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How cracking down on America’s painkiller capital led to a heroin crisis

The Guardian

America’s addiction epidemic
How cracking down on America’s painkiller capital led to a heroin crisis

Critics say Florida’s efforts to contain an epidemic unleashed within its borders have only had limited effect in curbing one crisis while making another worse
After Florida spent years trying to shake off its reputation by driving out of business the worst of the notorious ‘pill mills’, the twist came that Florida officials hadn’t predicted.
After Florida spent years trying to shake off its reputation by driving out of business the worst of the notorious ‘pill mills’, a twist came that officials hadn’t predicted. Photograph: Education Images/UIG via Getty Images

Chris McGreal in Fort Lauderdale

Wednesday 25 May 2016 06.30 EDT
Last modified on Wednesday 25 May 2016 17.00 EDT

For James Fata, the transition from prescription painkillers to heroin was seamless.

The 24-year-old came to Florida to shake an addiction to opioid pills, but trying to go through rehab in a region known as the prescription capital of America proved too much. When a government crackdown curtailed his supply of pills, Fata turned to readily available heroin to fill the void.

“The pills were hard to get. They got to be very expensive. Heroin is cheap,” said Fata, 24. “Almost everyone that I was close to, anybody that was doing pills with me, typically they would at least get to the point where pills were not an option. You were either snorting heroin or shooting heroin.”

Florida was the crucible of the opioid epidemic now gripping the US. Before deaths from opiates spiked nationwide, the state’s south corridor earned the name “Oxy Express” for its liberal access to the extraordinarily powerful synthetic heroin painkiller, OxyContin.

But after Florida spent years trying to shake off its reputation by driving out of business the worst of the notorious “pill mills”, the twist came that state officials hadn’t predicted.

When the addicts Florida facilitated could not get prescription opioids any more, they turned to heroin.

“I’d like to say it’s getting better because I see at least things are being brought to the surface and there’s an advocacy movement,” Fata said. “But on a numbers level, it’s getting worse. On the amount of deaths I see, it’s getting worse. The amount of heroin use I’m seeing, it’s getting worse.”

As heroin deaths in the US have more than tripled nationwide since 2010, critics say Florida’s efforts to contain an epidemic unleashed within its borders have only had limited effect in curbing one crisis while making another worse.

Florida’s problems started after OxyContin swept on to the market in 1996, just as medical authorities began pressing doctors to pay greater attention to alleviating pain. Unscrupulous businessmen in Florida spotted an opportunity.

Within a few years, hundreds of pain clinics popped up around the state dispensing opioid pills to just about anyone who asked. Among the earliest and biggest was American Pain in the Miami-Fort Lauderdale metro area, with a pharmacy run by former strippers and doctors carrying guns under their white coats.

It took in tens of millions of dollars a year selling OxyContin and generic versions containing oxycodone to people who travelled from Kentucky and West Virginia where painkillers were known as “hillbilly heroin”. They came south along the “Oxy Express” by bus or the carload, sometimes driven by dealers who took a cut of the pills.

At one point, more than 90% of all the prescription opioids dispensed by doctors in the US were sold in Florida.
James Fata: ‘On a numbers level, it’s getting worse. On the amount of deaths I see, it’s getting worse. The amount of heroin use I’m seeing, it’s getting worse.’
James Fata: ‘On a numbers level, it’s getting worse. On the amount of deaths I see, it’s getting worse. The amount of heroin use I’m seeing, it’s getting worse.’ Photograph: Chris McGreal for the Guardian
‘Nothing had ever brought me to my knees’

Robert Eaton was introduced to opioids at the age of 24 after suffering herniated discs in 2009. After a couple of months of therapy and low levels of painkillers, his doctor said he had done all he could for Eaton. The doctor pointed him to the pill mills.

“He recommended me to go see a pain management doctor. I started seeing him every month. Immediately he increased all of my prescriptions,” he said.

Eaton reels off a list of hundreds of oxycodone, methadone and muscle relaxants he was prescribed each month.

The pills were hard to get. They got to be very expensive. Heroin is cheap.
James Fata

“It’s a lot but by the time I got to him, the pills already had a stranglehold on me. A lot more just seemed better. I didn’t realize at the time just how far this thing was going to take me,” he said. “Nothing had ever brought me to my knees. Once the pills went into my body, it was over. As soon I took that drug I was like, ‘whoa, this is good. I need more of this now’.”

Those hooked on oxycodone say that they do not so much feel a craving for pills as a fear of not getting them and, as they put it, getting sick. If they don’t get a fix, they get hit by increasingly intense pain from withdrawal much worse than the pain they were treating.

“By the end, I was locking myself in a room, never getting that kind of high,” Eaton said. “Needing this to not get sick and to be able to get out of bed.”

Eaton quickly came to realize that the doctor wasn’t so much treating him as taking his money, writing a prescription, and getting him out of the door as fast as possible in order to get the next patient in.

“Not once did he ever ask me: ‘Did your pain improve this month?’ There was no intention to ever bring the medication level down at all. You’re walking in and he’s prescribing you the max,” he said. “If you had insurance, it didn’t matter. You paid cash to see the doctor.”

Eaton is still not sure how much he spent between the doctors and the pills but said it ran into hundreds of dollars a day.
Robert Eaton: ‘Once the pills went into my body, it was over.’

Robert Eaton: ‘Once the pills went into my body, it was over.’

He lost his job as a Budweiser delivery driver because the pills affected his work. He lost his house. He even sold his stepchildren’s toys.

“I would take the mortgage money. My wife at the time would try and scrounge up money to pay for things and I would steal it,” he said.

Eaton found another job training as an emergency medic with a fire department and managed to keep his addiction hidden for a while.

“One day we walked into this lady’s house. It was a grandma. She’s sitting in her bed. She’s dead and she had a pill bottle in her hand,” he said. “That messed me up so bad I went and did roxies [oxycodone].

“My way to fix what I was experiencing was to go do the very drug that just killed her.”

There was no intention to ever bring the medication level down. You’re walking in and he’s prescribing you the max.

Oxycodone down; heroin up

Florida started to crack down on “pill mills” in 2010.

American Pain was shut down in an FBI raid and its owners were imprisoned. The Florida legislature passed laws to kill off other pill mills and curtail the largely unfettered prescription of opioids. Deaths from oxycodone in Florida dropped 69% in the five years from 2010.

But the clampdown left those already addicted without a ready supply. It limited access to pills, forced up prices on the street, and made heroin a cheaper alternative. As the drug flooded in from Mexico, heroin deaths in Florida more than doubled in 2014 alone to a record 408.
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Doctors also reported an increase in the number of babies born addicted to heroin, and Florida leads the US in new HIV-Aids infections, attributed to needle-sharing by drug users.

“What was going on here in Florida was different to any other place,” Fata said. “The pill mills were blatantly illegal. Anybody could walk in and get a prescription. When that stopped, those people either latched on to people who still had a prescription or they moved to heroin. As those people they could latch on to dwindled and dwindled because it got stricter and more restrictive, the shift was to heroin.”

The National Institute on Drug Abuse declared a heroin epidemic in south Florida two years ago.

The Journal of the American Medical Association Psychiatry noted a shift toward greater use by white people from affluent backgrounds and said that most were drawn to heroin after becoming addicted to opioid painkillers.
The Journal of the American Medical Association Psychiatry noted a shift toward greater use by white people from affluent backgrounds and said that most were drawn to heroin after becoming addicted to opioid painkillers.

The Journal of the American Medical Association Psychiatry noted a shift toward greater use by white people from affluent backgrounds and said that most were drawn to heroin after becoming addicted to opioid painkillers.

The 2014 study reported that 75% of those on heroin said they came to it via prescription opioids and noted a rise in heroin use as prescription opioid use decreased.
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Florida officials were as caught off guard by the rise of heroin as they were by the sudden boom of the pill mills in the late 2000s.

Fata got hooked on prescription pills in his home state of Texas, where he grew up in what he describes as an upper-middle-class family. He began popping painkillers he found in his parents’ cabinet when he was in his mid-teens, a pastime he said was common among his friends.

Before long he was hooked and taking even larger doses supplemented with heroin. He paid for his habit by dealing in drugs. But at the age of 20, after four years of drugs, his parents forced him to go to rehab in Florida.

“It got to a point where I was about to die and my parents said: ‘You need to go to treatment’,” he said.

Fata was clean for about six months but, surrounded by people with easy access to prescriptions painkillers, his resolve failed.

“I was living in a halfway house when I relapsed. Working in a menial job. I just felt stuck. There was nowhere for me to go,” he said.

As soon as the prices of the pills went up, I knew I would just use heroin
James Fata

But already the pills were becoming harder to find.

The federal authorities were moving against businessmen running Florida’s pain clinics. Prosecutors called American Pain the US’s largest illegal prescription drug ring, earning an estimated $43m in three years, and said it was responsible for at least 50 overdose deaths in Florida alone. Owner Jeff George was sent to prison for 20 years for the death of one of those patients. His brother Chris George received a reduced sentence of 14 years after testifying against doctors he hired.

The Florida legislature passed a package of reforms five years ago requiring that pain clinics be owned and run by a doctor. It also established a system to allow doctors and pharmacies to track prescriptions in an attempt to put an end to doctor shopping.

“I already knew that the scandal was shutting the pill mills down, so there’s no way somebody like me, without a legitimate ailment, to get pills,” Fata said.

Fata moved in with the man who would become his main supplier. His housemate had a prescription for back pain, still did a bit of doctor shopping, and sold some of the drugs. But it became more difficult as doctors became more wary with the Drug Enforcement Administration (DEA) and prosecutors sniffing around.

And the shortage drove the price of pills up on the black market.

“As soon as the prices of the pills went up, I knew I would just use heroin,” Fata said. “I moved to heroin because the price of OxyContin turned to more expensive than the price per ounce of gold.”
Residents from the House of Hope rehab center appear in court in Fort Lauderdale.
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Residents from the House of Hope rehab center appear in court in Fort Lauderdale.

Heron was about one-eighth of the price of pills for the same hit and more readily available.

With its rise has come an increase in deaths from a drug authorities say is as much as 50 times more powerful – fentanyl, a synthetic opiate frequently laced into heroin. The DEA last year issued a nationwide alert over what it called an alarming increase in the number of deaths related to fentanyl and heroin.
‘New addictions every day’

But the rise of heroin does not mean the prescription opioid crisis is going away.

Janet Colbert was instrumental in getting the pill mills closed down. Working as a neonatal intensive care nurse near Fort Lauderdale, Colbert had to deal with children born addicted to opioids through their mothers.

“In years past we had a cocaine baby once in a while. All of a sudden our unit is full of these babies. We’re all like, what’s going on? We had no idea why there were so many. Screaming. It was bad. You couldn’t feed them. They’re in withdrawal,” she said.

We’ll never control the heroin if we don’t control the opiates because there are new addictions every day
Janet Colbert

“If there is a heroin epidemic, nine out of 10 heroin users start with prescription opiates. We’ll never control the heroin if we don’t control the opiates because there are new addictions every day.”

Colbert points the finger at the drug manufacturers – led by Purdue Pharma, the maker of OxyContin – and a medical establishment she said that puts too much emphasis on prescribing powerful drugs to deal with pain.

In 2007, Purdue paid a $634m penalty for misrepresenting the drug’s addictiveness. In December it reached a $24m settlement with Kentucky after the state claimed Purdue cost it “an entire generation” to OxyContin.

Colbert accuses the pharmaceutical companies and doctors of attempting to shift blame for the epidemic by accusing those hooked on prescription opioids of “abusing” the drugs.

That was the experience of Eaton, who calmly recalls the trauma of his years of addiction but becomes visibly angry when talking about drug manufacturers and doctors.
Police stand outside Pain Relief Orlando. Drug agents have called them the worst pill mills in central Florida and among the worst in the state.

Police stand outside Pain Relief Orlando. Drug agents have called them the worst pill mills in central Florida and among the worst in the state. Photograph: Orlando Sentinel/MCT via Getty Images

“This thing took me to a place where I didn’t want to live any more, really. Do I have to accept responsibility? Yeah. I’m a drug addict. Am I a bad person? No. I was going to a doctor who was just taking my money from me. He wasn’t trying to help me get better at all,” he said. “I have a lot of friends who are dead who were getting prescriptions from doctors, and it’s a doctor’s job to protect them. It gets me really pissed off that they weren’t protected.”
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Florida’s attorney general, Pam Bondi, called doctors working in pill mills “drug dealers in white coats”.

Some physicians have been called to account. A Lake Worth doctor, Sergio Rodriguez, was sentenced to 27 years in prison over more than four overdose deaths. But it has proved hard to convict others. Cynthia Cadet wrote more prescriptions than any other doctor at American Pain and was paid $1.5m. But a jury cleared her of criminal charges after she said she could not know if patients were lying about pain levels. She was later imprisoned for money laundering.

Colbert said that jailing a few doctors does not go far enough when hundreds were employed in what she regards as a criminal racket. She would like to see the state medical authorities strip them of their licences to practice.

Her organisation, Stopp Now, is also pushing for doctors to be required to use a monitoring programme that would tell them if a patient is obtaining prescriptions from another doctor. The programme is compulsory in 20 states but voluntary in Florida.

I was going to a doctor who was just taking my money from me. He wasn’t trying to help me get better at all
Robert Eaton

Colbert said state legislators have told her they will not support the measure because it is opposed by the Florida Medical Association.

“The doctors have a lot of clout and they don’t want the legislation because somebody’s telling them what to do,” she said.

The Florida Medical Association did not respond to a request for comment.

Fata said he finally kicked heroin when he recognised it was going to kill him. He is studying to be a social worker and plans to return to Texas.

“I knew this past time, right before I got clean, that I was ready to kill myself,” he said. “I was at breaking point.”

Eaton also shook his reliance on drugs with the help of a religious group and now runs a personal training business. But getting off the pills came at a price. His marriage broke up. Friends were dying around him.

“My best friend died on just the prescriptions alone. His sister found him on the morning of his 30th birthday, dead in his room,” he said.

Eaton missed the funeral because he was on the hunt for a fix.

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10 Things Sobriety Is Not

10 Things Sobriety Is Not
By Kelly Fitzgerald 03/29/16
We often think sobriety is the end of the world, that our lives are over, and we’ll never have fun again. But that’s not true.
10 Things Sobriety Is Not

Let’s face it. Getting sober can be the scariest time in your life. We often think it’s the end of the world, that our lives are over, and that we’ll never have fun again. But these are all just a few common misconceptions about the sober life. Although getting sober can be tough, it’s rewarding, and to shut down any fears you may have about sobriety, we’re talking about exactly what sobriety is and what it isn’t.

1. Sobriety is not boring

This has to be the one number one reason I didn’t get sober sooner. I was convinced that sobriety was synonymous with boring. I used to see people at parties who didn’t drink and actually felt bad for them, viewing them as people who had boring lives. There was nothing worse to me than living a boring life, and that kept me drinking for a long time. Surprisingly, when I made the decision to stop drinking and using drugs, I began to feel better physically and see much clearer. I found friends, activities, and an entire life outside of my addiction. It was anything but boring, it was exciting and freeing.

2. Sobriety is not easy

Too bad we can’t just snap our fingers and be sober. Life and sobriety would be so much easier. Unfortunately, sobriety is not easy, it’s hard. You’ll have to feel emotions, get through hard days, and learn a whole new way of being you. At first this can seem like a daunting task, but luckily we don’t have to complete it all in one day. Sobriety is a process and a lifelong journey that takes hard work and dedication. It’s worth every second that you put into it.

3. Sobriety is not the end of your life

It’s common to think, “I’m sober and my life is over.” We often associate parties and anything fun in life with alcohol and drugs. Therefore, it’s not uncommon to believe that life will end once you stop drinking. I was shocked to find out that my life didn’t end when I got sober, it actually truly began for the first time. A woman once told me when I was four days sober that I would “live a life beyond my wildest dreams.” I didn’t believe her then, but now I know exactly what she meant, and she was right. Sobriety has given me my life back and has allowed me to construct a happy and healthy life I never had during my years of using.

4. Sobriety is not only for alcoholics

Contrary to popular belief, sobriety is not just for alcoholics, it can work for anybody. For me, I was hesitant to label myself as an alcoholic for a long time. In fact, I didn’t say the words “I’m Kelly and I’m alcoholic” until over a year into my sobriety. The truth is, I wasn’t sure if I was going to stay sober forever or if it was something only alcoholics could experience. Labels aside, sobriety is a lifestyle that everyone can benefit from, whether you have one drink a week or 50. So if you’re afraid of determining whether or not you’re an alcoholic, save the labels for later and give sobriety a try.

5. Sobriety is not a sign of weakness

We often come into sobriety feeling bad about ourselves, wondering why we can’t drink like others can. I felt weak and inadequate and asked myself, “What’s wrong with me?” In recovery, I’ve learned that sobriety is not a sign of a weakness, it’s actually one of the bravest things someone can do. It takes courage and heart to admit you have a problem and to take steps toward change. You’re not weak, you’re strong for making a great decision for your life.

6. Sobriety is not something to be ashamed of

There is still stigma associated with addiction, and therefore, sobriety. You may run into reactions from people that include assumptions that you’re an addict, that addicts are bad people, or that you should be ashamed of your sober status. Shame can keep people drinking and using for years and is not a positive feeling to have when sober. Most of us carry some sort of shame into sobriety from our drinking days, but there is absolutely no reason we should be ashamed of being sober. We should be proud we’ve changed our lives in a healthy way.

7. Sobriety is not a secret you should keep

You’ll hear a common phrase in recovery that goes, “secrets keep you sick.” For many of us, addiction taught us how to lie, take advantage of people and situations, and live a dishonest life. In recovery we learn how essential it is to be honest about everything. Secrets can cause you more pain and guilt, and can be detrimental to your sobriety. My advice is to be honest about your new life so that you can be your best authentic self going forward.

8. Sobriety is not the norm

Once you start your sober life you may notice that society revolves around alcohol and other drugs. We are constantly being fed advertisements and media that are geared towards drinkers and send the message that we need to drink to numb emotions and cope with life. Once I stopped drinking I quickly found out that sobriety is not the norm. Being sober is different and it feels good to make this choice for myself. In a world where everyone drinks and uses, it takes a special person to stand up and be sober.

9. Sobriety is not just about quitting alcohol and drugs

It was a wake up call when I heard that sobriety does not begin and end with abstinence from drugs and alcohol. It’s much more than that. Becoming sober allows you to get in touch with who you really are, to make amends to those you have hurt in the past, to learn new coping mechanisms, and how to deal with everyday life. It’s a complete transformation of the mind, body, and soul.

10. Sobriety is not for everyone

With all of this being said, it’s fair to say that sobriety isn’t for everyone. That’s because it takes commitment, honesty, faith, and working through a lot of pain. It requires facing yourself head on. It requires dedication and time, and not everyone is ready to give what is needed.

If you no longer enjoy the way drugs and alcohol are making you feel, sobriety is for you. Sobriety is not boring, it can be the first step to the rest of your life.

Kelly Fitzgerald is a sober writer based in Southwest Florida whose work has been published on the Huffington Post among other sites. She is best known for her personal blog, The Adventures of The Sober Señorita, where she writes about life as a former party girl living in recovery.

Heroin Epidemic in Tampa Bay

Heroin has killed four times as many people in Hillsborough in the past two years as it did in all of the previous four years combined.

Data from the Hillsborough Medical Examiner’s Department reflects a dramatic increase in fatalities attributed to the drug, which has seen a resurgence statewide and nationally following a crackdown on the prescription drug abuse epidemic.

Heroin was a contributing factor in the deaths of 18 people in Hillsborough County in the first half of 2015. The county saw 22 heroin-related deaths in all of 2014 — an increase of more than 700 percent from the year before. In that year, 2013, there were just three heroin deaths, two each in 2012 and 2011, and three in 2010.

In Pinellas County, while the numbers are not as high, they’re also on the rise. The county has six heroin-related fatalities so far this year, compared with five in 2014, four in 2013 and one each in 2012 and 2011. Pasco County had one heroin-related death in 2014 and has had one in 2015.

Heroin-related deaths have risen while the number of prescription drug abuse deaths has steadily declined. Oxycodone, one of the deadliest prescription drugs, was cited in the deaths of 23 people in Hillsborough in 2014, down from 133 fatalities in 2010 — a drop of 83 percent. In Pinellas County, oxycodone killed 172 people in 2010, but those deaths fell to 45 in 2014, a decrease of 74 percent.

So why have heroin deaths skyrocketed, particularly in Hillsborough?

“We’re seeing a big surge in heroin use,” said Hills­borough sheriff’s Capt. Frank Losat, who oversees the agency’s narcotics division. “But we can’t put our finger exactly on why we have a surge.”

In Pinellas County, authorities are at a similar loss to explain the difference in the number of heroin deaths. They noted, though, that prescription drug abuse has not gone away.

“It’s not like it was in 2010,” said Pinellas sheriff’s Lt. Dan Zsido, a narcotics division commander. “But prescription drugs are still prevalent.”

Losat believes the increase in Hillsborough heroin deaths is linked to the quality of the heroin that is reaching local streets, and whether it’s mixed with other drugs.

Investigators have frequently seen heroin mixed with fentanyl, an opioid medication often used to treat chronic pain. It is used as a “booster sedative,” making up for the typical low potency of heroin smuggled into the United States from Mexico.

“What is alarming is the fentanyl, which is particularly responsible for the increased number of deaths,” said James Hall, a drug abuse epidemiologist at Nova Southeastern University in Fort Lauderdale. “That tends to be what puts it over the edge.”

Of the 18 heroin deaths in Hillsborough this year, at least seven were also linked to fentanyl, according to the medical examiner. Several other cases saw heroin mixed with various other drugs like alprazolam, the key ingredient in the antianxiety drug Xanax, which are commonly obtained through prescriptions.

That particular aspect of heroin-related deaths can be detected by looking at the number of deaths in a wider area, Hall said. He noted that several counties near Hillsborough are also seeing an increase in heroin deaths. In nearby Manatee County the number of heroin-related overdose deaths through May of this year was 54.

“When we see these deaths, they’re often in local outbreaks,” Hall said.

The local surge is in keeping with an overall statewide trend. The state Medical Examiner’s Commission reported a sharp rise in heroin deaths beginning in 2012. That year, there were 108 deaths statewide, compared with 57 the year before. In 2013, the total reached 199 deaths. The number of statewide deaths in 2014 — scheduled to be released today in a state medical examiner’s report — is likely to surpass that.

The last time the statewide death toll rose this high was in 2003, when there were 230 deaths. That was about the time that the state’s prescription drug crisis began to take hold. Now, with state authorities having cracked down on pill mills and doctor shopping, that trend appears to be reversing.

The same is true nationally. The 2014 National Survey on Drug Use and Health, released this month, noted heroin as one of the few drugs that has seen an increase in the past year. The survey estimated that 435,000 people in the United States used heroin in 2014. Its use has particularly grown among people in the age range of 18 to 25.

State officials recently took measures to combat the problem. A bill signed into law by Gov. Rick Scott in July makes it easier for patients, caregivers and first responders to purchase and administer naloxone.

The drug, known by the brand name Narcan, is an opioid antagonist capable of reversing the effects of an overdose. Paramedics for both Tampa and Hillsborough County Fire Rescue and Pinellas County Emergency Management Services all carry the drug.

But Hall said Florida has another problem: It doesn’t have adequate resources in place to help the addicts left in the wake of the prescription drug epidemic.

“While Florida was successful in being able to cut its supply of medical use opioids,” Hall said, “the state, at the same time, totally failed to address the demand side.”

In 2012, Florida ranked 49th in the nation in funding for substance abuse and mental health programs, according to the Henry J. Kaiser Family Foundation. That year, per capita spending on mental health services in the United States was $124.99 per person. And 29 out of 50 states spent more than $100 on those services for their residents.

But Florida spent just $37.28 per person.

Attempts to address that disparity have failed in Tallahassee. Several pieces of legislation to fund behavioral health and addiction treatment did not make it through this past legislative session. And so pain pills continue to give way to heroin.

“In the storm of opioid withdrawal,” Hall said, “any port will do.”

Contact Dan Sullivan at dsullivan@tampabay.com or (813) 226-3386. Follow @TimesDan.
Heroin deaths rise in Tampa Bay, but surge in Hillsborough 09/27/15 [Last modified: Sunday, September 27, 2015 9:29pm] Photo reprints | Article reprints
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