities. They highlight that the compulsion to use crack cocaine weakens them and their mind must be busy all the time so that they are able to defeat craving:

A treatment that keeps our mind busy, like a course, a distraction, a school, a tour, some kind of leisure, a group activity, something like this would be good for us, right? So that our mind is distracted and forgets, right? Because it always comes to our mind. (Coral, 24, female)

What should a good treatment have?! I think that the group should talk less about crack. Just this, I think. (Coral, 24, female)

Being dependent on crack cocaine means living around the drug. Thus, other activities are inexistent in these users’ life. Therefore, offering diversified activities is a fundamental therapeutic resource for them to experience other pleasures and meanings without the use of crack cocaine, and to help controlling craving. Therapeutic groups are important tools in the treatment for chemical dependence, but perhaps other activities that are more dynamic, creative and pleasant contribute more to the success of some users’ treatment.36

In order to provide comprehensive care, we need to reflect that, in the singular space of each healthcare service, the team must strive to translate and meet each complex need the individuals have.37 Alves38 adds that the diversification of programs is fundamental to embrace someone in a comprehensive way, as, with varied and diversified options of activities, the possibility of users’ participation is increased, while the tendency of selection in the follow-up on the part of the professional is reduced.

Thus, we can think about care as Leonardo Boff39 proposes: “Providing care for someone is more than an act; it is an attitude. Therefore, it encompasses more than a moment of attention, zeal and tendance. It represents an attitude of occupation, concern, accountability and affective involvement with the other” (p. 73).

The increase in the number of available activities represents, therefore, this singular and comprehensive care. It represents concern for the different demands, needs and identifications brought by the crack cocaine users who are undergoing treatment.

Against crack cocaine: a protected space

At some moment of the treatment for harmful crack cocaine use, a space protected from the drug becomes necessary, where the user can be sure that there will be no contact with the substance.

Take him out of the street, right, not leave him on the street..., how can a person spend the day here, eating, and in the evening he uses crack? Then, on the next day, he arrives here completely destroyed [...] (Sapphire, 26, male)

A place where I can spend the night. Getting out is pure trouble. (Brazilianite, 23, female)

I think that any place is ok, but not in the same city, because you know, there is the knowledge that can make a person who helps want to bring the drug inside the place, here, while in another city I think nothing happens, because you know, it is harder for you to obtain it, [...] (Labradorite, 29, male)

The dependence clinic points that, at some moments in the therapeutic trajectory of people in harmful drug use, it becomes necessary to drive them away from their surroundings. It is fundamental to break the paradigm according to which a mental healthcare network does not need a space for inpatient treatment.40

In the Brazilian Psychiatric Reform, it is necessary to reflect on the importance of protected spaces that do not present the conception of long-permanence hospitalization, which segregates people who use drugs from their environment for long periods, without the construction of new life projects. It is necessary to understand that, in the protected spaces demanded by the interviewees, care practices that support the development of skills and potentialities must be provided, strengthening autonomy and self-care, expanding protection factors that help to cope with risk situations, and including the individual in the community and, whenever possible, in the family context.

In Pernambuco, some successful experiences corroborate the importance of protected spaces in the treatment of people in harmful drug use. The Casas do Meio do Caminho (CMC - Houses in the Middle of the Way), in the mental health network of Recife, and the Center for Intensive Embracement of the ATITUDE Program are examples of these experiences.

The CMC emerge from the fact that the Psychosocial Care Centers (CAPS), even those which are open 24 hours a day, are not able to contain the anxiety and suffering of severe users.41 The CMC are complementary spaces in the healthcare network, and their function has been amplified beyond treatment, as a protection space41.

This amplification makes a difference in the lives of people who wish to remain abstinent, but have the substance within their reach very easily. Being certain about the possibility of remaining far from drug consumption is important to many interviewees.

Towards a new project of life: professional qualification and inclusion in the job market

This category portrays the need of professional qualification and productive inclusion in the process of maintaing the treatment of people in harmful crack cocaine use. This need emerges explicitly in the interviewees’ discourse:

I think that there should be many workshops with many qualification courses, many qualification courses, and after you have attended the course, the government should refer you to a job. When you have recovered, when you are cured, it should refer you to a job... (Garnet, 27, male)

More activities, right, that were, like, vocational, which approached our motivation to go out...if we attended a course, any course, handicraft, one thing or another, it would help, if we go out already having a job, I think many groups do this... (Amethyst, 36, transvestite)

An occupation, like, in the case of this one, it forms a group, we eat and sleep, for many people this is good, but for me, it could be better. An occupation, a vocational course. After attending a course, we should be referred to a job, always maintaining the mind busy, things that I used as a strategy not to smoke crack... (Topaz, 31, male)

What is evident is that professional qualification needs to be an aspect of the therapeutic project; however, the interviewees themselves highlight that a course is not enough to contribute to the treatment. This qualification must be linked to inclusion in the job market.

To Arenari and Dutra42, when functions of responsibility are designated, even with low expectation of good results, a relationship of affective and moral “obligations” is established. This social recognition stimulates, in the individual, the construction of viable short-run obligatory goals, breaking the destructive cycle that exclusion, together with crack cocaine consumption, can generate.

In this perspective, the users stress the need of having an occupation, in addition to attending vocational courses, so that they feel integrated into society and with conditions to play their role as citizens. Thus, possibilities of socio-productive inclusion must be a concern of the government.

Final remarks

This article aimed to investigate, based on users’ discourse, the fundamental aspects that are necessary for a successful treatment. The results indicated that people who use crack cocaine identify issues that we can consider to be individual and also institutional issues.

Valuing the desire to undergo treatment, as well as respecting the different ways of experiencing spirituality or religiosity are individual aspects that need to be understood in the conduction of therapeutic processes with these people.

As for the institutional questions, the qualification of the therapeutic project and of the service’s technical team, the offer of diversified activities and of a space protected from the drug, as well as professional qualification linked with inclusion in the job market were mentioned as important resources in the treatment. Thus, institutions that propose some form of care/treatment must take into account these demands pointed by the interviewees in the construction of therapeutic projects.

As this is a qualitative research, the data collected in this study should not be generalized; however, the singularity of these users can relate to other individuals involved in the same problem. Therefore, the demands described in this study, although singular, can produce resonance for professionals who work in the area, contributing to a better understanding of this population, so that more adequate and realistic public policies are developed in this context.

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f The study was approved by the Research Ethics Committee under number CAE 25250413.6.0000.5190, with the title “Infection rates of HIV, syphilis, hepatitis (B and C) and tuberculosis; knowledge, attitudes and practices related to sexually transmitted infections and the culture of use of crack cocaine and other drugs among users in Pernambuco”.

Received: December 03, 2016; Accepted: June 05, 2017

Collaborators

The authors participated equally in discussing the results, reviewing and approving the final version of the manuscript.

Translated by Carolina Ventura

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