
OxyContin billionaire has patented a drug to wean addicts from opioids - dsr12
https://www.washingtonpost.com/news/business/wp/2018/09/08/the-man-who-made-billions-of-dollars-from-oxycontin-is-pushing-a-drug-to-wean-addicts-off-opioids
======
elipsey
The patent is for sublingual buprenorphine, which has appears to have been
available since the early 80's, while buprenorphine has existed for 50
years.[1] It seems like we're getting the exactly patent ever-greening
behavior we have incentivized.

*[https://en.wikipedia.org/wiki/Buprenorphine#History](https://en.wikipedia.org/wiki/Buprenorphine#History)

~~~
epmaybe
I disagree that this is not novel. It's an _immediately_ dissolvable
buprenorphine. I discussed this in my top level comment, but subutex has been
abused because it does take some time to dissolve, so patients will sometimes
take it out of their mouth when the healthcare provider is not looking in
order to inject later. This version avoids that to some extent, which is novel
enough to be patentable.

~~~
girvo
Eh. Bupe isn’t that abusable, so you very quickly get a couple weeks of take-
home doses. So if you’re going to IV it, this new patent makes zero
difference.

~~~
epmaybe
sublingual buprenorphine like Subutex is only indicated for take-home if the
patient can not tolerate suboxone (oral buprenorphine/naloxone). If you're
prescribing subutex take-home just because, you're not following the preferred
prescribing practices. Suboxone and subutex are not used the same way, as I
described in my top level comment in this thread.

Subutex is for patients that are not clinically stable, so they get daily
doses from their treatment center and are watched as they take the medicine.
You could argue that the providers should watch them until they have dissolved
it, and thus this patent is over-engineering a solution, but that's not what
you argued.

Suboxone is for patients that are clinically stable, compliant, and/or are
unable to make frequent visits to their treatment center, so they are able to
take-home their medication and take it as prescribed. These are patients that
you as the healthcare provider are relatively certain wouldn't abuse it.

And yes, while buprenorphine isn't as abusable as most other medications, and
is far more forgiving than methadone, it's not perfect, and there is still
some liability for abuse, especially with subutex. So while I agree that this
patent makes very little difference (again, check my longer comment), it's not
all that bad of an idea, hence why Purdue likely patented it.

~~~
girvo
Which is why I said "bupe" instead of naming either formulation. Suboxone is
just as IV-abusable as Subutex itself. It makes little difference in practice.
(I'm on Subutex, but that's because I'm on 0.8mg daily -- down from 32mg
originally. I've never abused mine, because I really don't see the point, but
I've seen enough people who have). Subutex is barely prescribed at all in
Australia, where I'm from, but it makes effectively zero difference in IV
usage -- the naltrexone does nothing compared to how strongly bupe itself
binds to your receptors.

~~~
epmaybe
Sure, they're both IV abusable, but my point was that for the patients that
are still addicted to opioids the more immediate dissolve of the patented
formulation would make it more preferable to subutex for providers, simply
because they know that a patient couldn't take the tablet out of their mouth
since it would have dissolved immediately. It's those patients we're trying to
get back on track with something better, not the patients we know are able to
manage on take-home regimens.

> the naltrexone does nothing compared to how strongly bupe itself binds to
> your receptors.

What? First of all, it's naloxone rather than naltrexone that is found in
suboxone. Subutex doesn't have either of them. And secondly, it's very, VERY
well known that naloxone/naltrexone have far more binding affinity to the mu-
opioid receptor (the type that we think causes euphoria/analgesia) compared to
any sort of opioid we have on the market (maybe not sufentanyl, but even that
I'm fairly certain is weaker affinity). That's exactly why we can use Narcan
effectively to combat opioid overdose.

~~~
girvo
> What? First of all, it's naloxone rather than naltrexone that is found in
> suboxone. Subutex doesn't have either of them.

I always get them mixed up, but it really isn't changing my point. And yes, no
kidding, you brought up Suboxone as well as Subutex which is why I'm
discussing it! I'd really prefer if you read my comments with a little more
charity. Anyway, it doesn't appear as if you're listening to my point here,
and that's okay :) Have a good day

------
md224
People will abuse anything that helps to numb painful emotions. Demonizing the
drug isn't helpful; if you get rid of one, people will lean on something else.
The solution to drug addiction is very simple: give people better ways of
dealing with their emotional pain. Of course, actually accomplishing that is
the hard part.

My personal belief is that we need a two-fold attack:

1) Harm reduction: provide people with less harmful emotional anesthetics
(like Kratom)

2) Fix the underlying problem: provide people with better mental health care,
better coping strategies, more community and more human connection.

Most people agree that #2 is needed, but #1 is controversial. I think that we
should treat emotional injuries like physical injuries. When someone breaks
their leg and they ask for painkillers, we don't tell them "sorry, but you
know that painkillers aren't going to help you heal any faster."

Sometimes people need palliative treatments, but we're unwilling to provide
these when it comes to psychological pain. As far as I can tell, this
unwillingness is based entirely on an aphoristic assumption: "if you want to
heal it, you have to feel it." Okay, great, but where's the science? Where's
the research? Do you have to feel it completely to heal it, or can you take a
drug that helps you feel it a bit less? What's the exact relationship between
experiencing distress and healing that distress? We can't allow slogans to
guide the treatment of psychological trauma.

~~~
caseymarquis
Addiction is physiological. You're describing psychological dependence. You
can die from drug withdrawal. Given that, medicine which aids in weaning off
addictive drugs seem useful.

------
sgibat
If you read the patent, this is simply a faster dissolving suboxone, which is
already an extremely common form of substitution therapy. This isn't anything
radically new. I would say it doesn't deem itself worthy of patent, but I know
nothing of patent laws.

~~~
mtgx
This is the type of "research" Big Pharma often does that needs all of those
billions of dollars and 4,000% price increases of life-saving drugs, according
to some.

------
olliej
The correct course of action is to charge the manufacturers of addictive drugs
for the recovery costs.

It would discourage pushing over prescription, encourage more work into
accurately identifying addictiveness (and presumably reducing it), and if all
else fails would encourage them to develop cheap drugs to recover from
addiction.

~~~
tejtm
A more abrupt correct course of action comes to mind followed by seizing all
assets even tangentially related as inadequate compensation for horrific
damages. ya know, to make an example, like we do with the little people.

~~~
meowface
So if a manufacturer produces a drug which saves tens of millions of people
from suffering and a few million of those don't follow manufacturer or doctor
instructions and abuse it, the drug manufacturer should be shut down?

~~~
wjn0
If a drug dealer sells a drug that people enjoy and use to improve their
quality of life, but a few people don't follow his advice and become addicted
and die as a result, the drug dealer should go to prison for manslaughter?

~~~
meowface
No, I don't think they should, if what they're selling is what they claim to
be selling. If it's laced with fentanyl or some other adulterant, that's
another story (regardless of whether they were aware it was adulterated or
not).

------
dillondoyle
I hate this profit seeking marketing BS and I think it's kind of evil. They
must know better. I can't believe they don't have data on actual use of
Buprenorphine specifically the number of patients who take it long term and
have huge issues tapering off Buprenorphine itself.

Getting off suboxone itself is very difficult. It seems most users describe
the withdrawal as harder than heroin because it lasts a much longer time. [1]
[2]

I'm perfectly fine with the idea of replacement therapy. And in fact I
actually think we should just provide pure morphine to users for free it would
actually be pretty safe for long term use (and WAY cheaper).

Long term Suboxone replacement therapy also sounds like a great tool if it
weren't for the marketing lies and profit. That's where my huge beef is.

Yet again making big profit by marketing the (at best not the whole truth, I
think truth is closer to false and morally corrupt) idea that this is
temporary. Maybe after they make a few billion and get people hooked on subs
they will pivot to sell another expensive patented drug to 'wean off' suboxone
and continue the profits. Of course there are examples of users being able to
taper off. But there seems to be far more examples of users not being able to
wean from Buprenorphine itself.

1: [https://www.nytimes.com/2013/11/17/health/in-demand-in-
clini...](https://www.nytimes.com/2013/11/17/health/in-demand-in-clinics-and-
on-the-street-bupe-can-be-savior-or-menace.html) 2:
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5398454/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5398454/)

~~~
coleifer
There was a prominent doctor here in Topeka who was fired from the hospital
for keeping folks on Suboxone. The idea of course is that you can have a nice
gentle taper, same with methadone, but the reality is you can't "beat"
withdrawal. So people stay on it. The euphoria from these drugs doesn't come
close to heroin, so people are continually going back and forth. There's an
added danger because buprenorphine binds tighter that if it's in your system
it takes a lot more dope to kick the buprenorphine off the receptors, so lots
of overdoses. This, I believe, is the reality.

Of course Suboxone and methadone are so much safer to use than street heroin.
And doctors will help those who want to, to taper. I just don't think that
describes most sub/methadone users.

I don't think the issue is a lack of safer alternatives. It's whatever is
driving the person to seek out the effects produced by those drugs in the
first place.

~~~
girvo
Very few of us want to be on subs or done, and even fewer enjoy being an
addict. Even if it is safer than H. Your “I think” doesn’t really align with
my experience at all, at least here in Australia. Shout out to Biala, they
saved my life.

------
CodeWriter23
Also, all forms of buprenorphine (aka Suboxone) often end up being a heroin
substitute rather than weaning the addict from heroin. Kinda like how Oxy
functions in real-world application.

The difference is, Suboxone is mandated in alternative sentencing programs by
the judiciary of certain states. And in some states, with no consideration of
whether the addict was addicted to opiates/opioids.

~~~
drooogs
plenty of people successfully use buprenorphine to taper off heroin. some
people do end up going on long term buprenorphine maintenance, but the harm
there is radically less than an active oxy/heroin addiction. even in the worst
case scenario, any day that an opioid addict takes buprenorphine is a day
where they have far less risk of fatal overdose.

~~~
stochastic_monk
Exactly. Additionally, methadone increases cardiac mortality by increasing the
QT interval, so the drug with better efficacy and safety profile should fully
replace it.

Buprenorphine is good. And someone can’t get on it if they’re too addicted to
opiates because as a partial agonist it can precipitate accelerated
withdrawal, which acts as a protective mechanism, I imagine.

~~~
mveety
Buprenorphine also increases cardiac mortality by increasing the QT interval.
Buprenorphine is used over methadone mostly because its a partial agonist of
the mu-opioid receptor which basically limits how high you can get.

~~~
stochastic_monk
You’re right! I hadn’t known that buprenorphine also caused it, but it seems
all of the drugs used for that purpose. I did find a 2013 study stating that
the effect was significantly less than that from methadone, but it’s good to
know that both come with cardiac risks.

------
ChuckMcM
It would be an interesting use of civil asset forfeiture to seize the patent
on this drug and make it free for anyone to produce.

~~~
Dowwie
Economic incentives were likely the only reason for this development, though.
Claim civil asset forfeiture on drug patents and watch how quickly the well
dries. Oxy won't be the last dangerous, addictive drug that society faces.

~~~
timr
Buprenorphine has been a drug for decades.

------
fapjacks
“We believe it is inappropriate for the state to substitute its judgment for
the judgment of the regulatory, scientific and medical experts at FDA.”

If this doesn't tell you all you need to know about regulatory capture and the
FDA...

~~~
Nasrudith
To be fair I wouldn't want that either - especially depending on the state.
The state positions are far too subject to demagoguery for the sake of career
advancement. An appointed and tenured agency like the FDA is at least better
in that respect that they are more likely to act based upon actual problems
with some degree of caution and attention to evidence instead of stirring up
panics for the sake of advancement. Unlike literally every 'tough on crime'
politician and the abhorrent historical trends. Precisely the reason why they
are appointed instead of elected officials.

~~~
fapjacks
You are right, of course, generally speaking. It -- corruption -- seems to be
one of humanity's most intractable problems. But just talking only about the
FDA specifically, they are clearly in the pockets of the pharmaceutical
industry. The FDA makes policy decisions that are highly influenced by
pharmaceutical companies and completely counter to the body of scientific
evidence. Just go read Scott Gottlieb's Twitter feed. Or do even the most
minimal, cursory research on the FDA's history. This may not mean anything to
you, but I personally believe that regulatory capture is _greater_ in the FDA
than it is in the CPUC, California's hilarious "public" utilities commission.

~~~
Nasrudith
Yeah it is all heuristic at this point. There is one radical theoretical
solution for regulatory capture that I can see which could have its own issues
both economically and incentive wise: regulatory jobs are the last job one
takes. In exchange for a lifelong pension they can never work or accept any
form of compensation ever again. This would include running their own business
and indeeed all forms of compensation including speaking fees and even
amenities. You are free to go speak at every Ivy league after retirement but
that is essentially just a hobby. It would no doubt be expensive in itself but
it could pay off in reduced corruption costs.

------
jwilk
Archived copy without GDPR nag screen:

[https://web.archive.org/web/20180908213017/https://www.washi...](https://web.archive.org/web/20180908213017/https://www.washingtonpost.com/news/business/wp/2018/09/08/the-
man-who-made-billions-of-dollars-from-oxycontin-is-pushing-a-drug-to-wean-
addicts-off-opioids)

------
fenwick67
"We share the state’s concern about the opioid crisis. While our opioid
medicines account for less than 2% of total prescriptions, we will continue to
work collaboratively with the state toward bringing meaningful solutions to
address this public health challenge"

This is such a scummy spin.

~~~
lostlogin
I wonder how they count that too. Number of script letter? Number of pills
charted, or boxes shipped? Number of dollars earned?

You can bet it’s a carefully chosen statistic.

------
bogomipz
>"And it comes amid news that the company’s former chairman and president,
Richard Sackler, has patented a new drug to help wean addicts from opioids"

For those who aren't familiar with Richard Sackler or the Sackler family. I
highly recommend this piece:

[https://www.newyorker.com/magazine/2017/10/30/the-family-
tha...](https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-
an-empire-of-pain)

------
fipple
I’d support a political platform to create a legal framework to execute high-
level corporate criminals like the Sacklers and their henchmen.

~~~
java_script
Slippery slope. Reminds me of that one poem.

“First they came for the big pharma capitalists that caused opioid epidemic,
and I did not speak up because I was not a big pharma capitalist that caused
the opioid epidemic.” Etc.

What if I work real hard and become one of those guys one day. I don’t wanna
get executed.

~~~
fipple
Don’t knowingly create a mass death epidemic and you won’t be executed.

~~~
Nasrudith
That sounds literally identical to 'If you're not doing anything wrong do you
haven't anything to hide.' or 'Don't commit crime if you don't want to be
raped in prison.' "Lets just throw out civil rights." is an incredibly
dangerous notion.

~~~
fipple
Don’t see anything anti “civil rights” about using a punishment often given to
people who kill a single victim to people who kill hundreds of thousands, just
because the more efficient killers do so from an office building.

------
dixie_land
I was prescribed Oxycondon (the generic) for kidney stones and it really
helped me get through excruciating pain. (My stones are not seriously enough
to require surgery but you gotta sit through the pain to wait for them to pass
through).

But as soon as the pain become remotely manageable I stopped it and just used
NSAIDs.

Because it doesn't take a genius to look up online what you're taking and know
the side effects (I'm counting addition as one)

To this day I keep the unused pills close just in case but I honestly never
once tempted to use them for recreational purposes.

I guess my point is that it takes two to tango and let's not throw personal
responsibility out of the window when talking about opioids.

~~~
dixie_land
for people downvoting this: did you have something to add to the discussion?

or do you just have to downvote anyone who shares a first hand experience that
happen to not fit into your narrative?

~~~
stefan_
I thought the judging was a bit much and highly ironic when coupled with early
addict behavior ("let's keep those opioids around _just in case_ ").

~~~
penagwin
I think by "just in case" he meant in the case of needing them therapeutically
not recreationally.

If you have the self-control the idea is having some in case you fall and
break your arm or something(Obviously only for serious injuries).

~~~
stefan_
If your problem warrants opioid painkillers you'll get them as part of your
_hospital visit_ to fix the actual problem.

~~~
drooogs
i'm curious whether you experience chronic pain yourself. opioids are a
dangerous class of drugs, and the decision to use them is based on weighing
the severity of a person's pain against the inherent risks of using the drugs.
in a certain sense, i find it quite inhumane that this decision can only be
made by someone who has no accurate way of knowing how much pain the patient
feels.

------
village-idiot
While I'm interested in anything to halt or stop the opioid crisis, anything
from the owners of OkyContin must be treated with a _large_ grain of salt.
OxyContin was nominally supposed to be a slow release low risk opioid for
chronic pain sufferers. Not only has that not worked out so well, it's pretty
clear that they understood the risks and basically straight up lied to doctors
about the risks. They have the capability to create these compounds, but they
also have very low trustworthiness.

------
cityzen
If you understand who Richard "Dirty Dick" Sadler is, the story makes a lot
more sense:

Sackler joined Purdue Pharma in 1971, as assistant to the president.[8] He
became head of R&D and head of marketing before becoming president in 1999,
and co-chairman in 2003.[8] Sackler was in charge of the research department
that developed OxyContin. As president, he approved the targeted marketing
schemes to promote sales of OxyContin to doctors, pharmacists, nurses,
academics, and others. Shelby Sherman, an ex-Purdue sales rep, has called
these marketing schemes "graft".[2]

In 2015, Sackler was deposed by four lawyers in Louisville, Kentucky. The
deposition concerned the development and marketing of OxyContin under the
watch of him and his family, who were and are active board members of their
private company, Purdue Pharma. The marketing and prescribing of OxyContin in
Pike County, Kentucky, was of particular interest.

Before the case could go to trial and thus before the deposition could become
a matter of public record, Purdue settled for $24 million, admitting no
liability, sealing the deposition, and requiring the Kentucky prosecutors to
destroy, or return to Purdue, millions of pages of internal documents obtained
from the company during discovery. The medical news website STAT then sued to
unseal Richard Sackler's deposition. A state judge ruled in its favor. Purdue
appealed, and, as of October 26, 2017, that appeal remains outstanding. The
deposition cannot be made public unless the appeal is decided in favor of STAT
again.[9]

Sackler has donated to both Republican and Democratic politicians, though
chiefly to Republicans.[3] His charitable foundation, the Richard and Beth
Sackler Foundation, has donated to anti-Muslim organizations, as well as to
organizations that have promoted the falsehood that millions of undocumented
immigrants voted in the 2016 presidential election.[3]

Sackler is a member of the board of advisors of the Koch Institute for
Integrative Cancer Research.[7]

\--------------------

Even when they were developing opioids, they knew that that long term care was
ineffective and that the risks outweigh the benefits for long term care. This
guy does not care. Politicians are on the take so they don't care. As long as
companies can patent and profit off of prescription drugs, this problem will
continue. It's that simple, yet no one in government has the guts to take
these people on. For starters, someone get that damn transcript because I'm
sure it has plenty of information to blow the lid off of this.

------
codr4
Been there, done that; went through hell to get off OxyContin after a climbing
accident.

Repeat customers are created by doing long term harm while providing short
term relief, expecting corporations to actually solve problems or have a
conscience is beyond silly.

~~~
hansthehorse
I was switched from Oxy (liquid) to morphine after tongue cancer surgery and
months of mouth and neck radiation treatment. Was on a maintenance plus "break
through pain" prescription for 6 months. It took a week to get withdrawal
symptom free with the first 3 days being the worst. It wasn't terrible but I
don't want to have to do it again.

------
epmaybe
Just some background information on the drug patent (which washington post's
link to the patent is paywalled, so here:
[https://patentimages.storage.googleapis.com/85/96/76/8ba72da...](https://patentimages.storage.googleapis.com/85/96/76/8ba72daaca8a42/US20160235739A1.pdf)).
It's basically buprenorphine (an opioid agonist that is technically non-
addictive and indicated for pain control in opioid dependent patients) in a
different delivery package that is quite frankly superior to our current
versions of buprenorphine.

Our current methods of providing buprenorphine are via sublingual (under your
tongue, Subutex) or orally (Suboxone, which is actually buprenorphine plus
naloxone). It's a wafer that immediately dissolves when taken delivering the
drug orally.

Now, these methods of administration are pretty good. Subutex will dissolve
relatively quickly and you've got good pain management in recovering addicts.
However, patients will sometimes take these out of their mouth quickly before
the healthcare provider notices, so that they can inject it later (which can
definitely provide the euphoria associated with opioids).

Suboxone gets around that somewhat, by combining the buprenorphine with
naloxone, an opioid antagonist. This works because if the provider wants to
give the patient a longer term supply, the user can't abuse it by dissolving
the med and injecting it. Why? Because the opioid antagonist that is built in
only works when injected, causing severe withdrawal. The issue with this,
however, is that opioid addicts are smart. They burn off the naloxone and then
inject.

So this drug patent offers an alternative: give wafers of buprenorphine at
addiction centers that dissolve immediately in front of the healthcare
provider. This avoids the hiding issue of subutex, and provides the same route
of administration which is the benefit of subutex over suboxone.

Now, at the end of the day, does any of this matter? Not really. Subutex is
still hard to get covered by insurance, so most providers stick with Suboxone
(or generics, as I think that's available now) anyways. Do you think that this
new medication will make it into practice? We don't even have phase 1 trial
data on the drug, just a patent.

If you're really outraged over a drug being patented, though, then the
discussion becomes far more complicated. Smarter individuals than myself argue
that on HN all the time.

------
conchy
This guy is the Sylvester McMonkey McBean of pharmaceuticals

------
coleifer
Crazy. Sub clinics are sad places. Gray-faced junkies paying $3-400/month to
stay hooked. A buprenorphine script is probably $10/month. It's a racket.
Capitalism at work.

~~~
tmp-20150107
Wow! This makes slightly less angry about the hoops I had to jump through to
get on a treatment program with the NHS in the UK. (Well, the part of it where
prescriptions are still free.) At least they don't add to the problem by
making you pay to get help...

------
stevebmark

        Jack Donaghy: Imagine that your favorite corn chip manufacturer also owned the number one diarrhea medication.
    
        Liz Lemon: That'd be great, 'cause then they could put a little sample of the medicine in each bag.
    
        Jack Donaghy: Keep thinking.
    
        Liz Lemon: [beat] Except then they might be tempted to make the corn chips give you...
    
        Jack Donaghy: Vertical integration.

------
peakai
Build the poison, with the antidote to (much) later follow ... A perfectly
sound business model. Reinforce the pathways that ensure that an industry's
products (prescription drugs) will never fall out of vogue as the mechanism to
solve all of people's problems, and make (a lot of) money all the while.
Subjugation through palliation, a textbook case.

~~~
pizzazzaro
Remember when Oxycontin was supposed to be a pain pill that was "impossible to
get addicted to"? Yeah... I'm trusting this "relief measure" about as much as
I trusted that line in the 90s.

This is just gonna be their new wave of "milder" Oxy, that people get hooked
on first. Sure, we're sold that its for helping things now... But give it a
few years and this will be just another prescription opiate slung by street
dealers. "Oh its safer!"

Methadone is addictive too. And so is this filth.

~~~
blattimwind
> Remember when Oxycontin was supposed to be a pain pill that was "impossible
> to get addicted to"? Yeah... I'm trusting this "relief measure" about as
> much as I trusted that line in the 90s.

Huh? Oxycodone is extremely addictive, just like every other opioid. This has
been well known since always.

~~~
0xcde4c3db
I don't know that they ever flat-out phrased it as extremely as "impossible to
get addicted to", but Purdue Pharma definitely made puffed-up claims that the
extended-release nature of OxyContin drastically lowered addiction potential
compared to immediate-release opioids. They were fined $600M for aggressively
misleading marketing about its addiction potential and reduced side effects
[1].

[1] [https://www.nytimes.com/2007/05/10/business/11drug-
web.html](https://www.nytimes.com/2007/05/10/business/11drug-web.html)

------
hn_throwaway_99
Sometimes I wonder what it would be like to go through life with no
conscience. I don't really want to be a sociopath but I admit that to be free
from guilt or anxiety over my actions at even a level one tenth of this guy
would be nice.

~~~
rubbingalcohol
Opioid pain drugs are life savers for people who actually need them, so I
think this is a bit more complicated than capitalist Satan-incarnate vs. the
poor helpless fools duped into taking his wicked drug.

~~~
maxerickson
OxyContin was largely a gimmick to market a drug that was long out of patent
(Oxycodone was first synthesized in 1916):

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/)

~~~
pizzazzaro
The real gimmick? That it would be "non-addictive".

------
RickJWagner
This is great news. Anything to fight the opioid epidemic is a good thing.

~~~
lostlogin
If this drug works it may well fuel the fire.

