Addictions
Alberta and opioids II: Marshall Smith’s ambitious campaign
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Marshall Smith. Photo: PW
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Alberta’s system builder
The Alberta model, made in BC
“I, as you know, have been everywhere in this field, from eating out of garbage cans to this office,” Marshall Smith said. “So I have a deep respect for everybody who works along that continuum.”
We were sitting in the office at the Alberta Legislature reserved for chiefs of staff to Alberta premiers. That’s Smith’s current job. Premier Danielle Smith was probably nearby, though I didn’t see her on this trip. On a shelf behind Marshall Smith were two coffee mugs of different design, each bearing the inscription WAKE UP. SAVE LIVES. REPEAT.
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Anyway, Marshall Smith (all future uses of “Smith” in this post will refer to him, unless I specify the premier) was talking about the continuum from dumpsters to the centre of power. “Where you work on that continuum obviously colours the way that you enter this conversation,” he said. “When you are standing on a sidewalk with a person in front of you, the solutions to that person’s problem look very different than what you might do to plan a broader system of care, for a large population of people.”
This was his way of anticipating criticisms he faces as a leading strategist behind Alberta’s emerging strategy for handling a deadly progression in opioid doses. Since he entered Alberta’s government as a more junior staffer in the government of former premier Jason Kenney in 2019, Smith has been working to put a much greater emphasis on recovery from addiction than on “harm reduction,” whose valuable goal is to keep drug users alive whether they recover or not. This makes him a bête noire among harm-reduction advocates. (You can read a mild critique of his efforts here; or a real scorcher here).
What Smith was saying was, in effect, If you work on the street, you’re going to be all about harm reduction, and I respect that. But he is working on drug policy for a whole province, and perhaps beyond, so he needs a broader perspective. “I’m a system builder. So I don’t have the luxury of just focusing on one particular substance. I have to worry about the whole population. I have to worry about the disease burden of addiction and drug use more broadly.”
He sees much to worry about. “Over the last 30 years in Canada, successive governments have failed miserably to anticipate and adequately address the type of services — both from a capital investment and an operating investment — to help people do this.” By “this,” he means escaping addiction. “We have not cared about people with mental health and addiction issues. And we had the ability to not care because up until the last six or seven years, the evidence of them was hidden away.”
Smith first started thinking about this when he was in British Columbia, where he began his recovery from a history of drug use. In 2018, at the BC Centre for Substance Use, Smith co-wrote a report with Dr. Evan Wood that called for a large new investment in facilities and programs to help people recover from addiction. The report is no longer on the BCCSU website, but you can download a copy here.
“It was a 39-point strategy to transform the system in British Columbia,” Smith recalled. “The government of British Columbia wasn’t interested in that strategy. They wanted to go a particular direction.
“So that report is now known as the Alberta model.”
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Marshall Smith in the dining hall of the Lakeview Recovery Community, opening in July. Photo: PW
In its first page, the Wood/Smith report said “British Columbia has long suffered because of the lack of an effective system to support individuals in and pursuing recovery from substance use disorders.” The system’s “overwhelming focus” was on keeping people alive rather than helping them get better. Wood and Smith wanted that to change.
The need for major new investments in addiction recovery was essentially uncontroversial in B.C. Indeed governments there still periodically announce they are making such investments. But Smith was perpetually unsatisfied with the scale of that commitment.
A year after BC’s new NDP government could-shouldered his report, Smith began working in the UCP government of Alberta’s then-new premier, Jason Kenney.
“Obviously we started off very modestly,” Smith said. “I worked in an office down in the basement. Mental health and addiction wasn’t a big deal. It really was very much a group of cubicles.”
Today, Alberta’s department of mental health and addiction is the seventh-largest ministry in the provincial government.
“The ROSC transformation that is going on in Alberta is massive. It is one of the most massive whole-of-government system transformations that I’ve seen,” Smith said. The premier chairs a ROSC committee of cabinet with seven ministers.
I guess I’d better unpack that acronym. ROSC stands for “recovery-oriented system of care,” a term that appeared in the 2018 report Smith co-wrote.
So you get the premier and her ministers of mental health and addiction, Indigenous relations, advanced education, health, community and social services, public safety and the attorney general meeting regularly to coordinate recovery policy. The premier’s chief of staff is on the file constantly. As I mentioned on Monday, he devoted a full day to explaining this broad effort to me.
“We spend enormous amounts of time and energy,” Smith said. “All of us live and breathe this. Anybody out there that thinks that we’re just, from a conservative perspective, just cavalierly doing this, that just couldn’t be more untrue. We we are in this completely and totally. We monitor almost everything that goes on in the system.”
What are they working on? Smith said the “recovery” part of that “recovery-oriented system of care” jargon-ball gets most of the attention, because it draws attention to the contrast between harm-reduction and abstinence-based recovery models. But Smith is a wonk, and if anything he is more interested in the “system of care” part. His goal is to ensure that every interaction an opioid user has with the modern government apparatus is designed to encourage recovery from dependency. Since people who use drugs tend to bump up against the state a lot, Alberta’s emerging system has a lot of moving parts. The goal is to hook the parts up more effectively.
One of the other men in Smith’s office, Dr. Nathaniel Day, chimed in. He’s been the lead strategist on substance use at Alberta Health Services. He’s an important Smith collaborator.
“Across Canada,” he said, “the system of care for people with addiction has been fragmented, poorly thought out — convenient.” He meant services had generally only been provided when, and where, it was easy for government to provide them. “If you look at opioid dependency treatment, if you lived in a suburban or rural community, it didn’t matter that you had an opioid use disorder. Tough. We had no services for you.”
Day designed the Virtual Opioid Dependency Program, which provides online consultations to patients anywhere in Alberta, and if needed, prescriptions to medications that can be filled at local pharmacies. For patients without coverage, the medication is free and if their local pharmacist has it in stock, available on the day of the call.
“We went in and said, enough is enough,” Day said. “What would be good enough for you and your family? And how do we take that to everybody?”
Which medication? “In this province, we’re huge fans of gold-standard opioid-replacement medications, and we use it a lot,” Smith said. “We have Sublocade, which is something that other provinces don’t have because it’s very expensive. It’s the injectable version of Suboxone. It’s a subcutaneous injection, it goes under the skin, it lasts for 30 days, where the oral is 24-hour. So that’s a thousand bucks a shot, and we pay for that.”
An obvious point about this is that these so-called opioid agonist treatments, or OATs, are big-time harm reduction. They greatly reduce both withdrawal symptoms and highs. One question that I still have, after watching everything Smith and the Alberta government are doing on drug recovery, is whether other provinces could afford to match it.
Running into those institutions
VODP is useful for people who are able to reach out for help from home. But other potential beneficiaries are distracted, or in distress. Very often they run into the police.
“So we took that technology” — the virtual access to physicians and treatment — “and we gave it to the 34 police agencies that we have in the province,” Smith said.
“We said to the officers, ‘If you encounter somebody who has an opioid-use disorder, you can get them started on opioid-use medication. You can, officer. Here’s the phone number to call. Put them on. We make the arrangements. They go to the pharmacy, right then and there. If they’re on the street, that can be done right in the back of a police car.
“If they are in custody at the cell block and they go into the cell block, we have put paramedics in every cell block in Alberta. So the first thing that happens to somebody when they’re arrested and they go into into municipal cells, they’re met by a paramedic that says, ‘Let’s talk about your substance use. Are you an opioid user? We can offer you immediate treatment right now. Right here. Would you like to do that?’ Through our police programs, we’re probably up to like 4,000 people who have taken us up on that.”
That’s what you can get done in a police cruiser or a holding pen. Lots of people go much further into the correctional system than that. So does Smith’s system of care.
“[Alberta’s] focus on corrections and police right now, admittedly, is the opposite of what some other jurisdictions are focusing on,” Smith said. If anything this was an understatement. A major argument for decriminalization and safe supply is that the last thing a drug user needs is the stigma of a criminal record. Other jurisdictions, Smith said, “are running away from those institutions when they should be running into those institutions.
“I’ll give you a very direct example why.
“We know, from the 2017 coroner’s report in Alberta that 40 percent of the people who died [of opioid-related causes] were in custody in the year prior to their death. That’s a really important piece of information, because it tells me I have a big chunk of population there that — if I can get at them, and if we can change the way that they experience this process — we can make a big dent in these numbers.”
A lot of people in the correctional system have substance-use disorder, even if that’s not what they’re in for. “We said, ‘Let’s really do a different way of thinking on this,’” Smith said. “Even though Corrections is a public-safety agency, we want the Ministry of Mental Health and Addiction to take over all Corrections health care.”
Perhaps four in five detainees, he said, “have alcoholism, addiction and mental-health issues. They’re all pooled up in one place and they’re not doing anything. They’ve got nothing but time on their hands. And I don’t have to build a new building? You’re kidding me! This is fantastic! Why wouldn’t I just put therapists in? So we now have treatment programs inside correctional centers.”
Of course a lot of places do programs for inmates. “But what they’re going to show you when you unpack that is, ‘Well, we give them this workbook,’” Smith said. “What they’re not doing is the deep transformative, therapy work that is necessary. And honestly, Paul, our Therapeutic Living Units are probably the best treatment programs we have in Alberta.”
With that, we piled into Smith’s SUV — Smith, Day and the third member of Smith’s team that day, a physician and consultant named Dr. Paul Sobey. A half-hour later we arrived at the Fort Saskatchewan Correctional Centre, northeast of Edmonton.
Here we visited the Therapeutic Living Unit, a full-time addiction-recovery program for 21 women who are housed separately from the general inmate population. That’s about 10% of the total population of women at Fort Saskatchewan. The program opened in February. Participants, who must apply, run through a 12-hour daily program of activity: morning check-in meetings, physical exercise, twice-daily smudge ceremonies reflecting the large Indigenous population in the correctional system, frequent meetings of Alcoholics Anonymous and Narcotics Anonymous as well as the more recently developed SMART Recovery system. Participants are rarely alone during daylight hours. The program is designed to last for months, which struck me as an unusually long time for a recovery program.
Four of the program’s participants sat on a sofa and talked about their experience in the program. “I’ve been wondering and wondering if a program like this was going to happen,” one said.
“It’s like an answered prayer, honestly,” said another. “So I would just encourage you to keep opening places like this.”
That’s the plan. “We’ve got 12 correctional centers in Alberta,” Smith told me before our road trip. “Our goal is to have Therapeutic Living Units [in all of them]. There will come a time where we have whole correctional centers that are working on this model, right? This requires massive intervention, not tinkering around the edges. This is generational change in the way that we do corrections in Alberta.”
Connections
All of the four young women we heard from said they’re nervous about what happens when they get out of detention. Old acquaintances can encourage a return to old habits. Which is part of the reason why Alberta is also building a network of live-in Recovery Communities, long-term residential rehab programs to reinforce the lessons learned in the TLUs — or to help other people begin recovery if they didn’t arrive via the correctional system.
Once the system is fully built in 2027, “every correctional centre will have a sister Recovery Community,” Smith said. “That’s why we’re building 11 of them around the province. Five of them are on First Nations, in partnership with the First Nations.”
Here’s where the system starts to look like a system. After all, in the broadest outlines nothing’s new here. People in prisons have long received addiction counselling, and the Alberta government and various private groups have long run rehabs. But for the longest time, these assorted parts of the system could barely talk to one another. So the chances of a seamless transition from the correctional system to recovery care were lousy. They’re still not great, because the system is still being built, but the goal is a seamless network of care.
“Services in 2018, 2019 were very disconnected,” Warren Driechel, the Edmonton Police Service deputy chief we met the other day, told me. The bureaucratic runaround that we all have to face can be brutal on people with high needs and impaired function. Say you want to get on AISH, an income-support program for people with a medical condition. To do that, you need a doctor’s appointment. To get one, you need identification. To get ID, you need an address.
Public officials are working to provide services that match that complexity.
In January 2021, the EPS launched a “HELP Unit” to refer people to social services instead of just arresting them.
In September 2023, the police replaced the old holding cells where intoxicated people could dry out and then get dumped back on the street with an Integrated Care Centre where they could connect with social services that operate right in the centre.
And in January 2024, after many of the tent encampments were dismantled, a new Navigation and Support Centre became the city’s hub for providing medical, legal and bureaucratic help for people who have often been bereft.
The Nav Centre has nine shelter beds in the back where people can rest, if needed, while on-site staff and volunteers process their files. (Pets are welcome, unlike in some of the city’s shelters.) The centre has the province’s only on-site Service Alberta photo-ID station. On the day I visited, the Nav Centre assisted 50 people, with 24 visiting the desk run by the Hope Mission, 10 being helped by staff from Radius Health, 12 by the provincial department of mental health and addiction.
Everything old is new
Our final stop was the Lakeview Recovery Community outside Gunn, northwest of Edmonton. When it opens in July, it’ll be the third or fourth in a network of such long-term residential programs. Lethbridge and Red Deer have been open for a while. The goal is to have 11 centres up and running across the province by 2027. Smith hopes that once the full network of centres is open, long wait times in Red Deer and Lethbridge will shrink, perhaps to the point where some beds will be available on-demand.
Each recovery community has its quirks. Lakeview will be for men only. Five of the centres will be on Indigenous land. The minimum stay will be four months, with some residents staying for up to a year. That’s a long stint for a rehab; in some private rehabs, it’s unusual to stay for even a month. In theory every day you spend with a combination of counselling, group therapy, twelve-step programs and medical care will increase your chances of success. No resident will pay for their stay at any recovery community. It’s covered by the government.
Work crews have been renovating the Lakeview site since 2022. It’s an impressive place, roomy and bright, with rooms where residents can meet visiting family, a huge kitchen where residents will learn cooking skills, and a dispensary for opioid agonist treatment. Residents will share bungalows while they’re in the program, five or six to a house.
But it didn’t just come into existence. What’s now Lakeview began its existence as the McCullough Centre for homeless World War II veterans. It had been operating for years as an addiction rehab centre when Jason Kenney’s government closed it in 2021. When the government announced the site’s eventual reopening barely a year later, observers were baffled. Closing the centre fit a narrative about a government that put the bottom line over Albertans’ wellbeing. Refurbishing and reopening it was.. harder to explain. Fitting it into a network of nearly a dozen such centres that will, themselves, be better connected to street-level services and to the corrections system… well, we’ll see, won’t we?
I’m conscious of ending this installment in my series on opioids in Alberta on an ambivalent note. I simply don’t know how this will turn out. My first article, earlier this week, was about the scale of the challenge. This one is about the scale of the response. It’s impressive. It’s getting attention across the country. Sobey, the physician who was the third member of our little party as we toured the region’s facilities, has a consulting firm whose aim is to design recovery-oriented systems of care to any government that wants to start the conversation. His phone pinged with an inquiry from another provincial government while we were visiting the Fort Saskatchewan prison. These ideas may come soon to a province near you.
What we don’t know yet is whether they’ll work, or how well. In the third and final installment in this series, I’ll discuss a few reasons to reserve judgment.
But what Alberta is trying is, in many ways, not heretical. Nobody thinks it’s great design to leave desperate people to wander helplessly thorugh a piecemeal hodge-podge of social services and treatment options, with police and corrections hovering over it all as an aloof menace. Smith, his boss the premier, and several government departments are trying to build a better system.
There is room for many devils in the details. But if federalism is supposed to be a laboratory for testing different approaches to thorny problems, Alberta is testing this approach ambitiously. Watching Marshall Smith, I found myself wondering what other intractable governance problems could benefit from the sustained attention of an empowered senior staffer, a supportive head of government, and ministers and public servants working in close coordination.
Addictions
Calls for Public Inquiry Into BC Health Ministry Opioid Dealing Corruption
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The leaked audit shows from 2022 to 2024, a staggering 22,418,000 doses of opioids were prescribed by doctors and pharmacists to approximately 5,000 clients in B.C., including fentanyl patches.
A confidential investigation by British Columbia’s Ministry of Health, Financial Operations and Audit Branch has uncovered explosive allegations of fraud, abuse, and organized crime infiltration within PharmaCare’s prescribed opioid alternatives program. Internal audit findings, obtained by The Bureau, suggest that millions of taxpayer dollars are being diverted into illicit drug trafficking networks rather than serving harm reduction efforts.
The leaked documents include photographs from vehicle searches that show collections of fentanyl patches and Dilaudid (hydromorphone) apparently packaged for resale after being stolen from the taxpayer-funded “safer supply” program. This program expanded dramatically following a federal law change implemented by Prime Minister Justin Trudeau’s government in 2020, which broadened circumstances in which pharmacy staff could dispense opioids, according to the document’s evidence.
“Prior to March 17, 2020, only pharmacists in BC were permitted to deliver [addiction therapy treatment] drugs,” the audit says.
B.C.’s safer supply program was launched in March 2020 as a response to the opioid overdose crisis, declared in 2016. It allows people with opioid-use disorder to receive prescribed drugs to be used on-site or taken away for later use.
The Special Investigations Unit and PharmaCare Audit Intelligence team identified a disturbing link between doctors, pharmacists, assisted living residences, and organized crime, where prescription opioids meant to replace illicit drugs are instead being diverted, sold, and trafficked at scale.
“A significant portion of the opioids being freely prescribed by doctors and pharmacists are not being consumed by their intended recipients,” the document states.
It suggests that financial incentives have created a business model for organized crime, asserting that “prescribed alternatives (safe supply opioids) are trafficked provincially, nationally, and internationally,” and that “proceeds of fraud” are being used to pay incentives to doctors, pharmacists, and intermediaries.
BC Conservative critic Elenore Sturko, a former RCMP officer, began raising concerns about the program two years ago after hearing anecdotes about prescribed opioids being trafficked. She asserts that the program is a failure in public policy and insists that Provincial Health Officer Dr. Bonnie Henry be dismissed for having “denied and downplayed” problems as they emerged. Sturko also argues that B.C. must change its drug policy in light of U.S. President Donald Trump’s stance linking the trafficking of fentanyl and other opioids to potential trade sanctions against Canada.
The document shows that PharmaCare’s dispensing fee loophole has incentivized pharmacies to maximize billings per patient, with some locations charging up to $11,000 per patient per year—compared to just $120 in normal cases.
Perhaps most alarming is the deep infiltration of B.C.’s safer supply program by criminal networks. The Ministry of Health report lists “Gang Members/Organized Crime” as key players in the prescription drug pipeline, which includes “Doctors, pharmacies, and assisted living residences.”
This revelation confirms long-standing fears that B.C.’s “safe supply” policy—originally designed to prevent deaths from contaminated street drugs—is instead sometimes supplying criminal organizations with pharmaceutical-grade opioids.
The leaked audit shows from 2022 to 2024, a staggering 22,418,000 doses of opioids were prescribed by doctors and pharmacists to approximately 5,000 clients in B.C., including fentanyl patches.
Beyond organized crime’s direct involvement, pharmacies themselves have exploited regulatory gaps to generate massive profits from PharmaCare’s policies:
- Pharmacies offer kickbacks to doctors, housing staff, and medical professionals to steer patients toward specific locations.
- Financial incentives fuel fraud, with multiple investigations identifying 60+ pharmacies offering incentives to clients.
- Non-health professionals, including housing staff, are witnessing OAT (opioid agonist treatment) dosing, violating patient safety protocols.
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Addictions
Provinces are underspending on addiction and mental health care, new report says
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The Greta and Robert H. N. Ho Psychiatry and Education Centre, the HOpe Centre, a health care facility for mental illness and addiction in North Vancouver, B.C. (Dreamstime)
By Alexandra Keeler
The provinces are receiving billions in federal funds to address mental health and substance use. Why are so many spending so little?
The provinces are failing to allocate sufficient funding to addiction and mental health care services, a new report says.
The report, released Dec. 19 by the Canadian Alliance on Mental Illness and Mental Health, criticizes the provinces for a “long history of … demanding maximum cash for health care from the federal government with minimum accountability.”
The alliance is a coalition of 18 prominent health organizations dedicated to improving Canada’s mental health care. Its members include the Canadian Medical Association, the Canadian Psychiatric Association and the Canadian Mental Health Association.
On average, the provinces have allocated just 16 per cent of $25 billion in federal health-care funding toward mental health and addiction services, the report says.
“Given the crisis of timely access to care for those with mental health and substance use health problems, why are so many provinces and territories investing so little new federal dollars to improve and expand access to mental health and substance use health care services?” the report asks.
However, some provinces dispute the report’s criticisms.
“The funding received from the federal government is only a small part of Alberta’s total $1.7 billion allocation towards mental health, addiction and recovery-related services,” an Alberta Ministry of Mental Health and Addiction spokesperson told Canadian Affairs in an emailed statement.
“[This] is a nation leading level of investment response.”
‘Take the money and run?’
In 2023, Ottawa and the provinces committed to spend $25 billion over 10 years investing in four priority areas. These areas are mental health and substance use, family health services, health workers and backlogs, and a modernized health system.
The alliance’s report, which looks at provincial investments in years 2023 through 2026, says mental health and substance use are being given short shrift.
B.C., Manitoba and P.E.I. have allocated zero per cent of the federal funds to mental health and substance use, the report says. Three other provinces allocated 10 per cent or less.
By contrast, Alberta allocated 25 per cent, Ontario, 24 per cent, and Nova Scotia, 19 per cent, the report says.
The underspending by some provinces occurs against a backdrop of mental health care already receiving inadequate investment.
“[P]ublicly available data tells us that Canada’s mental health investments account for roughly 5% of their health budgets, which is significantly below the recommended 12% by the Royal Society of Canada,” the report says.
However, several provinces told Canadian Affairs they took issue with the report’s findings.
“Neither the Department of Health and Wellness nor Health PEI received requests to provide information to inform the [alliance’s] report,” Morgan Martin, a spokesperson for P.E.I.’s Department of Health and Wellness, told Canadian Affairs.
Martin pointed to P.E.I.’s investments in opioid replacement therapy, a mobile mental health crisis unit and school health services as some examples of the province’s commitment to providing mental health and addiction care.
But Matthew MacFarlane, Green Party MLA for P.E.I.’s Borden-Kinkora riding, says these investments have been inadequate.
“P.E.I. has seen little to no investments into acute mental health or substance use services,” he said. He criticized a lack of new detox beds, unmet promises of a new mental health hospital and long wait times.
The alliance’s report says New Brunswick has allocated just 3.2 per cent of federal funds to mental health and addiction services.
However, a New Brunswick Department of Health spokesperson Tara Chislett said the province’s allocation of $15.4 million annually from the federal funds does not reflect the additional $200 million of provincial funding that New Brunswick has committed to mental health and substance use.
In response to requests for comment, a spokesperson for the alliance said the federal funding is important, but “does not nearly move the yardsticks fast enough in terms of expanding the capacity of provincial health systems to meet the growing demand for mental health and substance use health care services.”
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‘Blaming and shaming’
The discrepancies between the report’s findings and the provinces’ claims highlight a need for standardized metrics around mental health and addiction spending.
The report calls on federal and provincial governments to develop national performance indicators for mental health and substance use services.
“At the end-of-the day you cannot manage what you do not measure,” the report reads.
It advises governments to communicate their performance to Canadians via a national dashboard.
“Dashboards are being used with increasing frequency in the health system and other sectors to summarize complex information and would be one way to effectively tell a story … to the public,” the report says.
It also urges Ottawa to introduce legislation — what it dubs the Mental Health and Substance Use Health Care For All Parity Act — to ensure equal treatment for mental and physical health within Canada’s health-care system.
This call for mental and physical health parity echoes the perspective of other health-care professionals. In a recent Canadian Affairs opinion editorial, a panel of mental health physicians argued Canada’s failure to prioritize mental health care affects millions of Canadians, leading to lower medication reimbursement rates and longer wait times.
The alliance says its call for more aggressive and transparent spending on mental health and addictions care is not intended to criticize or cast blame.
“This is not about blaming and shaming, but rather, this is about accelerating the sharing of lessons learned and the impact of innovative programs,” the report says.
This article was produced through the Breaking Needles Fellowship Program, which provided a grant to Canadian Affairs, a digital media outlet, to fund journalism exploring addiction and crime in Canada. Articles produced through the Fellowship are co-published by Break The Needle and Canadian Affairs.
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