PSYCHOTHERAPY, BEHAVIOR THERAPY, AND COUNSELING IN DRUG DEPENDENCETREATMENT NIH GUIDE, Volume 21, Number 44, December 11, 1992 PA NUMBER: PA-93-27 P.T. 34 Keywords: Psychotherapy Drugs/Drug Abuse Social Psychology National Institute on Drug Abuse PURPOSE The purpose of this Program Announcement (PA) is to encourage the study of psychotherapy, behavior therapy, drug abuse counseling, and other psychosocial interventions in the treatment of drug abuse and dependence. Studies involving the use of controlled clinical trials or other scientifically established research methods are encouraged. A secondary aim is to encourage the development of instruments to measure the process and outcome of psychotherapy/counseling of drug addicts and instruments that may be useful in determining therapist and patient characteristics predictive of treatment outcome. This announcement is intended to encourage the investigation of the treatment of individuals who are dependent upon cocaine, opiates, and other types of drugs (including polydrug abusers). This announcement is not intended to support therapy development research. HEALTHY PEOPLE 2000 The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of Healthy People 2000, a PHS-led national activity for setting priority areas. This PA, Psychotherapy, Behavior Therapy, and Counseling in Drug Dependence Treatment, is related to the priority area of alcohol and other drugs. Potential applicants may obtain a copy of Healthy People 2000 (Full Report: Stock No. 017-001-00474-0 or Summary Report: Stock No. 017-001-00473-1) through the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325 (telephone 202-783-3238). ELIGIBILITY REQUIREMENTS Applications may be submitted by foreign and domestic, for-profit and non-profit organizations, public and private, such as universities, colleges, hospitals, laboratories, units of State and local governments, and eligible agencies of the Federal government. Applications from minority individuals and women are encouraged. Foreign applicants are not eligible for First Independent Research Support and Transition (FIRST) awards (R29). MECHANISM OF SUPPORT Support mechanisms include: research projects (R01), small grants (R03), and FIRST awards (R29). Most investigator-initiated research is supported by regular research grants. Research grants are awarded to institutions on behalf of Principal Investigators who have designed and will direct a specific project or set of projects. Except for small grants (R03) and FIRST awards (R29), investigator(s) may apply for a renewal (competing continuation) of the project by submitting an application for further support, including a report of progress and including specific plans for future work. For details on a particular support mechanism or program, contact the program staff listed under INQUIRIES. RESEARCH OBJECTIVES Background Some form of psychotherapy, behavior therapy, or drug abuse counseling occurs in virtually every type of drug abuse/dependence treatment. Even where effective pharmacological treatments exist, such as the use of methadone for opiate dependence, they are usually administered with appropriate psychosocial/behavioral interventions (Grabowski et al., 1984). Numerous behavioral interventions have been studied in attempts to improve the efficacy of drug abuse treatment. Contingency management has been shown to have some efficacy in medically withdrawing patients from methadone (Higgins et al., 1986) for some methadone-maintained individuals, but not all (Stitzer et al., 1986; Iguchi et al., 1988; Stitzer et al., 1992). Where the methadone dose has been decreased as a consequence to drug positive urine specimens, treatment dropout has been exacerbated (Stitzer et al., 1986; Iguchi et al., 1988). While it has been suggested that the use of "negative incentives" increases dropout rate, the extent to which the observed increases in dropout rate are due to methadone dose reduction per se has not been established. Operant behavioral interventions appear to be most effective when integrated into a complete treatment package, as in the Community Reinforcement Approach (Hunt & Azrin, 1973; Azrin, 1976). This approach, originally developed for alcoholics, has been modified for cocaine abusers and has shown promise (Higgins et al., 1991). Behavioral interventions based upon principles of classical conditioning, such as cue exposure, are also believed to have promise. When used as an adjunct to a comprehensive outpatient cocaine treatment program, patients given repeated cue exposure (to induce "extinction" to cocaine-related cues) evidenced better retention in treatment and fewer cocaine-positive urine specimens than patients not receiving the cue exposure (Childress, et al., 1992). Individual cognitive-behavioral and psychodynamic as well as family approaches have all been demonstrated to have some efficacy (Stanton et al., 1982; Woody et al., 1983, 1987; Rounsaville et al., 1983; Carroll et al., 1991), but none has been demonstrated consistently to be more effective than another. This is congruent with findings in the psychotherapy research field at large; that is, it has not been consistently demonstrated that one type of psychotherapy is more effective than another (Luborsky et al., 1975; Smith & Glass 1977; Lambert et al., 1986; Stiles et al., 1986). For particular subgroups of patients, however, there is reason to believe that particular types of therapies may be more useful than others. For example, there is some evidence that a structured, behavioral therapy may be more effective for substance abusers with sociopathic characteristics than an interactionally focused therapy (Kadden et al., 1989). In subgroups of patients with antisocial personality disorder who have an additional diagnosis of depression, cognitive-behavioral and supportive-expressive psychotherapy appears to be of some benefit. However, antisocial personality disorder alone appears to be a negative indicator for response to psychotherapy (Woody et al., 1985). There is also some evidence that the addition of psychotherapy to drug abuse counseling may be necessary for other subgroups of addicts. For example, in a methadone-maintenance program, drug abuse counseling is a sufficient complement to the treatment of opiate addicts with low levels of psychiatric severity. Providing psychotherapy to low psychiatric severity methadone-maintained opiate addicts who are already receiving drug abuse counseling does not appear to yield any further benefit (Woody et al., 1984). However, in methadone-maintained opiate addicts with high levels of psychiatric severity, psychotherapy in addition to drug abuse counseling is significantly more effective than drug counseling alone (Woody et al., 1984). Inherent in doing research on psychosocial treatments for drug dependence are substantial methodological difficulties. Attrition is a problem in any form of behavioral treatment research, but especially so in drug dependence treatment. While there are numerous statistical procedures for dealing with the problem of attrition (Howard et al., 1990), none can replace lost data. It is, therefore, important to be aware of the ramifications of utilizing the array of available statistical techniques that are sometimes used to partially "correct" for lost data. Defining and including control groups as opposed to comparison groups (Borkovec, 1990) also presents a dilemma in comparative psychosocial treatment research. While there is no "perfect" design in such research, there are more or less perfect designs depending upon the research question we are asking. Other methodological and statistical issues, such as those dealing with therapist/counselor variance (Crits-Christoph et al., 1990) and choosing appropriate outcome measures (Lambert, 1990) are also important considerations and have been discussed at length elsewhere (Onken and Blaine, 1990). Additional research is needed to answer a number of questions in this field such as: 1. Are certain strategies of drug abuse counseling/psychotherapy more effective than others in helping individuals achieve treatment goals? 2. In what way are various immediate treatment goals related to long-term outcome goals? 3. What is the relative efficacy of drug abuse counseling versus psychotherapy, and when and with whom is drug abuse counseling sufficient? 4. What populations of drug addicts (e.g., the dually diagnosed, racial and ethnic minorities, women, adolescents, etc.) require what types of counseling or psychotherapy? 5. How is the process of psychotherapy or counseling related to outcome in drug dependence treatment? 6. What are the characteristics of successful therapists, patients, and therapist/patient pairs? Specific Areas of Interest: 1. Development of Psychotherapy/Counseling Instruments and Research Methods. Psychotherapy research, particularly with drug addicts, is in an early stage of development. The development and the refinement of instruments and methods that measure the theoretical constructs in the fields of psychotherapy and counseling are needed. Without instruments that measure these constructs in a valid and reliable manner, the controlled, scientific study of psychotherapy and counseling is impossible. Investigators are encouraged to develop new instruments and refine existing instruments from the mental health field that can be used in controlled psychotherapy/counseling research studies with drug addicts. The development of valid and reliable instruments that measure various aspects of the process and strategies of psychotherapy/counseling, the immediate goals and outcome of these treatments, therapist characteristics predictive of treatment outcome, and patient characteristics predictive of outcome are encouraged. 2. Comparative Psychosocial Treatment Research with Drug Addicts. Controlled clinical trials that examine the relative efficacy of psychotherapy, behavior therapy, counseling, pharmacotherapy, and the many combinations of these forms of treatment with various populations of drug addicts are encouraged. The goal of such comparative treatment research is not to determine which treatments "win," but, rather to determine which treatments are most efficacious with which populations, and under what conditions. Studies that investigate the relative efficacy of individual, group, or family psychotherapy, behavior therapy, and drug abuse counseling in patients with various co-morbid Axis I and Axis II disorders are particularly encouraged. Investigations that compare the efficacy of one form or combination of psychotherapy, behavior therapy, or counseling to another in other subpopulations of drug addicts (e.g., racial and ethnic minorities, pregnant women, and individuals who abuse cocaine intravenously) are also encouraged. Where effective pharmacotherapies are available, research projects that attempt to maximize the efficacy of that pharmacotherapy through integration with psychosocial treatment are encouraged. Applicants proposing comparative psychosocial treatment research studies are encouraged to examine the interactions of relevant therapist/patient characteristics with therapy type and to assess the relative contribution of therapist, patient, and type of therapy to treatment outcome. For these studies, it is imperative that investigators accurately measure and control for the psychiatric diagnosis and problem severity level of the patients. It is also necessary that clear definitions of treatment outcome variables be specified, and that valid and reliable measures of outcome be used. It is recommended that therapists/counselors providing the treatment be systematically trained, that manuals be used to guide the treatments, that valid and reliable therapist competence and adherence scales be used, and that the treatment process be measured accurately. For all efficacy studies, it is recommended that adequate followup assessments be planned. It is also important that these studies use procedures and methods that can be replicated. It is strongly suggested that pilot data showing that a counseling or psychotherapy strategy is promising be provided when proposing comparative research involving this treatment. These pilot data should indicate that the utilization of the therapy approach shows promise in its ability to produce a decrease in drug use, dropout rate, or psychiatric symptoms. 3. Research on Therapist and Patient Variables in Psychotherapy and Counseling. Researchers have highlighted the importance of individual differences among therapists and counselors independent of the form of treatment. Some studies have shown that certain therapists/counselors are more successful than others, and that this success is more related to the treatment provider than to the type of treatment provided (e.g., McLellan et al., 1988). Studies are sought that assess therapist and/or counselor characteristics and relate these characteristics to effective treatment. Studies that examine the interaction of therapist/counselor and patient variables as related to outcome are also encouraged. Additionally, studies that link the characteristics of patients with successful psychotherapeutic, behavioral, or drug abuse counseling treatment are desired. Measurements of therapist and patient characteristics should be obtained using psychometrically sound instruments. These studies should control for the type of treatment offered and should use objective, empirical measures of the treatment process that occurs. 4. Short-Term vs. Long-Term Goals of Drug Abuse Counseling/Psychotherapy/Behavior Therapy. The treatment process may be viewed as having two distinctive but interrelated sets of goals. One set involves long-term objectives to be achieved as a result of involvement in the treatment program. These goals include reduction in illicit drug use, reduction in illegal activities, improvement in social adjustment, etc. The other set of goals involves specific objectives to be achieved within the treatment program that, it is assumed, will allow clients to attain the long-term treatment goals. These immediate goals include assisting the client in recognizing the harm caused by drug dependence, developing personal strategies for reducing or avoiding stress, recognizing irrational ideas or beliefs, developing realistic strategies for interpreting life events, etc. Research is needed to determine how immediate treatment goals are related to long-term treatment goals (i.e., how success in achieving goals within treatment is related to success in achieving goals that result from treatment). For example, investigators may wish to establish different measures of immediate treatment goals, evaluate clients on success in achieving those goals, and then relate success in attaining immediate treatment goals to outcome measures of drug use or social adjustment. Research is also needed to identify, operationally define, and compare the efficacy of different strategies for attaining immediate treatment goals. For example, investigators may wish to establish different measures of immediate treatment goals, evaluate clients on success in achieving those goals, and then relate success in attaining immediate treatment goals to outcome measures of drug use or social adjustment. Also, investigators may wish to establish two distinctive procedures for achieving stress management (or employment) by clients and then compare the efficacy of the two procedures in terms of stress management. Controlled clinical trials or other rigorous research methods should be used. 5. Component Analysis Research. Knowing the effective components of treatment can greatly aid in improving the quality of treatment. Theoretically based research that attempts to determine the effective components or combination of components in drug dependence psychotherapies, behavior therapies, or counseling strategies is encouraged. Where there is more than one way to answer a proposed research question, investigators are urged to state their theoretical, ethical, and practical reasons for choosing one research design over another (see Borkovec, 1990). Investigators should address the issues of selection bias and attrition (Howard et al., 1990), and any other pertinent methodological issues (see Onken and Blaine, 1990). If a subject is identified as being at risk for HIV acquisition and/or transmission, HIV testing and counseling should be offered to the subject in accordance with current guidelines. Furthermore, in high-risk populations, investigators are encouraged to assess the effect of the new therapy on the acquisition/ transmission of associated infectious disease, including HIV. STUDY POPULATION SPECIAL INSTRUCTIONS TO APPLICANTS REGARDING IMPLEMENTATION OF NIH POLICIES CONCERNING INCLUSION OF WOMEN AND MINORITIES IN CLINICAL RESEARCH STUDY POPULATIONS NIH policy is that applicants for NIH clinical research grants and cooperative agreements will be required to include minorities and women in study populations so that research findings can be of benefit to all persons at risk of the disease, disorder or condition under study; special emphasis should be placed on the need for inclusion of minorities and women in studies of diseases, disorders and conditions which disproportionately affect them. This policy is intended to apply to males and females of all ages. If women or minorities are excluded or inadequately represented in clinical research, particularly in proposed population-based studies, a clear compelling rationale should be provided. The composition of the proposed study population must be described in terms of gender and racial/ethnic group. In addition, gender and racial/ethnic issues should be addressed in developing a research design and sample size appropriate for the scientific objectives of the study. This information should be included in the form PHS 398 in Sections 1-4 of the Research Plan AND summarized in Section 5, Human Subjects. Applicants are urged to assess carefully the feasibility of including the broadest possible representation of minority groups. However, NIH recognizes that it may not be feasible or appropriate in all research projects to include representation of the full array of United States racial/ethnic minority populations (i.e., Native Americans (including American Indians or Alaskan Natives), Asian/Pacific Islanders, Blacks, Hispanics). The rationale for studies on single minority population groups should be provided. For the purpose of this policy, clinical research includes human biomedical and behavioral studies of etiology, epidemiology, prevention (and preventive strategies), diagnosis, or treatment of diseases, disorders or conditions, including but not limited to clinical trials. The usual NIH policies concerning research on human subjects also apply. Basic research or clinical studies in which human tissues cannot be identified or linked to individuals are excluded. However, every effort should be made to include human tissues from women and racial/ethnic minorities when it is important to apply the results of the study broadly, and this should be addressed by applicants. For foreign awards, the policy on inclusion of women applies fully; since the definition of minority differs in other countries, the applicant must discuss the relevance of research involving foreign population groups to the United States' populations, including minorities. If the required information is not contained within the application, the application will be returned. Peer reviewers will address specifically whether the research plan in the application conforms to these policies. If the representation of women or minorities in a study design is inadequate to answer the scientific question(s) addressed AND the justification for the selected study population is inadequate, it will be considered a scientific weakness or deficiency in the study design and will be reflected in assigning the priority score to the application. All applications for clinical research submitted to NIH are required to address these policies. NIH funding components will not award grants or cooperative agreements that do not comply with these policies. APPLICATION PROCEDURES Applications are to be submitted on the grant application form PHS 398 (rev. 9/91) and will be accepted at the standard application deadlines as indicated in the application kit. The receipt dates for applications for AIDS-related research are found in the PHS 398 instructions. Application kits are available at most institutional offices of sponsored research and may be obtained from the Office of Grant Inquiries, Division of Research Grants, National Institutes of Health, Westwood Building, Room 449, Bethesda, MD 20892, telephone (301) 496-7441. The title and number of the announcement must be typed in Section 2a on the face page of the application. FIRST award applications must include at least three sealed letters of reference attached to the face page of the original application. FIRST award applications submitted without the required number of reference letters will be considered incomplete and will be returned without review. The completed original application and five legible copies must be sent or delivered to: Division of Research Grants National Institutes of Health Westwood Building, Room 240 Bethesda, MD 20892** REVIEW PROCEDURES Applications will be assigned on the basis of established PHS referral guidelines. Applications will be reviewed for scientific and technical merit by an initial review group in accordance with the standard NIH peer review procedures. Following scientific-technical review, the applications will receive a second-level review by the appropriate national advisory council. Small grant applications (R03) do not receive a second-level review. AWARD CRITERIA Applications will compete for available funds with all other approved applications assigned to that Institute/Center/Division. The following will be considered in making funding decisions: o Scientific and technical merit of the proposed project as determined by peer review o Availability of funds o Institute program needs and balance INQUIRIES Written and telephone inquiries are encouraged. The opportunity to clarify any issues or questions from potential applications is welcome. Direct inquiries regarding programmatic issues to: Dr. Lisa Onken Treatment Research Branch National Institute on Drug Abuse 5600 Fishers Lane, Room 10A-30 Rockville, MD 20857 Telephone: (301) 443-4060 Direct inquiries regarding fiscal matters to: Mrs. Shirley Denney, Chief Grants Management Branch National Institute on Drug Abuse 5600 Fishers Lane, Room 8A-54 Rockville, MD 20857 Telephone: (301) 443-6710 AUTHORITY AND REGULATIONS This program is described in the Catalog of Federal Domestic Assistance No. 93.279. Awards are made under authorization of the Public Health Service Act, Section 301 and administered under PHS grants policies and Federal Regulations at Title 42 CFR Part 52, Grants for Research Projects, Title 45 CFR part 74 and 92, Administration of Grants, and 45 CFR Part 46, Protection of Human Subjects. Title 42 CFR Part 2, Confidentiality of Alcohol and Drug Abuse Patient Records, may also be applicable to these awards. This program is not subject to the intergovernmental review requirements of Executive Order 12372 or Health Systems Agency review. Sections of the Code of Federal Regulations are available in booklet form from the U.S. Government Printing Office. Awards must be administered in accordance with the PHS Grants Policy Statement, (rev. 10/90), which is available from institutional offices of sponsored research. REFERENCES Azrin, N., "Improvements in the community reinforcement approach to alcoholism," Behavior Research and Therapy, 14: 339-348, 1976. Borkovec, T.D., "Control groups and comparison groups in psychotherapy outcome research," In Onken, L. Simon and Blaine, J.D. (Eds.) Psychotherapy and counseling in the treatment of drug abuse, NIDA Research Monograph #104, Department of Health and Human Services Publication Number (ADM)90-1722, 1990. Carroll, K., Rounsaville, B., and Gawin, F., "A comparative trial of psychotherapies for ambulatory cocaine abusers: Relapse Prevention and Interpersonal Psychotherapy," American Journal of Drug and Alcohol Abuse, 17: 229-247, 1991. Childress, A.R., Ehrman, R., McLellan, A.T., and O'Brien, C.P., "Cue reactivity assessment and a cue exposure intervention in cocaine dependence," American Journal of Psychiatry, under review. Crits-Christoph, P., Beebe, K., and Connolly, M.B. "Therapists effects in the treatment of drug dependence: Implications for conducting comparative treatment studies," In Onken, L. Simon and Blaine, J.D. (Eds.) Psychotherapy and counseling in the treatment of drug abuse, NIDA Research Monograph #104, Department of Health and Human Services Publication Number (ADM)90-1722, 1990. Grabowski, J., Stitzer, M.L., and Henningfeld, J.E., "Therapeutic applications of behavioral techniques: An overview,". In Behavioral Intervention Techniques in Drug Abuse Treatment, Grabowski, J., Stitzer, M.L., and Henningfeld, J.E.(Eds.) NIDA Research Monograph #46, Department of Health and Human Services Publication Number (ADM)86-1282, 1984. Higgins, S.T., Stitzer, M.L., Bigelow, G.E. and Liebson, I.A., "Contingent methadone delivery: Effects on illicit opiate use," Drug and Alcohol Dependence; 17: 311-322, 1986. Higgins, S.T., Delaney, D.D., Budney, A.J., Bickel, W.K., Hughes, J.R., Foerg, F., and Fenwick. J.W., "A behavioral approach to achieving initial cocaine abstinence," American Journal of Psychiatry, 148,9: 1218-1224, 1991. Howard, K.I., Cox, M., and Saunders, S.M., "Attrition in substance abuse comparative treatment research: The illusion of randomization," In Onken, L. Simon and Blaine, J.D. (Eds.) Psychotherapy and counseling in the treatment of drug abuse, NIDA Research Monograph #104, Department of Health and Human Services Publication Number (ADM)90-1722, 1990. Hunt, G.M., and Azrin, N., A community reinforcement approach to alcoholism. Behavior Research and Therapy, 11: 91-104, 1973. Iguchi, M.Y., Stitzer, M.L., Bigelow, G.E., and Liebson, I.A., "Contingency management in methadone maintenance: Effects of reinforcing and aversive consequences on illicit polydrug use," Drug and Alcohol Dependence; 22: 1-7, 1988. Kadden, R.M., Cooney, N.L., Getter, H., and Litt, M.D., "Matching alcoholics to coping skills or interactional therapies: Posttreatment results," Journal of Consulting and Clinical Psychology, 57: 698-704, 1989. Lambert, M.J., Shapiro, D.A., and Bergin, A.E., "The effectiveness of psychotherapy," In Garfield, S.L. and Bergin, A.E. (Eds.) Handbook of Psychotherapy and Behavior Change. New York: Wiley, 157-211, 1986. Lambert, M.J., "Conceptualizing and selecting measures of treatment outcome: Implications for drug abuse outcome studies," In Onken, L. Simon and Blaine, J.D. (Eds.) Psychotherapy and counseling in the treatment of drug abuse, NIDA Research Monograph #104, Department of Health and Human Services Publication Number (ADM)90-1722, 1990. Luborsky, L., Singer, B., and Luborsky, L., "Comparative studies of psychotherapies: Is it true that "everyone has won and all must have prizes?" Archives of General Psychiatry 32: 995-1007, 1975. McLellan, A.T., Woody, G.E., Luborsky, L, and Goehl, L., "Is the counselor an 'active ingredient' in substance abuse rehabilitation? An examination of treatment success among four counselors," The Journal of Nervous and Mental Disease, 176: 423-430, 1988. Onken, L. Simon and Blaine, J.D. (Eds.) Psychotherapy and counseling in the treatment of drug abuse, NIDA Research Monograph #104, Department of Health and Human Services Publication Number (ADM)90-1722, 1990. Rounsaville, B.J., Glazer, W., Wilbur, C.H., Weissman, M.M., and Kleber, H.D., "Short-term interpersonal psychotherapy in methadone maintained opiate addicts," Archives of General Psychiatry 40: 629-636, 1983. Smith, M.L. and Glass, G.V., "Meta-analysis of psychotherapy outcome studies," American Psychologist 32: 752-760, 1977. Stanton, M.D., and Todd, T.C. and Associates, The Family Therapy of Drug Abuse and Addiction. New York: The Guilford Press, 1982. Stiles, W.B., Shapiro, D.A., and Elliott, R., "Are all psychotherapies equivalent?" American Psychologist 41: 165-180, 1986. Stitzer, M.L., Bickel, W.K., Bigelow, G.E., and Liebson, I.A., "Effect of methadone dose contingencies on urinalysis results of polydrug-abusing methadone-maintenance patients," Drug and Alcohol Dependence; 18: 341-348, 1986. Stitzer, M.L., Iguchi, M.Y., and Felch, L.J., "Contingent take-home incentive: Effects on drug use of methadone maintenance patients," Journal of Consulting and Clinical Psychology, In press. Woody, G.E., Luborsky, L., McLellan, A.T., O'Brien, C.P., Beck, A.T., Blaine, J., Herman, I., and Hole, A., "Psychotherapy for opiate addicts- Does it help?" Archives of General Psychiatry 40: 639-645, 1983. Woody, G.E., McLellan, A.T., Luborsky, L., and O'Brien, C.P., Blaine, J., Fox, S., Herman, I., and Beck, A.T., "Severity of psychiatric symptoms as a predictor of benefits from psychotherapy: The Veterans Administration-Penn Study," American Journal Of Psychiatry 141: 1172-1177, 1984. Woody, G.E., McLellan, A.T., Luborsky, L., and O'Brien, C.P., "Sociopathy and psychotherapy outcome," Archives of General Psychiatry 42: 1081-1086, 1985. Woody, G.E., McLellan, A.T., Luborsky, L., and O'Brien, C.P., "Psychotherapy and counseling for methadone-maintained opiate addicts: Results of research studies," In Psychotherapy and Counseling in Drug Abuse Treatment, Onken, L. Simon and Blaine, J.D., NIDA Research Monograph #104, Department of Health and Human Services Publication Number (ADM)90-1722, 1990. .
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