Support Recovery: It’s a Marathon, Not a Sprint

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    Takeaways

    • Most people with AUD can and do recover, and their individual paths to recovery vary widely. By highlighting the likelihood of recovery, you may encourage more patients with AUD to accept treatment or to reduce their drinking with or without treatment.
    • Recovery is a long-term change process that may be characterized by occasional returns to heavy drinking. Especially in the bumpy first year, patients will benefit from ongoing support to help maintain the changes they are making.
    • Healthcare professionals can support recovery by offering AUD medications in primary care, referring to specialists as needed, encouraging engagement with supportive people and activities that do not involve alcohol, and offering ways to help prevent or recover from drinking episodes.
    • It helps to apply compassion and awareness of the difficulty of behavior change when encouraging patients to get back on track after a drinking episode. Avoid criticizing the patient for the episode, which can stigmatize rather than normalize an expected part of the recovery process.
    • Online resources from NIAAA can help you support your patients by providing modules on building drink refusal skills and handling urges to drink as well as a treatment navigator to help locate healthcare professionals who offer evidence-based care.

    For different patients, both alcohol use disorder (AUD) and its recovery will play out differently. Here, we provide tips to help you understand and support your patients with AUD as they forge their individual paths to recovery.

    A note on a drinking level term used in this Core article: Heavy drinking has been defined for women as 4 or more drinks on any day or 8 or more per week, and for men as 5 or more drinks on any day or 15 or more per week.

    How is recovery defined?

    Definitions of recovery from AUD can vary in their emphasis on different physical or psychosocial outcomes or quality of life dimensions. Recently NIAAA developed a definition of recovery to provide a research and clinical framework.1,2 It states that recovery is a dynamic process with two clinical goals:  

    • Remission from AUD symptoms as listed in the DSM-5 with the exception of craving (a DSM-5 symptom checklist is provided in the Core article on assessment and can be downloaded here [PDF – 80 KB]); and
    • Cessation from heavy drinking, defined for women as no more than 3 drinks on a single day and no more than 7 drinks per week, and for men as no more than 4 standard drinks on a single day and no more than 14 drinks per week.

    If people achieve both goals and maintain them over time, they are considered clinically recovered from AUD. Importantly, more broadly, the NIAAA definition also notes that recovery is often marked by improvements in physical health, mental health, relationships, spirituality, and other measures of well-being, which, in turn, help sustain recovery.

    What are the odds for recovery?

    The majority of people with AUD can reduce their drinking and alcohol-related problems over time, with studies showing a reliable pattern of improvement that counters views of AUD as an inevitably worsening disorder.3–5 A 2019 analysis of nationally representative data, for example, found a “substantial level of recovery” among people who had AUD a year or more before being surveyed.4 More than half of the nearly 7,800 participants reported no longer having AUD symptoms (other than craving) for the previous 12 months. This recovery rate is similar to findings from other population surveys, community studies, and follow-up studies.4,5

    Even patients in recovery who have some periods of heavy drinking following alcohol treatment may reduce their consumption and alcohol-related problems by more than half,6 a substantial improvement that can be maintained for many years after treatment.7–9 By highlighting the likelihood of improvements and recovery, you may encourage more patients with AUD to reduce their drinking with or without treatment.

    What does the change process for AUD recovery look like?

    The emerging picture of recovery from AUD is one of a dynamic, individualized process with multiple viable pathways and predictable challenges and improvements.

    • AUD severity and other factors influence treatment seeking. Many people with AUD, particularly those with less severe disorder, recover without treatment.4,5 Those who do seek treatment tend to have greater AUD severity and more comorbid mental health disorders, trauma, or stress.10–13
    • Many people choose a goal of cutting back rather than quitting drinking. Although abstinence is often the objective in recovery, many people choose to continue to drink, and some drink heavily at times.4 Stable, low levels of drinking in recovery are more common among people who do not seek treatment and who tend to have had milder AUD.5 Conversely, abstinence is a more common goal for those who seek treatment and typically have more serious alcohol problems.5 Abstinence is a more stable form of remission for those with more severe AUD than continuing to drink.14
    • Success often happens after just a few serious attempts. The median number of serious recovery attempts is just two, with a mean of five, according to a national survey of 2,000 people who resolved a significant drug or alcohol problem.15 Patients who expect “seemingly endless” tries may feel encouraged and motivated to seek treatment if made aware of how few tries may actually be needed. Those with mental health comorbidities tend to have more attempts.15
    • Relapses to heavy drinking in recovery are common and tend to decrease over time. The majority of people recovering from AUD report at least some occasions of heavy drinking.16 Drinking patterns in the first year of recovery often include one to several short periods or a few longer periods of heavy drinking.16 With time, drinking episodes tend to become less frequent.17 For better outcomes, it is important for patients to avoid periods of heavy drinking, and if they happen, to keep them as few and brief as possible, and to promptly re-engage with treatment.16
    • Negative emotional states, cravings, and sleep issues can persist after people quit or reduce drinking.18,19 Changes in brain neurocircuits as a result of heavy drinking underly these problems. (See Core article on neuroscience.) Initiating and maintaining abstinence can help reduce craving and negative moods over time,18,20 which, in turn, can help reduce relapses, the majority of which may occur during situations involving negative emotional states.21   
    • Improvements can be steady or bumpy. Early recovery from an alcohol problem may be a mixed bag, with steady gains in meeting personal, social, and other basic needs (called “recovery capital”), while other areas of functioning and well-being may worsen before they get better.22 At first, for example, happiness and self-esteem may dip, but these measures gradually increase beginning 6 to 12 months into recovery.22 In the long term, quality of life measures such as relationship satisfaction tend to improve and psychological distress decreases.22

    How can healthcare professionals support recovery?

    Here are a few ways healthcare professionals can support individuals in the AUD recovery process:

    • Negotiate recovery goals with your patient. Advise abstinence for those with AUD as the safest route, but if a patient is hesitant to abstain, then negotiate stepped treatment goals that start with significantly cutting back, such as having no heavy drinking days. Emphasize future-oriented values and goal setting, and help patients see the tradeoff between any immediate, short-term rewards of alcohol and delayed, longer-term rewards of value to them, such as improvements in health, relationships, and work.
    • Recommend evidence-based AUD treatment with continuing care. Patients may wish for a quick fix, so emphasize that AUD recovery is more a marathon than a sprint. Particularly for those with moderate to severe AUD, it is important to make both initial and continuing care plans to help reduce the number and severity of heavy drinking episodes.23,24 Treatment plans can involve FDA-approved AUD medications, which you can prescribe in primary or specialty care; behavioral healthcare, which can include individual, couples, or family therapy; and mutual support groups. You can use the NIAAA Alcohol Treatment Navigator to find specialist prescribers and therapists who provide evidence-based care. (See Core articles on treatment and referrals.)
    • Normalize the difficulties on the path to change. Provide compassionate and supportive education about the recovery process, noting that craving, alcohol-related thoughts and dreams, and challenges maintaining abstinence or drinking reduction are not a failure, but to be expected. Avoid criticism or shaming in response to a relapse to heavy drinking or related problems, which can be stigmatizing. Be optimistic. Note that change is possible, even in the face of challenges and even when prior attempts have not fully met the goal. Share the premise of “progress, not perfection.”
    • Encourage engagement with activities that do not revolve around alcohol. People with AUD often have social networks and activities centered around drinking. Research has found that substance-free activity scheduling is effective in reducing heavy drinking.25 Recommend that patients develop or rekindle interests that do not involve alcohol and encourage them to schedule these activities. Also help your patients identify supportive people with whom they can schedule enjoyable alcohol-free activities.
    • Help your patients identify people who can offer a variety of support. Different people will offer different types of support, and it is important for a patient to identify who can help them with what. These people may be friends, family members, or mutual support group sponsors who would be available, for example, when your patient has a craving or needs moral support. For many, this contact is critical to reduce the risk of a return to heavy drinking.
    • Suggest joining a mutual support group. You can find links to Alcoholics Anonymous (AA), groups for women only, and groups structured without spiritual or 12 step components such as Secular AA or SMART Recovery, in the Resources below. Many groups are now online. Groups vary widely even within the same organization, so encourage patients to try several to find a good match.
    • Help patients who smoke to quit. About 4 in 10 people with AUD smoke cigarettes, more than twice the rate for people without AUD.26 Continuing to smoke during recovery may increase their risk of returns to heavy drinking.27 Effective smoking interventions include nicotine replacement therapy, behavioral healthcare, medications, or a combination of approaches.28 More research on treatment timing is needed, but some studies indicate that concurrent treatments for AUD and smoking can be successful rather than waiting to start the smoking treatment until AUD treatment is completed.28

    What strategies can help patients prevent or recover from a return to heavy drinking?

    Share the strategies below with your patients to help them recognize, avoid, and cope with common causes of heavy drinking episodes.

    • Manage stress. Stress and negative mood (see next bullet) are significantly linked with increased craving and relapse.29 Inform patients that it’s especially important to learn effective stress management strategies to use throughout recovery, especially in early abstinence in which stress-related symptoms may be more prominent.29 Cognitive behavioral therapy (CBT) and other AUD-focused behavioral care can help patients develop skills to avoid heavy drinking by managing stressors and emotions. (See Core article on treatment.)
    • Recognize the cycle of drinking and negative mood. Patients who experience more negative moods in recovery have the highest odds of heavy and frequent drinking, and conversely, those who drink more heavily and frequently have more negative moods.30 Help patients understand that drinking to reduce a negative mood fuels a feedback cycle and that abstinence will likely decrease negative affect over time.30 “Mindfulness-based relapse prevention” may be an optimal behavioral treatment for patients caught in the dynamic of drinking to regulate negative moods.31 (See Core articles on neuroscience, treatment, and mental health issues.)
    • Handle urges to drink. An urge to drink can be set off both by external triggers in the environment and by internal triggers within the patient. External triggers, or “cues,” are people, places, things, times of day, or days of the week that remind people of drinking. These cues create “high-risk situations” that are often more obvious, predictable, and avoidable than internal triggers. Internal triggers can be a fleeting thought, a positive emotion such as excitement, a negative emotional state such as low mood or frustration, or a physical sensation such as a headache, tension, or nervousness. The combination of external and internal triggers can be particularly problematic. Talking with your patients about potential triggers can raise their awareness. Inform them that urges to drink are often short-lived, predictable, and controllable, and they can learn ways to manage them with AUD-focused CBT therapy32 and through a CBT-based self-help module on Handling Urges to Drink from NIAAA’s Rethinking Drinking website.
    • Plan how to refuse drink offers. Social pressure to drink can make it hard for people with AUD to cut back or quit. Rethinking Drinking offers a short module on Building Drink Refusal Skills, which, like the module noted above, applies a recognize-avoid-cope approach commonly used in CBT. It includes worksheets where patients can make their own plans and “scripts” to resist pressure to drink.
    • Recover from a drinking episode. For patients who drink more than they intend, emphasize that setbacks are common, and that each day is a new day to make a fresh start. Help the patient figure out, if possible, what external or internal triggers led to the episode and make use of these findings to plan for the future, while avoiding blame or discouragement. Share this handout of nine tips for Recovering from a Drinking Episode (printable here [PDF – 108 KB]), also from Rethinking Drinking.

    In closing, recovery from AUD is more attainable, the paths people take more varied, the challenges more predictable, and the support strategies more plentiful and effective than you and your patients may expect. By sharing a realistic and hopeful picture of recovery, and by offering your support along the way, you may encourage more patients with AUD to take their first steps, to persevere, and to thrive.

    Resources

    Further Reading in the NIAAA Journal, Alcohol Research Current Reviews

    Alcohol Use Disorder Medication Guides

    Referral Resources

    Therapy Guides for Mental Health Specialists

    Mutual Support Groups

    Resources to Share with Patients Related to this Article

    More resources for a variety of healthcare professionals can be found in the Additional Links for Patient Care.

    References

    1. NIAAA Recovery Research Definitions | National Institute on Alcohol Abuse and Alcoholism (NIAAA). Accessed June 28, 2021. https://www.niaaa.nih.gov/research/niaaa-recovery-from-alcohol-use-diso…
    2. Hagman BT, Falk D, Litten R, Koob GF. Defining Recovery From Alcohol Use Disorder: Development of an NIAAA Research Definition. Am J Psychiatry. 2022 Apr 12:appiajp21090963. doi: 10.1176/appi.ajp.21090963. Epub ahead of print. PMID: 35410494.
    3. Kelly JF, Bergman B, Hoeppner BB, Vilsaint C, White WL. Prevalence and pathways of recovery from drug and alcohol problems in the United States population: Implications for practice, research, and policy. Drug Alcohol Depend. 2017;181:162-169. doi:10.1016/j.drugalcdep.2017.09.028
    4. Fan AZ, Chou SP, Zhang H, Jung J, Grant BF. Prevalence and Correlates of Past-Year Recovery From DSM-5 Alcohol Use Disorder: Results From National Epidemiologic Survey on Alcohol and Related Conditions-III. Alcohol Clin Exp Res. 2019;43(11):2406-2420. doi:10.1111/acer.14192
    5. Tucker JA, Chandler SD, Witkiewitz K. Epidemiology of Recovery From Alcohol Use Disorder. Alcohol Res Curr Rev. 2020;40(3):02. doi:10.35946/arcr.v40.3.02
    6. Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcohol Clin Exp Res. 1998;22(6):1300-1311. doi:10.1111/j.1530-0277.1998.tb03912.x
    7. Witkiewitz K, Wilson AD, Roos CR, et al. Can Individuals With Alcohol Use Disorder Sustain Non-abstinent Recovery? Non-abstinent Outcomes 10 Years After Alcohol Use Disorder Treatment. J Addict Med. Published online October 14, 2020. doi:10.1097/ADM.0000000000000760
    8. Witkiewitz K, Pearson MR, Wilson AD, et al. Can Alcohol Use Disorder Recovery Include Some Heavy Drinking? A Replication and Extension up to 9 Years Following Treatment. Alcohol Clin Exp Res. 2020;44(9):1862-1874. doi:10.1111/acer.14413
    9. Moos RH, Moos BS. Protective resources and long-term recovery from alcohol use disorders. Drug Alcohol Depend. 2007;86(1):46-54. doi:10.1016/j.drugalcdep.2006.04.015
    10. Edlund MJ, Booth BM, Han X. Who Seeks Care Where? Utilization of Mental Health and Substance Use Disorder Treatment in Two National Samples of Individuals with Alcohol Use Disorders. J Stud Alcohol Drugs. 2012;73(4):635-646. doi:10.15288/jsad.2012.73.635
    11. Cohen E, Feinn R, Arias A, Kranzler HR. Alcohol treatment utilization: findings from the National Epidemiologic Survey on Alcohol and Related Conditions. Drug Alcohol Depend. 2007;86(2-3):214-221. doi:10.1016/j.drugalcdep.2006.06.008
    12. Blanco C, Iza M, Rodríguez-Fernández JM, Baca-García E, Wang S, Olfson M. Probability and predictors of treatment-seeking for substance use disorders in the U.S. Drug Alcohol Depend. 2015;149:136-144. doi:10.1016/j.drugalcdep.2015.01.031
    13. Rohn MCH, Lee MR, Kleuter SB, Schwandt ML, Falk DE, Leggio L. Differences Between Treatment-Seeking and Nontreatment-Seeking Alcohol-Dependent Research Participants: An Exploratory Analysis. Alcohol Clin Exp Res. 2017;41(2):414-420. doi:10.1111/acer.13304
    14. Dawson DA, Goldstein RB, Grant BF. Rates and correlates of relapse among individuals in remission from DSM-IV alcohol dependence: a 3-year follow-up. Alcohol Clin Exp Res. 2007;31(12):2036-2045. doi:10.1111/j.1530-0277.2007.00536.x
    15. Kelly JF, Greene MC, Bergman BG, White WL, Hoeppner BB. How Many Recovery Attempts Does it Take to Successfully Resolve an Alcohol or Drug Problem? Estimates and Correlates From a National Study of Recovering U.S. Adults. Alcohol Clin Exp Res. 2019;43(7):1533-1544. doi:10.1111/acer.14067
    16. Maisto SA, Hallgren KA, Roos CR, Witkiewitz K. Course of remission from and relapse to heavy drinking following outpatient treatment of alcohol use disorder. Drug Alcohol Depend. 2018;187:319-326. doi:10.1016/j.drugalcdep.2018.03.011
    17. Witkiewitz K, Masyn KE. Drinking trajectories following an initial lapse. Psychol Addict Behav. 2008;22(2):157-167. doi:10.1037/0893-164X.22.2.157
    18. Hallgren KA, Delker BC, Simpson TL. Effects of Initiating Abstinence from Alcohol on Daily Craving and Negative Affect: Results from a Pharmacotherapy Clinical Trial. Alcohol Clin Exp Res. 2018;42(3):634-645. doi:10.1111/acer.13591
    19. Koob GF, Colrain IM. Alcohol use disorder and sleep disturbances: a feed-forward allostatic framework. Neuropsychopharmacol Off Publ Am Coll Neuropsychopharmacol. 2020;45(1):141-165. doi:10.1038/s41386-019-0446-0
    20. Hallgren KA, McCrady BS, Epstein EE. Trajectories of drinking urges and the initiation of abstinence during cognitive-behavioral alcohol treatment. Addict Abingdon Engl. 2016;111(5):854-865. doi:10.1111/add.13291
    21. Larimer ME, Palmer RS, Marlatt GA. Relapse prevention. An overview of Marlatt’s cognitive-behavioral model. Alcohol Res Health J Natl Inst Alcohol Abuse Alcohol. 1999;23(2):151-160.
    22. Kelly JF, Greene MC, Bergman BG. Beyond Abstinence: Changes in Indices of Quality of Life with Time in Recovery in a Nationally Representative Sample of U.S. Adults. Alcohol Clin Exp Res. 2018;42(4):770-780. doi:10.1111/acer.13604
    23. Bowen S, Witkiewitz K, Clifasefi SL, et al. Relative Efficacy of Mindfulness-Based Relapse Prevention, Standard Relapse Prevention, and Treatment as Usual for Substance Use Disorders. JAMA Psychiatry. 2014;71(5):547-556. doi:10.1001/jamapsychiatry.2013.4546
    24. McKay JR. Impact of Continuing Care on Recovery From Substance Use Disorder. Alcohol Res Curr Rev. 2021;41(1):01. doi:10.35946/arcr.v41.1.01
    25. Meyers RJ, Roozen HG, Smith JE. The community reinforcement approach: an update of the evidence. Alcohol Res Health J Natl Inst Alcohol Abuse Alcohol. 2011;33(4):380-388.
    26. Weinberger AH, Pacek LR, Giovenco D, et al. Cigarette Use Among Individuals with Alcohol Use Disorders in the United States, 2002 to 2016: Trends Overall and by Race/Ethnicity. Alcohol Clin Exp Res. 2019;43(1):79-90. doi:10.1111/acer.13922
    27. Sliedrecht W, de Waart R, Witkiewitz K, Roozen HG. Alcohol use disorder relapse factors: A systematic review. Psychiatry Res. 2019;278:97-115. doi:10.1016/j.psychres.2019.05.038
    28. Thurgood SL, McNeill A, Clark-Carter D, Brose LS. A Systematic Review of Smoking Cessation Interventions for Adults in Substance Abuse Treatment or Recovery. Nicotine Tob Res. 2016;18(5):993-1001. doi:10.1093/ntr/ntv127
    29. Sinha R. How Does Stress Lead to Risk of Alcohol Relapse? Alcohol Res Curr Rev. 2012;34(4):432-440.
    30. Witkiewitz K, Villarroel NA. Dynamic Association Between Negative Affect and Alcohol Lapses Following Alcohol Treatment. J Consult Clin Psychol. 2009;77(4):633-644. doi:10.1037/a0015647
    31. Roos CR, Bowen S, Witkiewitz K. Baseline patterns of substance use disorder severity and depression and anxiety symptoms moderate the efficacy of mindfulness-based relapse prevention. J Consult Clin Psychol. 2017;85(11):1041-1051. doi:10.1037/ccp0000249
    32. Miller W. COMBINE Monograph Series, Volume 1. Combined Behavioral Intervention Manual: A Clinical Guide for Therapists Treating People With Alcohol Abuse and Dependence. DHHS Publication No. (NIH) 04-5288 Accessed July 1, 2021. https://www.niaaa.nih.gov/sites/default/files/NIAAA-combined-behavioral-intervention-manual.pdf
    Earn CME/CE Credit

    We invite healthcare professionals including primary care physicians, physician assistants, nurses, pharmacists, and psychologists to complete a post-test after reviewing this article to earn FREE continuing education (CME/CE) credit. This CME/CE credit opportunity is jointly provided by the Postgraduate Institute for Medicine and NIAAA.

    CME/CE Activity — Support Recovery: It’s a Marathon, Not a Sprint

    Released on 5/6/2022
    Expires on 5/10/2023

    Complete CME/CE Post-Test

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    Learning Objectives

    After completing this activity, the participant should be better able to:

    • Identify at least three characteristics of AUD recovery.
    • Summarize strategies that healthcare providers can use to support individuals in the AUD recovery process.
    • Describe approaches to help patients prevent or recover from heavy drinking episodes.

    Contributors

    Contributors to this article for the NIAAA Core Resource on Alcohol include the writer for the full article, content contributors to subsections, reviewers, and editorial staff. These contributors included both experts external to NIAAA as well as NIAAA staff.

    External Writer

    Katie Witkiewitz, PhD
    Professor, Department of Psychology,
    University of New Mexico, Albuquerque, NM

    NIAAA Content Contributors

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    External Reviewers

    Anika A. Alvanzo, MD, MS, FACP, DFASAM
    Managing Partner, Uzima Consulting
    Group LLC, Middle River, MD;
    Eastern Region Medical Director, Pyramid
    Healthcare, Inc., Duncansville, PA

    Julianne Flanagan, PhD
    Associate Professor, Department of Psychiatry
    and Behavioral Sciences, MUSC
    Staff Psychologist, Ralph H. Johnson VA
    Medical Center, Charleston, SC.

    John F. Kelly, PhD, ABPP
    Elizabeth R. Spallin Professor of Psychiatry in
    Addiction Medicine, Harvard Medical School;
    Director, MGH Recovery Research Institute,
    Massachusetts General Hospital, Boston, MA

    Jalie A. Tucker, PhD, MPH
    Professor, Department of Health Education &
    Behavior and Director, UF Center for
    Behavioral Economic Health Research,
    University of Florida, Gainesville, FL

    NIAAA Reviewers

    George F. Koob, PhD
    Director, NIAAA

    Patricia Powell, PhD
    Deputy Director, NIAAA

    Nancy Diazgranados, MD, MS, DFAPA
    Deputy Clinical Director, NIAAA

    Brett T. Hagman, PhD
    Program Director, Treatment, Health Services,
    and Recovery Branch, NIAAA

    Lorenzo Leggio, MD, PhD
    NIDA/NIAAA Senior Clinical Investigator and Section Chief;
    NIDA Branch Chief;
    NIDA Deputy Scientific Director;
    Senior Medical Advisor to the NIAAA Director

    Aaron White, PhD
    Senior Scientific Advisor to
    the NIAAA Director, NIAAA

    Editorial Team

    NIAAA

    Raye Z. Litten, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Director, Division of Treatment and Recovery, NIAAA

    Laura E. Kwako, PhD
    Editor and Content Advisor for the Core Resource on Alcohol,
    Health Scientist Administrator,
    Division of Treatment and Recovery, NIAAA

    Maureen B. Gardner
    Project Manager, Co-Lead Technical Editor, and
    Writer for the Core Resource on Alcohol,
    Division of Treatment and Recovery, NIAAA

    Contractor Support

    Elyssa Warner, PhD
    Co-Lead Technical Editor,
    Ripple Effect

    Daria Turner, MPH
    Reference and Resource Analyst,
    Ripple Effect

    To learn more about CME/CE credit offered as well as disclosures, visit our CME/CE General Information page. You may also click here to learn more about contributors.

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