Milk, Bread, Ground Beef, and Overdose Medication

By: Marcus J. Hopkins, Blogger

The HEAL Blog has been following the issue of opioid addiction very closely, largely because Injection Drug Users (IDUs) represent a large proportion of new Hepatitis C (HCV) infections in the U.S., particularly in rural parts of the country. The Appalachian Mountain region serves as a prime example of how heroin and opioid addiction can lead to a rash of both HIV and HCV outbreaks; it also serves as excellent proving grounds for how Harm Reduction methods can help to prevent mass outbreaks, as well as save lives.

Harm Reductions measures are those that focus on preventive measures that have been shown to lessen the risk to individuals through various legal means. As they relate to opioid addiction, one of the most important measures is increased access to Naloxone, a medication that is used to block the effects of opioid drugs, such as slowed breathing and loss of consciousness. Naloxone – sold under the brand name, Narcan – is a nasal spray that is used to counteract the effects of an opioid overdose. It is currently listed on the World Health Organization’s “List of Essential Medicines,” the most important medications needed in a basic health system, and increasing ease of access without a prescription is something for which advocates have long fought.

Last week, in the city of Huntington, WV, 26 people overdosed on opioid drugs in a period of only four hours from a particularly potent batch of heroin. Of those 26 overdose cases, none of the patients died, as first responders and hospitals were quick to react, delivering a total of 12 doses of Naloxone, including the two used by Huntington police. One patient had to be revived using three doses (Struck, 2016). The remaining patients were revived using bag valve masks, a handheld device used to provide ventilation to patients who aren’t breathing. The users who overdosed ranged in age from 20 to 59, demonstrating that the opioid epidemic affects people of virtually every age range. In Cabell County, where Huntington is located, there were 440 overdoses by June of this year, 26 of which resulted in death; the state of West Virginia, itself, ranks highest in the number of overdose deaths in the U.S.

In Kentucky, the next state over and less than fifteen miles from Huntington, Kroger grocery store locations with pharmacies on site began offering Naloxone over the counter without a prescription at 96 locations, including 80 pharmacies in the Louisville Division (Warren, 2016). Kentucky currently ranks in the top five states for overdose deaths, which makes it an excellent test market for the efficacy of offering Naloxone without a prescription. That said, the Kroger locations in Ashland, KY – the city nearest Huntington, WV – does not yet offer the drug over the counter.

Naloxone rescue kit

Photo Source: Yourblogondrugs.com

When we discuss expanding Naloxone access, there are a number of ways that access can be broadened – (1.) Naloxone can be carried by first responders; (2.) Naloxone can be carried also by state employees (such as school officials); (3.) Naloxone can be sold without a prescription to anyone. WV does not currently allow the sale of Naloxone without a prescription, although WV HB 4035 seeks to do just that. Access to first responders, including police and other emergency personnel, was expanded beyond just Emergency Medical Technicians (EMTs) in May of this year, but it is unclear, yet, whether or not HB 4035 will be ratified and made into law by the end of this year. In an election year, particularly in the latter half, little of substance seems to get done.

What is important, however, is that we continue to fight to expand access to this lifesaving drug. Politics and personal peccadillos aside, saving someone’s life should never fall prey to moralizing of whether or not opioid abuse is wrong, nor should saving a life be predicated upon whether or not one agrees with the lifestyle choices of the victim. When lives are at risk, every reasonable action should be taken to ensure that those lives are saved.

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Rhode Island Reports Explosion of Chronic HCV, Injection Drug Use

By: Marcus J. Hopkins, Blogger

A new report from the Rhode Island Public Health Institute at Brown University found that the state is currently in the midst of a steep rise in chronic Hepatitis C (HCV) infections, as well as in opioid dependence and overdose. Referred to in the report as a “syndemic,” the study paints a grim picture for the densely populated New England state.

Report Cover: Epidemiological Profile: The Hepatitis C Epidemic in Rhode Island

Photo Source: Rhode Island Department of Health

The study found a 500% increase in HCV-related deaths in the state; it also estimated a prevalence rate of 3.7% – 6%, suggesting that the HCV disease burden – the impact of a health problem as measured by financial cost, mortality, morbidity, or other indicators – may be higher than the state previously estimated. Additionally, Rhode Island’s Medicaid program reporting data suggests that 13,000 Medicaid beneficiaries were screened for HCV in 2014 and 2015; of those beneficiaries, approximately 1,700 returned HCV-positive test results in 2014 and 2015, though it is unknown if all of those individuals sought treatment for their diagnoses. Medicaid reported financing treatment for 215 Medicaid beneficiaries in 2015.

As it relates to last week’s HEAL Blog (HCV in prison populations), the Rhode Island Department of Correction (RIDOC) reported that the prevalence rate for inmates screened for HCV is 17%, and have responded with increased screening, treatment, and cure efforts in the last year.

This new report also indicates that opioid addition and overdose is on the rise within the state, ranking 6th in the nation for drug overdose deaths, the highest in New England. More concerning, perhaps, than the fata overdose rate is that of the non-fatal – at least five times as many non-fatal drug overdoses were reported, which suggests a high level of drug dependence in a relatively small, but densely packed state.

New England, as a whole, continues to battle a growing opioid addiction and overdose epidemic, particularly in the rural and suburban parts of the states – areas which had previously managed to be largely unaffected by the ravages of drug abuse. This trend is reflective of the opioid epidemic in most of the country, and speak to a larger national opioid abuse issue that Federal, state, and local governments are desperate to adequately address.

On the national front, efforts to tighten regulations on prescription opioid drugs face considerable pushback from pharmaceutical manufacturers, whose political sway has largely paralyzed regulatory bodies in their attempts to move forward on the issue. That said, the FY2017 budget currently working its way through the House and Senate includes a significant increase in funds to various programs directed at combating opioid abuse. There has been some movement on efforts to lift the blanket ban on Federal funding for syringe exchange programs, a harm reduction method proven to decrease the spread of blood borne infections, such as HIV and HCV, within Injection Drug User (IDU) populations.

At the state level, Rhode Island’s sole syringe exchange program, ENCORE (Education, Needle Exchange, Counseling, Outreach, and REferrals), is an anonymous program that can provide any individual over the age of 18 with safer sex materials, including clean syringes, bleach, alcohol swabs, cookers, and cotton, as well as condoms. ENCORE outreach workers can also provide anonymous HIV testing, referrals to drug treatment programs, medical care, and social services, as well as clothing and personal hygiene items. The program is located in Providence, RI, and information can be found at http://www.aidscareos.org/.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

 

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Intersection of Imprisonment and Healthcare

By: Marcus J. Hopkins, Blogger

“Nearly forty years ago, the U.S. Supreme Court ruled in Estelle v. Gamble that ignoring a prisoner’s serious medical needs can amount to cruel and unusual punishment, noting that “[a]n inmate must rely on prison authorities to treat his medical needs; if the authorities fail to do so, those needs will not be met. In the worst cases, such a failure may actually produce physical torture or a lingering death[.] … In less serious cases, denial of medical care may result in pain and suffering which no one suggests would serve any penological purpose” (American Civil Liberties Union, n.d.)

 

These words put forth in a Supreme Court ruling are vitally important in today’s society – one in which the Centers for Disease Control and Prevention (CDC) released its first ever National Survey of Prison Health Care, the results of which were rosy on the surface, but admittedly (on their part) limited in scope, because they only asked if the service was available, rather than checked to see if the services were actually delivered. In addition, numerous reports at the 2016 International AIDS Conference in Durban, South Africa point to a serious issue brewing in the world’s prisons, as the “War on Drugs,” mass incarceration of drug users, and the failure to provide proven harm reduction and treatment strategies has led to high levels of HIV, tuberculosis, and hepatitis B and C infection among prisoners—far higher than in the general population (Medical Express, 2016).

Two hands holding prison bars

Photo Source: News Limited

The U.S. is exceptional, when it comes to the number of inmates in prison for drug offenses: of the 182,924 inmates currently in Federal prison, 84,746 (46.3%) of them were there for drug-related offenses (Federal Bureau of Prisons, 2016). There are roughly 5 million drug-related arrests each year (Prison Policy Initiative, 2016), all of whom spend some portion of their time going in and out of the jail or prison population, which increases the risk of exposure to blood borne pathogens such a HIV, Hepatitis C (HCV), Hepatitis B (HBV), and Tuberculosis (TB) exponentially over that of the general population. As Injection Drug Users (IDUs) represent an ever-increasing percentage of new HCV infections in the U.S. and around the world, the risk of transmission amongst prison populations is an incredibly serious issue that needs to not only be watched, but addressed.

The unfortunate intersection of imprisonment and healthcare statistics is the reality of the HCV treatment landscape in our nation’s prisons. This has been brought into sharp focus, recently, by a Federal lawsuit against state prison officials in Tennessee, which asks the courts to force the state to start treating all inmates who have HCV (WBIR, 2016).. The Tennessean (part of USA Today) released a report in May 2016 finding that only 8 of the 3,487 inmates known to have HCV were being treated for the disease (Tennessean, 2016) – treatment to which these patients are constitutionally guaranteed, but for which few are ever approved. Further complicating the issue is that the number of HCV-infected inmates is likely much higher, but only a handful are ever tested, because “…acknowledging inmates have the disease means they must treat it.”

The lawsuit in Tennessee is just the latest in a string of Federal and class action lawsuits filed against state and Federal prisons over access to HCV drugs, which similar suits being filed in Pennsylvania, Massachusetts, and other states. Failure to adequately screen and treat all incoming patients for infectious diseases such as HIV and HCV is, in this writer’s opinion, a gross dereliction of duty on the part of prison officials that risks not only prison populations, but to all citizens at large, once those prisoners are released into general population. HIV and HCV that goes untreated is not only likelier to result to much more costly long-term health complications (and potentially death), but is also likely to result in greater overall infection rates, as untreated diseases are more easily spread from person to person.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

 

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AbbVie Receives FDA Approval for Viekira XR

By: Marcus J. Hopkins, Blogger

AbbVie, the makers of the Hepatitis C (HCV) Direct Acting Agent (DAA) drug regimen, Viekira Pak, have received final approval from the Food and Drug Administration (FDA) for their new combination regimen, Viekira XR. The move by AbbVie provides patients with a simpler regimen to follow, in the hopes of increasing regimen compliance.

Stamp marked, "Approved" next to the initial, "FDA"

Photo Source: 3Dprint.com

The chief complaints about the AbbVie regimens from physicians and patients, alike, have been the use of multiple individual component pills – four with the original Viekira Pak, three with Technivie, and now, three with Viekira XR – as well as the dosing guidelines, which require pills to be taken at different times of the day in order to maintain consistent levels of the drug in the body. These complaints hearken back to similar complaints made about multi-pill regimens used to treat HIV, that required multiple doses per day. Regimen compliance with multi-pill regimens is thought to be lower, because patients report feeling more burdened by having to stop what they’re doing, multiple times per day, in order to take their meds. This argument seems to hold sway, as many of the newest regimens for both HIV and HCV are single-pill regimens (occasionally boosted by a second pill), which require far less effort on the part of busy patients. Viekira XR responds to this by simplifying the regimen down to a once-daily dose of one pill containing ombitasvir, paritaprevir, and ritonavir, and a second pill containing dasabuvir.

Like Viekira Pak, Viekira XR is designed for use in patients living with HCV Genotypes 1a and 1b. Technivie, which has all of the same components as Viekira Pak minus the dasabuvir, is for use in patients with HCV Genotype 4, and was the first DAA drug that was specifically used for that genotype. AbbVie may, however, face considerable competition for their new drug, unless they choose to entre the drug into the market at a lower Wholesale Acquisition Cost (WAC) that Gilead Science’s latest pan-genotypic drug, Epclusa, which hit the market in late June at a price of $75,000 before discounts, rebates, or pricing negotiations. Viekira XR has not yet received a WAC announcement at the time of writing.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Prescribing Data Paints a Sobering Picture

By: Marcus J. Hopkins

Whenever I speak to colleagues in the medical profession about my work with Hepatitis C (HCV) and coverage data, I inevitably begin citing some of the grim statistics related to the disease: recent spikes in new HCV diagnoses indicate that poorer people between the ages of 13-35 are the new face of the disease; the most effective drugs to treat the virus cost more for twelve weeks of treatment than most Americans make in a single year; that opioid prescription drug and heroin abusers are likelier than virtually any other population to contract HCV; how the disease is largely un- or under-reported, because states lack the funds to adequately monitor and track the disease.

Bar Chart

Photo Source: kngac.ac.in

That I am familiar with the topic and can speak with some authority on the matter is clear, but what I am consistently asked by physicians, specifically, is why I believe we should make testing compulsory for those who are not Baby Boomers, the conventional wisdom being that this population, because they are likelier to have received blood transfusions prior to 1990, are high on the list o potential candidates for HCV. As I try to explain that, the new face of the disease is quickly becoming Injection Drug Users (IDUs) who are younger, whiter, and poorer, I find myself met with consternation. How can I possibly think that compulsory – and potentially costly – blanket screening would produce a net positive result?

My experience comes from having lived during and through the AIDS epidemic of the 1980s and 90s. As a kid and teenager growing up during the age of Comprehensive Sex Education, the constant mantra was “Get tested, get tested, get tested.” The campaign knew that teenagers and young adults were going to have sex with one another, and getting tested was one of the best ways to prevent the spread of HIV; by knowing your status, you could protect yourself and others with whom you might come in contact. These messages were blasted all over the media, in schools, in health classes, in science classes, on television shows, on the radio, in popular music – and, for the most part, this tactic was effective. New infections have largely plateaued over the past twenty years, or so, at roughly 50k annually in the U.S. That these types of marketing and policies directed toward HCV could produce similar results is, to me, a no-brainer.

Despite our differences on testing policies, a constant refrain I hear, especially from Appalachian physicians, is one detailing the woes of opioid drug abuse. “We see more people in the ER for drug abuse-related issues, than for virtually any other reason,” a nighttime ER nurse relayed to me, while collecting a throat culture to check for flu. “How these people get ahold of so many pills is beyond me!”

I hear that, a lot – doctors and nurses who seem simply flummoxed as to how patients come by these prescription drugs, considering the high number of opioid pain relievers prescribed in WV (137.6 for every 100 West Virginians) (Centers for Disease Control and Prevention, 2014). I’m told stories about how boring and pointless are the mandatory opioid educational courses, when they’re not a part of the problem; why should they have to take them, and waste their time on something that’s not really in their wheelhouse?

This might be the biggest disconnect that I encounter – how the behaviors of medical personal and prescribing physicians as they relate to opioid prescription drugs may be driving the increase in new drug abuse-related HCV infections. When a healthcare professional focuses only on the behaviors of patients, without acknowledging that their own role in providing their patients with access to these highly addictive drugs, it is a reminder of just how vital, and yet seemingly unheeded, those mandatory opioid education courses are. Their tacit assertion that common drug dealers, and not themselves, are the crux of the problem demonstrates how badly they need those courses.

Given the high correlative relationship between prescription drug abuse (and its potential, and perhaps eventual, path to heroin) and HCV infections, one might be led to think that the best place to stem the problem would be with the providers of the vice. Of course, a one-solution course of action will never be enough to effectively, or even adequately, combat the problem; multiple angles must be attacked in order to win the war against HCV, and unless we put forth adequate funding, staffing, and physical resources to fight these battles, we will likely fail to win the war.

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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Partisan Poison Pills for 2017

By: Marcus J. Hopkins, Blogger

Each year, the House Appropriations Committee – specifically, the Subcommittee for Labor, Health, and Human Services (LHHS) – releases a funding bill for the coming Fiscal Year (FY). In what is very likely highly partisan politics on the part of Congressional Republicans during a highly volatile election year, several hefty cuts and prohibitions were introduced into the spending bill which will likely – and in this writer’s opinion, hopefully – result in a veto from the President.

House Appropriations Chairman, Hal Rogers (R-KY), stated the following:

This is the 12th and final Appropriations bill to be considered by the Committee this year. It follows the responsible lead of the legislation before it –  investing in proven, effective programs, rolling back over‑regulation and overreach by the Administration that kills American jobs, and cutting spending to save hard‑earned taxpayer dollars.

Pill with the words, Poison Pill

Photo Source: Venitism

Anyone familiar with the coded language of politics knows that this is partisan fodder to try and bolster so-called “Conservative” bona fides during an election year, and the Republicans on this subcommittee pulled out all the stops ensuring that American families and individuals pay the price for their political pandering.

The final version of the bill, which has yet to go to the full House, contains the following (taken from the Appropriations site):

  • Centers for Disease Control and Prevention (CDC) – $90 million ($20m above 2016) to expand efforts to combat prescription drug abuse (a positive step, in HEAL Blog’s view). The bill also continues the “…longstanding prohibition against using federal funds to advocate or promote gun control,” which essentially forbids the CDC from labeling firearms and gun violence a public health crisis without risking severe cuts;
  • Substance Abuse and Mental Health Services Administration (SAMHSA) – $581 million to address opioid and heroin abuse, including $500m for a first-ever comprehensive state grant program that will address the opioid epidemic nationwide (another positive step), but “…maintains a prohibition on federal funds for the purchase of syringes or sterile needles, but allows communities with rapid increases in cases of HIV and Hepatitis to access federal funds for other activities, including substance use counseling and treatment referrals” (a halfway step that still ignores and fails to fund “proven” and “effective” harm reduction programs);
  • Health Resources and Services Administration (HRSA) – “Saves” taxpayers nearly $300m by eliminating all funding for the “controversial” Family Planning Program, a program that has existed and been funded since 1970 that provides contraceptive care to avert unintended pregnancies, screening for sexually transmitted diseases and infections, HIV testing, and cervical cancer screenings. These programs provide voluntary family planning information and services for their clients based on their ability to pay (on a sliding scale), and the stripping of these funds is likely to have a disproportionate impact upon lower income Americans and minorities;
  • Centers for Medicare and Medicaid Services (CMS) – Strips $576m in funds from FY16, and comes in a $1 billion below the President’s budget request. “The bill does not include additional funding to implement ObamaCare programs, and prohibits funds for the Center for Consumer Information and Insurance Oversight and Navigators programs,” essentially leaving consumers to fly blind in order to appease the anti-Affordable Care Act Republican party platform (which the chairman cannot even call by its proper name).

If it seems like anything is missing, you’ll notice from that there is no new funding for Viral Hepatitis, despite numerous Congressional hearings where representatives bemoaned the high prices of Hepatitis C (HCV) drugs and wrung their hands about the bleak prospect of exponential increases in new Hepatitis B (HBV) and HCV infections, largely related to the very same opioid and heroin abuse they managed to fund.

This bill, should it make it out of the House and Senate, is yet another example of the now-all-too-familiar dance of “Two Steps Forward; Three Steps Back” that has occurred for the past six years of Republican control of Congress. While some improvements are made, the vast majority of proposals tend to result in cuts that are sold as “cost saving” and sacrifice “controversial” programs (controversial only to the 1/3 or less of American constituents) that should leave taxpayers feeling like they’ve be presented with false advertising. Hopefully, some of these…unique proposals will be removed before a final bill is sent to the President for approval, but in an election year – particularly the one of the length and actual controversy we’re currently forced to endure – virtually anything can, and usually does, happen.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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Carolina on My Mind

By: Marcus J. Hopkins, Blogger

Every year, legislatures around the United States pass legislation that is a mixture of good and bad, and this year, North Carolina’s bill, H972, is no exception.

First and foremost, H972’s primary function is to codify into law that recordings made by law enforcement agencies are not public record, and therefore are not subject to Freedom of Information Act (FOIA) or public records requests. This portion of the bill – which makes up two-thirds of the document, itself – is the likeliest portion of the bill to head immediately to court. It is not, however, within the context of the purposes of HEAL Blog to comment either on the legality or constitutionality of this section, and we will therefore move on to the next.

For our purposes, the final two pages of the bill authorize the establishment of state-sanctioned needle exchange programs in the state of North Carolina. This is a fantastic step forward in a state hard hit by the ravages of opioid prescription drug and heroin abuse. Injection drug users (IDUs) represent an ever-increasing percentage of new HIV and Hepatitis C (HCV) infections in the United State, and syringe exchange programs as a measure of harm reduction have largely shown to be effective in preventing the spread of disease by reducing the likelihood that IDUs will share needles.

Image promoting needle exchange for IDUs

According to the Centers for Disease Control and Prevention (CDC), injection drug use accounted for a full 6% of new HIV infection in adults and adolescents in 2014. That number is likely to rise considerably for the year 2015, with the recent spate of widespread infection in rural and suburban areas in Indiana, Kentucky, Ohio, West Virginia, and Massachusetts.

Indiana’s well-publicized example of the risk of HIV and HCV exposure via injection drug use was so vast, it inspired a usually vehemently opposed conservative legislature to agree to pass emergency permission to establish state-sanctioned syringe exchange programs in the hardest hit areas of the state. Similar circumstances prompted certain areas in Kentucky and West Virginia – areas where syringe exchanges have been long needed, but never funded – to establish localized syringe exchange programs in some of the most impacted areas.

While North Carolina’s legislature should be lauded for their passage of Needle Exchange provisions, there is some concern that its inclusion in a bill designed to make secret the recordings of law enforcements agencies and the constitutional concerns that raises may prompt the governor to veto the bill. If that occurs, it is hoped that the tireless advocacy efforts of NC State Senator Stan Bingham and State Representative John Faircloth – both Republicans – will find their way back into another bill, as this issue is vitally important to preventing the further spread of HIV and HCV in North Carolina and beyond.
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Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.

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