What if the symptoms don’t seem like ADHD?
What if someone has abused stimulants before?
What if a client is abusing their medication?
ADHD treatment can bring to mind a few different things. Medications, particularly stimulants are usually at the top of the list. ADHD treatment for adults can be complicated due to the abuse of stimulant medications, the medical providers being hesitant to prescribe and the lack of access to psych testing to confirm a diagnosis. For our purposes, we are focused on the medication part and talking about what our role, as therapists, might be in this side of treatment.
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You’re listening to the All Things Substance podcast, the place for therapists to hear about substance abuse from a mental health perspective. I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor. It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice. So join me each week as we talk about All Things Substance.
Welcome back to the All Things Substance podcast. This is episode 45. Last week, we answered the question: how do ADHD medications work? We talked about the different types of medications and the subclasses underneath them. We talked about how the medications help the brain make the connections that help people stay on task.
This week we’re moving on to focus on ADHD treatment for adults. The reason we’re focusing on adults this week is that we’re talking about the potential abuse of stimulants and for a lot of children and kids, this isn’t really going to be an issue. Certainly it happens in high school and middle school, but not on the scale that we’re talking about with adults. With adults, there’s not as much supervision and someone’s partner or loved ones might not even know they’re taking a stimulant.
However, in our role as therapists we probably will know, and we’re going to run into some issues here. So that’s why we’re working this week on ADHD treatment for adults. ADHD is a big reason that people come to therapy. When I worked in the clinic and worked closely with the intake people, we heard this a lot. People calling because their child had ADHD or an adult talking about their belief that they may have ADHD.
We got calls for ADHD testing often, which sometimes is harder to come by, especially in rural areas. As a field, there was a time when it felt like ADHD was the diagnosis of the moment. It seems like every child I heard about was getting that diagnosis in the area where I live. The diagnosis of ADHD and adulthood has been growing quite a bit in the last decade.
This is not to say that it’s not real. It’s hard to know whether this diagnosis is from misdiagnosis or whether awareness of what adult ADHD would look like has just increased for us. When someone comes in and says, they think they have ADHD. Typically I think we’re listening for a number of things. It’s possible they have ADHD, but lack of concentration could be from any number of things.
I find that ADHD is sort of difficult to diagnose with a great deal of certainty without testing. There are great measures that can be used for ADHD that are not subjective. I have a lot of confidence whenever someone’s had a Tova and they’ve done a challenge Tova where they took a stimulant and then did the test.
Again, it’s been really great to be able to see the difference and know that the medication is really working. There’s plenty of anecdotal evidence of people talking about how much the stimulant that they take has made such a difference in their lives and their ability to complete tasks and to be more productive in their own life.
The struggle comes when people go to their doctors and they tell them they think they have ADHD and they want a stimulant. Asking for a stimulant isn’t necessarily the giant red flag that pops up when someone asks for pain pills. But I think it comes in a decent second.
Adults reporting ADHD
So let’s talk for a minute about what we do when an adult comes into our office and reports that they either have been diagnosed with ADHD or believe that they have ADHD. For me, one of the first things I want to know is do they have a diagnosis? Who gave them the diagnosis? And whether they’ve had psych testing as an adult, I’m not looking to discount this diagnosis only to understand where it came from. If they haven’t had a diagnosis, then I want to talk with them about specific symptoms and what specifically they would be wanting to treat.
I would say a large number of people don’t really understand the way ADHD medications work. When we’re talking about ADHD treatment for adults, what tends to happen is the adult comes in and they know that stimulants are often used to treat it. And that’s why they’re asking for that. Usually they’re looking for a way to help them concentrate or to clear what feels like a fog or feeling overwhelmed and not being able to focus on a particular task.
This can be really challenging when they feel like they’re not able to do the jobs that they have to do each day. They may have pressure at work to perform at a specific level and are not able to keep up with it. They may be forgetting to do things at home and it’s causing conflict in their relationship.
There are a number of reasons why people can’t concentrate. We know that it could be from any form of depression or anxiety, including PTSD or OCD. That it could be from lack of sleep. There are lots of reasons that somebody might be having this issue. A lot of this is about differential diagnosis to figure out what it is that’s causing this issue without access to testing.
This is going to be a lot of questions and searching to find the origin of this problem. If the person just wants stimulants, they’re not going to return. Sometimes we’d get people in the clinic who would be looking for us to give them basically a recommendation for medication, and they’re not interested in therapy.
And for those there’s not really much we can do, except let them know that we don’t have any power over prescribing whatsoever. For the others though they’re legitimately concerned and frustrated by these particular symptoms. So I start by making sure that I have a really good handle on what is happening and what they would like to be different.
I talk with them about what the experience has been historically. Was there a time when they used to be able to do these things in a better way or more reliably? I talk with them about when it gets bad and when it’s a little easier. I’m looking for social anxiety, I’m looking for depression and I’m ruling out different things as we go along.
I worked with a patient in her thirties who had a long history of depression and had chronic PTSD. Well, her depression and PTSD were well-managed and there was still quite a bit of what I think she would have said she felt scatter-brained. I saw her weekly. She was really stable emotionally, and I’d have to agree that what she was struggling with seemed to be the loss of information that we talked about in the last episode.
Last week I described what was happening in the brain as being similar to what happens on the internet when something doesn’t get connected correctly. There are lost packets of information. Essentially this is what’s happening in the brain with ADHD. The brain is trying to make these connections to carry out a task and the message isn’t quite getting to all the neurons that it needs to get to. And so the person gets distracted and isn’t able to complete the task.
For my client. I was able to watch this with her, even though she’s not having depressive episodes, not crying, not having panic attacks, using skills, and yet things that required sustained mental effort and things that required focus and complex thought were difficult for her. We were able to rule out a whole bunch of other things. And so I’m absolutely in support of her going to get stimulant medication.
Stimulant prescriptions make doctors nervous
Doctors have gotten burned with patients who were diverting and abusing medications they’re prescribing and stimulants are no different. Some prescribers want to know that the person’s been evaluated for ADHD, even if it’s not specifically from testing.
Well, that is something that we can do and that’s more accessible than getting specifically tested for ADHD, which has to be a psychologist who’s trained in doing testing. But then it comes down to us deciding whether or not this person can have stimulants. Most of us, that’s going to make us a little nervous.
We don’t prescribe. We know that we can’t suggest things medically to people. I can’t tell you how many times in my career I have said to people, I can’t advise you medically. And I can only tell you some things that I’ve heard from others. Of course, generally physicians are a hundred percent onboard with this as they definitely don’t want us telling them what to do.
I did have one doctor once who asked me outright. I called him about a teenage client of mine, who I wanted evaluated for antidepressant. And he said, what do you want me to give him? And I thought maybe he was being slightly snarky and he wasn’t. And he said, what medication do you want me to prescribe? And I said, um, well, uh, and was generally stuttering.
And he said, come on, how long have you been doing this? You know what things work? What do you want me to give him? And I was like, a lot of my teenage clients get started on Prozac or Zoloft and he’s like done. And I was like, holy shit. That was what? Thankfully, most doctors and prescribers aren’t asking us those questions.
I have diagnosed ADHD in adults and in teenagers and I know that they were given stimulant medication based on my diagnosis. This is part of the reason I wanted to talk in this podcast about how these medications work, so that we had a better idea of what is happening when those medications are being prescribed.
And so that we knew a little better what kind of behavioral interventions that we could use and why they might work. ADHD for a long time was just something that was talked about for kids, basically elementary school age. However, it’s changing quite a bit. And I’m not saying that’s a bad thing. I have a client in later teenage years who was just diagnosed after testing with ADHD. She is able to clearly and accurately describe to me the differences with, and without taking a stimulant.
I know that I’ve seen it for myself in raising a child with ADHD, and that I was always able to tell, even as an adult, now, when that medication isn’t on board. I can spot that in a heartbeat.. It is comforting to know that your loved one or one of our patients is taking medication because they really need to, with the risks associated with stimulants, this is also pretty important.
When a client has abused ADHD medications before
Let’s pretend that we have a client come in and they used to be on stimulants, but they got taken off because they’ve abused them. This is a more complicated situation. If someone has abused stimulant medications, that is an automatic red flag for a prescriber. Whether or not the prescriber is going to know that they had these trials in the past. We’re not sure.
In the United States, prescribers are required to put all controlled substances into a registry. And when new prescriptions are being written, they’re cross checking that registry to see if there are other prescriptions. A lot of times in a border place, such as the one where I live, the person will check the Wisconsin drug registry and the Minnesota drug registry, because it’s super easy for somebody to be on one side or the other of the bridge. This has helped a lot with the whole doctor shopping kind of thing.
Whether or not the person can safely use stimulants in the future. Isn’t going to be a clear cut answer. We have to know how they were abusing them. How often? For how long? In what way? And what made them stop or how did they get cut off from this medication?
If the abuse seems kind of low level, like they would occasionally take more than one if they felt like they were really tired and that the regular dose wasn’t working. Okay. That seems a little less concerning. If somebody was snorting these medications, that is a completely different thing as we’ve covered, because taking it in a way other than orally is where high comes from.
Sometimes people come in and have an opinion that stimulants are the only thing that’s going to work for them. And the only thing that has worked for them, I would challenge that carefully. Because stimulants do override some of the lethargy that happens when somebody is depressed, they do provide some motivation, so to speak, to get things done. In some ways it can be seen like a shortcut. The problem here is if we’re talking about it being a coverup for what’s really going on.
This is where our questions about what’s really happening and what a day to day situation is like for them. So that you can decide, does this sound like ADHD, or does this sound like a combination of things. Ultimately, whether your client takes stimulants or not, isn’t up to you thankfully, you don’t have to make that choice.
It’s not our job
You’re the one who is talking with them about clarifying symptoms and what pathway they want to take. We might be able to relay our findings to the doctor or the prescriber, but that’s pretty much where it ends. Most of the time anyway. Sometimes we can get pushed to an even further level of accountability when it comes to someone’s stimulant use. A fellow therapist wrote to me about this very thing, as they were asked by the client via the doctor to approve and to watch the use of stimulants in the patient.
Apparently the patient had abused stimulant medications before and wanted to go back on them. But the doctor was unwilling unless somebody was watching it and asked the therapist. This is a really hard situation to be in. Imagine that you are in this situation and that your client wants you to say yes, because in this case you are the gatekeeper because the doctor says so. Immediately that puts you in a place of policing their use. Asking them and seeing if they are telling you whether they’re abusing it or not. What would you do if they were? Do you tell the doctor the first time? Do you become the person who’s having to judge whether they’re telling you the truth or not? That is a really difficult position, but do you decline, do you tell your client that you’ll no longer be the one who is going to be watching this?
It kinda makes you feel like you’d have to be a snitch. And that’s so not our role. It is not the therapist’s role or our desire at all to be evaluating and then reporting to an outside person, how they’re doing with something this serious. I know for myself, I would be tempted to say yes, because it’s what my client wanted.
Even though I would talk with them about boundaries and limits of what I could and couldn’t do, and that it’s not super comfortable to do this, but that’s okay. We’ll try it for a while. And I think it would be messy and hard. Now if the person who was taking the stimulant really wanted to use them as prescribed and was doing really well and didn’t have any struggle, then great. They get the medication that they feel they need. And hopefully it’s working really well.
The trouble is, if somebody has had issues abusing these kinds of medications before, there’s a reason why they didn’t. If they’re not really cognizant of what caused them to abuse those medications, then they’re not necessarily watching for that. And it could be really easy for them to start doing that again, which puts them in a position of whether or not they’re going to tell you the truth.
We can’t predict what the doctor’s going to do. Let’s say the client tells you the truth that they’ve been taking a bit more than they should have been and so they’re running out a couple of days early. You have to decide, are you going to call the doctor and let them know? What if the doctor decides to cut them off after the first infraction? You would have no control over that. And while the client knew that you were obligated, I don’t know that they’re going to see that in the light we’d want them to.
So where does that leave? Us as therapists is specially with people who are coming in with a history of Matthew. Whether they’ve been using meth or just abusing stimulants. I think that puts us in a situation acting outside of what we typically would. Can we monitor those things? Well, absolutely. We could.
We see people far more often than a doctor and we can simply ask questions, but it puts us in a different role in the relationship. There’s already a power differential for us as therapists placing us in a position of power, further exacerbating that I don’t know that that’s wise. Often in my career, I know that I have moved at boundaries and later on regretted it. There are times I felt like, you know, I don’t normally do this, but I’m going to do it because I really think this client needs me to. More times than not it doesn’t work out.
I’ll give you a small example. So I have at times made extra appointments after hours and we’re not talking like 9:00 PM when I’m done with my day at five or six. I’m talking my last clients at four. And instead I decided, I’ll see a client at five or five 30, even though support staff are gone and the building’s locked.
It’s not necessarily a safety issue. I wouldn’t put myself in that situation, but there were times that somebody needed to come in and their new job wouldn’t let them take time off. And so I would do that for them. And wouldn’t, you know, it, they would almost always miss those appointments. And it would leave me feeling frustrated and somewhat dismissed because I had made this extra effort, told my family I wasn’t going to be home on time so that we could have this appointment and then they couldn’t make it anyway.
This would honestly happen more times than that, even though my cancel and no show rate has historically been low. This is an example of where I moved my boundary for the convenience of a client. And later on, felt like, eh, that wasn’t a great choice and I had to walk it back.
Shifting boundaries and walking them back
Walking back a boundary or a limit you’ve said, because you feel like you need to reign it in is super hard.
And I hate doing it. It makes me feel like, oh, I should have just set a harder limit. I knew this was going to be the problem. My gut was telling me not to do this, but my compassion won out and I wanted to be flexible. And so here we are. I have been in situations like this with clients and their physician.
Where I felt like I could be more eyes and ears than I really should have been and needed to walk that back for a client. The good news is that we can, we absolutely can walk it back. Yes. The client might be upset and they might terminate therapy. And all we can do is act in the way that we know is right. And we’ve made a good and well thought out decision and explained it in an appropriate and kind way. And the client’s going to respond how they respond.
So as you’re listening to this episode or any other episodes, and you feel like you want to set a boundary, let’s say you want to set a limit on don’t smoke weed before you come to school. That’s okay. Even if you’ve allowed it before, you’re allowed to talk to them about the relationship that you’re having and your expectations. You just have to think about how to say it and how to do it in a concise way so that the client really does understand what you’re saying. And we’re not using vague terms or euphemisms or anything.
Supporting the use of stimulants
Bringing this back to our stimulant conversation. If you have a client who’s coming in, who has a history of abusing stimulants, and we’re not just talking medications or meth, this could definitely be cocaine or other types of stimulants. There’s going to be a correlation between what they were using and prescription ADHD medications.
They may want you to support them taking stimulants. You certainly will make whatever choices best for your practice and in your knowledge base. But you’re here listening to this. So I’ll tell you my opinion. I think it best, if you tell the client that you are happy to report to their doctor what the symptoms are and that you’d like to do a really deep dive on the symptoms and talk with them about the results.
If you really don’t feel like stimulants are going to be the way to go, then you have that discussion with your client and you tell them. Because it’s done after pretty in-depth questioning, they’ll probably take it better. They might not. Again, how they respond to that really isn’t your problem. If you’ve done your job. Hopefully though they will understand. They can certainly pursue stimulants on their own with their doctor.
What they need to know is that you’re not going to be able to say anything to really help. You think that they might benefit from depression medication, anxiety medication, something else, and that you can agree that attention is a problem. In this case, you just walk alongside them and support what they choose to do.
If they go to their doctor and the doctor’s ready to write a prescription for stimulants, they don’t need to know what you have to say. And they show up and they’re like, I take Adderall now. Just because they disagree with your assessment. That doesn’t really mean anything. They disagree with us a lot. And you switch to, okay, well, let’s see how your motivation does and let’s see what symptoms are left over and what the side effects are. And let’s just see if this is working for you, because it might.
If you have gotten in a situation where you have had to try to manage those or be the reporter back to someone, this is where I would say it’s time to. You talk with the person about, I thought I was going to be able to do this, and I’m increasingly uncomfortable with it because of these reasons.
Now the client might be upset, but they might get taken off their medication if you do this and you can let them know that, you know, that that’s a possibility and you know that they might not want to see you anymore. You still have to do what you believe is right in an upfront and kind way. And they’re going to respond how they respond.
Clients for the most part in my experience, anyway, respect honesty and forthrightness. The chances that somebody who has abused stimulants to a moderate degree is not going to do it again. I would think it is pretty low. They’ve done it before. They’ve known that it’s worked and it’s going to be really tempting to do it again.
If you end up having to judge that, you’re trying to decide which excuse is reasonable for them to have taken more. And which excuse isn’t. That is a lot of judgment calls that I don’t think you want to make.
It is also not our responsibility to stop them from abusing their medications. Your responsibility; my responsibility as a therapist is to help them figure out what they want to do about their use. That is where we come in. Bringing ourselves back to our focus can be really helpful here.
ADHD treatment in adults with a meth history
Whether or not you’re going to support somebody being on stimulants is going to shift a bit when that person comes in and has been using meth, I cannot quantify the number of addicts that have come to me and told me that they think they have ADHD once they get sober. It is likely most of them like above 80%, most of them. Clearly, statistically speaking, that’s not possible. Recovering meth addicts may be at a higher percentage because it’s possible that they were using meth to begin with in order to treat their ADHD. But that doesn’t account for all of them.
It’s difficult because when someone is in recovery, especially within the first year of recovery from meth, their brain is a hot mess. There’s no dopamine going through because there is no dopamine receptors. And so there’s nothing coming in to make them have energy, motivation, focus. There’s just a wasteland.
It’s like they’ve been dropping a nuke on their brain for however long they were using. And they’re just coming out of it. Imagine what it looks like after a forest fire. And now it’s been a few years and you see growth. But it still looks like there was a forest fire. That’s what I imagine the brains look like in this population.
I personally don’t know how that feels, but I have heard it enough to know that it’s really unpleasant. A stimulant, like a methylphenidate or an amphetamine is a pale comparison to the amount of dopamine release that they were getting from meth. But it is something. And I understand the draw. The name of the game in the beginning is to help them through the beginning stages.
And by that, I would say three to six months where their brain is kind of like mush and they’re just trying to make it through each day. This is why I am a huge fan of intensive outpatient programs or lots of recovery meetings of whatever stripe someone wants. Because they need consistent help on a more consistent basis than once a week.
This doesn’t mean that you shouldn’t treat someone who has a methamphetamine addiction or is working on recovery. You are another tool in the tool belt, so to speak so that they can have more support. You are an anchor point for them. So don’t be scared off by this. Just know that it’s a matter of trying to help them regain daily functioning, daily habits, like showering, eating, sleeping, taking medications, maybe going to a job, hobbies, things like that.
The first few months though are going to be bleak. And the addition of stimulants is not going to help them. A lot of people who are recovering from meth have found that they cannot take things with a lot of stimulant properties because it is super triggering. It’s like trying to scratch an itch, but only getting a little bit of relief. And it reminds you of the relief that does exist. And that is super tempting and super hard to say no to.
Because I’m always straightforward. I will say I am not a fan of anyone with a methamphetamine abuse history taking stimulant medications. It is not about personal willpower. It is about biology. And I think that it’s a really dangerous and slippery slope.
If stimulants aren’t a good idea for some, then what?
That said, that leaves us with questions. Like, okay. Then past that point, what if somebody does have ADHD? What if they did have ADHD and we’re treating it with methamphetamine and it got out of control as meth does. I’ve seen that too. I’ve seen people in sustained recovery who were using meth and now are struggling with symptoms of ADHD.
Their brain might be recovering. They’re able to feel joy again, as the dopamine receptors are regrowing, but they’re still struggling with the inattention, with the lost connections in the brain. And it’s super frustrating and feels like they’re not recovering like they should. Well, there are a number of options of the non-stimulant kind, more than just Strattera.
Strattera is a non-stimulant ADHD medication that I have seen work in great ways for people. It’s just one medication that isn’t going to work for everyone. I have a client that I’ve worked with recently, who is in recovery from meth, who absolutely has ADHD. And I would put money that he had it when he was a child all the way through.
When we’re doing sessions, he is still trying to self stimulate by fidgeting with things. And while the hyper activity part tends to go away, it doesn’t go away with everyone. I’m not really sure what the effect of meth is on that, because it’s possible that he might have grown out of it and just been inattentive, except that the meth was in their sense about the time he was 17.
And so we never got to see that. What I have seen is that there are a few other options. One is Clonidine and the other Guanfacine. Those are options that can be used for ADHD that are non-stimulant. Additionally Wellbutrin or bupropion is also being used in a number of ways. And there’s kind of a lot of research about it.
I have known a few people in recovery who were not able to take Wellbutrin because they felt like it was triggering for them. And so they had to stay away from it personally. I don’t know that I would take that as broadly as other people are going to have that issue, but it is a possibility that that could be a medication that won’t work.
However, in research, it’s showing some really positive results. They’re small results because we’re talking about something that nuked the person’s brain, and there is no way to just repair that. But any improvement in a lot of ways is going to be significant for people in this particular group. I’ve linked articles in the show notes about some of the trials that are happening in different places, using bupropion for meth addicts.
These are some things that could be tried by doctors for their patients. You may be in a position where a doctor is asking you what they should do. While we are not advising them medically, you certainly can let them know that there are reports of people using guanfacine, Clonidine, and bupropion in order to help people in recovery for meth have better attention and focus, or for people that aren’t able to use stimulants. And have gotten benefit from .
It is up to the doctor then what they choose. But knowing that family medical prescribers don’t have specific training in chemical dependency, either this information could be something that they hadn’t heard about yet. And the research is there.
When ADHD pre-dates meth use
There has been some research on people in recovery from meth who thought they had ADHD before. And those that didn’t. What they have found is that those who felt like they had ADHD before and were able to describe those symptoms, of course, did seem to struggle more in recovery with memory recall and with attention factors than those who didn’t have. There is some thought that ADHD persists through the Matthews and even when someone’s brain is recovered, so to speak from using math, that those ADHD symptoms may still persist.
The line for me is about two years. If somebody has been clean for two years from meth and from stimulants in general, typically, and they’re struggling still with attention, then I’m a little more inclined to think. Maybe this is ADHD.
I realized that what I’m encouraging all of you to do is to add substance abuse, to your scope of practice, to step further into this realm. So you can serve more needs for your clients. However, there is a limit to where that scope ends.
It’s not our job to get them sober
Making decisions for somebody on what their recovery should be. That is not our job. We want to support where the client is and walk with them and whatever stage of change. I am certain that many of us have gotten in a situation where we felt like we were trying to pull a client into the next stage. Somewhat like walking a dog that refuses to go any further. And you end up trying to pull them along.
If you sense that you’re doing that, stop, let go and find out where they stopped moving and hang out with them as long as they need you to. As long as it feels healthy. Sometimes in working in recovery, it can feel like we got to keep moving people forward to the place where they have solid recovery. And we no longer have to really think about that. And while I wish that was the case, people’s recovery isn’t going to be a straight line, 98% of the time.
It’s going to be ups and downs and back and forth. It can make us feel confused and exhausted if we’re trying to keep them on the straight and narrow. So to say, We are a mirror to show them what’s happening in their lives and help them figure out what they would like to be different. If they’re missing something that is clearly in the mirror, then we may have to be a little more blunt and show it to them. What they’re going to do about it is up to them.
Sometimes I find it can be helpful for me to remind myself of that and that it is not my responsibility to get this person sober. My responsibility is to be present, to share information, to hear from them, introduce new skills, to help remove barriers. If they choose to implement new skills and new choices that is up to them.
If you feel like you are working harder than your client, that is a sign that you may need to step back and pause and see what’s happening. It is way less stressful when you’re not responsible for the outcome of someone else’s choice.
So with this influx of new ADHD diagnoses and with adults coming in for ADHD treatment, I hope that this conversation has been helpful as you think about these issues. You do have the skills and knowledge that you need to be able to help figure out what’s happening with this person and what direction might be the best to go.
If you haven’t had a chance, I would download the treatment planning tool that I created. It’s free. I would use it in your own formulation of working with those clients, even though they’re not maybe using at that moment, I would use it to help yourself figure out why they were using what got in the way so that you can see potential pitfalls.
Next week is interview week. We’ll be hearing from a therapist in recovery from the Detroit Metro area. I hope you’ll join me for that podcast. And until then have a great week.
Thank you for listening to the All Things Substance podcast. For show notes, links and downloads, please visit betsybyler.com/podcast. If you loved what you heard today, it’d be great if you would share those with your therapist friends and colleagues. If there are topics that you think would be useful and you’d like to hear me cover them, please let me know. Just send a message to email@example.com. I’ll see you on next week’s podcast. And until then have a great week.
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