Treatment for Substance Use Disorders

Subsections:

Related Chapters:

Looking for a referral to, or more information about, mental health or substance use treatment services? The American Board of Preventive Medicine provides this service to locate physicians who are certified in specialists in Addiction Medicine

The federal Substance Abuse and Mental Health Services Administration has a free, confidential National Helpline at 1-800-662-HELP (4357).
"SAMHSA’s National Helpline, 1-800-662-HELP (4357), (also known as the Treatment Referral Routing Service) is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental and/or substance use disorders. This service provides referrals to local treatment facilities, support groups, and community-based organizations. Callers can also order free publications and other information."
SAMHSA's website also offers a free, confidential Behavioral Health Treatment Services Locator.

41. Patient Response To Computerized Treatment Versus Therapist-Delivered Therapy

"Results: Compared with computer- or therapist-delivered CBT/MI [cognitive behaviour therapy and motivational interviewing], PCT [person-centred therapy] was associated with significantly less reduction in depression and alcohol consumption at 3 months. CAC [(clinician-assisted computerised] therapy was associated with improvement at least equivalent to that achieved by therapist-delivered treatment, with superior results as far as reducing alcohol consumption. Change in depression was significantly predicted by change in alcohol use (in the same direction) and an ability to determine primacy, irrespective of whether this was for drug use or depression. Change in alcohol use was significantly predicted by changes in cannabis use and depression, and change in cannabis use by change in alcohol use. In the regression model, treatment allocation did not independently predict change, but was associated with significant reduction in depression and alcohol use at 3 months.
"Conclusions: Over a 3-month period, CBT/MI was associated with a better treatment response than supportive counselling. CAC therapy was associated with greater reduction in alcohol use than therapist-delivered treatment."

Frances J Kay-Lambkin, Amanda L Baker, Brian Kelly and Terry J Lewin, "Clinician-assisted computerised versus therapist-delivered treatment for depressive and addictive disorders: a randomised controlled trial," Med Journal of Australia 2011; 195 (3): 44.
https://www.mja.com.au/journal...
https://www.mja.com.au/system/...

42. Substance Use Disorder Treatment Completion Rates by Race

"Across racial and ethnic groups, treatment completion rates were generally highest for people receiving treatment that primarily targeted alcohol abuse, followed by treatment for methamphetamines, and were lowest for treatment for heroin (Exhibit 2). Except for opiates and heroin, where the differences were not significant, Asian Americans were more likely than whites to complete treatment for all substances. Conversely, blacks and Hispanics were significantly less likely than whites to complete treatment for all substances except for opiates. Native Americans had significantly lower completion rates than whites for all substances except for cocaine and methamphetamines.
"Blacks and Hispanics were less likely than whites to complete treatment across all settings, and Asian Americans were more likely (Exhibit 3). The alcohol treatment completion rate was generally higher for people discharged from residential settings, followed by intensive outpatient settings. However, Asian Americans and Hispanics were just as likely to complete nonintensive as intensive outpatient alcohol treatment."

Brendan Saloner and Benjamin Lê Cook, "Blacks And Hispanics Are Less Likely Than Whites To Complete Addiction Treatment, Largely Due To Socioeconomic Factors," Health Affairs, 32, no.1 (2013):135-145 doi: 10.1377/hlthaff.2011.0983, p. 138.
healthaffairs.org

43. Treatment Effectiveness at Reducing Levels of Drug Use

"During the course of treatment, many treatment seekers stopped using the drugs that they reported using at entry to the study. Lower rates of drug use were recorded at each follow-up. Furthermore, those that continued to use tended to use less. Most of the changes observed occurred by first follow-up. For most forms of drug use, no particular treatment modality was more associated with cessation than any other and the route into treatment (CJS or non-CJS) did not influence drug-use outcomes.

"The proportion using each drug reduced significantly between baseline and follow-up (Figure 5). Most of this change occurred by first follow-up; indeed use of some drug types increased marginally, and levels of abstinence from all drugs decreased between first and second follow-up.

"The proportion of treatment seekers using heroin, crack, cocaine, amphetamine or benzodiazepines decreased between baseline and follow-up by around 50 per cent; the proportion using non-prescribed methadone or other opiates such as morphine, decreased by considerably more; but the proportion using cannabis or alcohol decreased by considerably less.The proportion who reported each drug to be causing problems fell substantially for all drug types, suggesting that continued use was often, in the client’s view, non-problematic."

Andrew Jones, et al., "Research Report 24: The Drug Treatment Outcomes Research Study (DTORS): Final Outcomes Report" (London, England: UK Government, Home Office Ministry, Research, Development & Statistics Directorate, December 2009), p. 10.
nationalarchives.gov.uk
nationalarchives.gov.uk

44. Treatment Effectiveness at Reducing Levels of Offending

"Overall, lower levels of acquisitive offending and high-cost offending were recorded at follow-up. Among those who continued to offend, improvements in offending behaviour at follow-up, in terms of a decrease in its volume and/ or the costs associated with it, were observed. Crack users, injecting users, users with high SDS [Severity of Dependence Scores] scores, and those with previous treatment experience were more likely to offend than others at any point. However, neither referral source nor the type of treatment modalities received, were significantly associated with the level of acquisitive offending at any point (within the adjusted model)."

Andrew Jones, et al., "Research Report 24: The Drug Treatment Outcomes Research Study (DTORS): Final Outcomes Report" (London, England: UK Government, Home Office Ministry, Research, Development & Statistics Directorate, December 2009), p. 10.
socialwelfare.bl.uk
socialwelfare.bl.uk

45. Substance Abuse Treatment and Crime Rates

"Increases in admissions to substance abuse treatment are associated with reductions in crime rates. Admissions to drug treatment increased 37.4 percent and federal spending on drug treatment increased 14.6 percent from 1995 to 2005. During the same period, violent crime fell 31.5 percent. Maryland experienced decreases in crime when jurisdictions increased the number of people sent to drug treatment."

Justice Policy Institute, "Substance Abuse Treatment and Public Safety," (Washington, DC: January 2008), p. 1.
http://www.justicepolicy.org/i...

46. Recidivism Post-Treatment

"Examination of all clients exiting [drug treatment] in 2005-06 revealed that 46% didn’t return to drug treatment nor had a drug related contact with the CJS [criminal justice system] in the following four years. This would suggest the majority of these individuals are managing to sustain their recovery from addiction though it is not possible to confirm this from the analysis presented in this report."

"A long-term study of the outcomes of drug users leaving treatment," National Treatment Agency for Substance Misuse (London, United Kingdom: September 2010), p. 9.
http://www.nta.nhs.uk/uploads/...

47. Effectiveness of Treatment on Employment and Social Reintegration

"The Drug Treatment Outcomes Research Study (DTORS) was one example of European research with encouraging results regarding employment (Jones et al., 2009). This study investigated drug use, health and psychosocial outcomes in 1 796 English drug users attending a range of different types of treatment service. Follow-up interviews were conducted between 3 and 13 months after baseline (soon after initial treatment entry). Regardless of the type of treatment received or drug use outcomes, employment levels increased from 9 % at baseline to 16 % at follow-up. This was accompanied by a corresponding increase in the amount of legitimate income earned per week. The proportion reporting being unemployed but actively looking for work decreased slightly from 27 % to 24 %, reflecting the increase in employment and a 5 percentage point increase in those reporting being unable to work (because of long-term sickness or disability). The proportion of participants classed as unemployed and not looking for work also fell from 24 % to 11 %. Treatment attendance was also associated with changes in housing status; the proportion staying in stable accommodation increased from 60 % to 77 % at follow-up. It should be noted that the findings of this study were weakened by use of a non-experimental design, failure to separate outcomes according to client type and treatment modality, and insufficient detail on the nature of the employment obtained."

European Monitoring Centre for Drugs and Drug Addiction, EMCDDA Insights Series No 13, "Social reintegration and employment: evidence and interventions for drug users in treatment" (Luxembourg: Publications Office of the European Union, 2012), ISBN: 978-92-9168-557-8, doi: 10.2810/72023, p. 67.
emcdda.europa.eu

48. Effectiveness of Treatment on Social Reintegration and Employment

"In a recent secondary analysis of a national US survey of clients conducted in the early 1990s (National Treatment Improvement Evaluation Study), researchers tried to identify which types of treatment modality (methadone-substitute prescribing, methadone-assisted detoxification, outpatient detoxification, short-term residential, long-term residential or criminal justice focused) and treatment characteristics (e.g. length of treatment) were associated with better employment outcomes (Dunlap et al., 2007). Overall, the treatment modality received and the characteristics of that treatment (such as length of stay or number of sessions completed) were not significantly associated with employment outcomes. The strongest predictor of employment was pre-treatment employments. The authors hypothesised that receipt of treatment services per se was less important than the quality of services received, although this was not tested."

European Monitoring Centre for Drugs and Drug Addiction, EMCDDA Insights Series No 13, "Social reintegration and employment: evidence and interventions for drug users in treatment" (Luxembourg: Publications Office of the European Union, 2012), ISBN: 978-92-9168-557-8, doi: 10.2810/72023, p. 67.
emcdda.europa.eu

49. Cost Effectiveness of Treatment vs. Law Enforcement in Reducing Substance Use

Cost Effectiveness of Substance Use Treatment

The RAND Corporation found that the additional spending needed to achieve a 1% reduction in the number of cocaine users varies according to the sort of program used, and that treatment is the most cost-effective:

Table comparing cost effectiveness of spending on treatment versus law enforcement for reducing substance use

Rydell, C.P. & Everingham, S.S., Controlling Cocaine, Prepared for the Office of National Drug Control Policy and the United States Army (Santa Monica, CA: Drug Policy Research Center, RAND Corporation, 1994), p. 36.
http://www.rand.org/pubs/monog...

50. Cost Effectiveness of Substance Abuse Treatment

"Substance abuse treatment is more cost-effective than prison or other punitive measures. The Washington State Institute for Public Policy (WSIPP) found that drug treatment conducted within the community is extremely beneficial in terms of cost, especially compared to prison. Every dollar spent on drug treatment in the community is estimated to return $18.52 in benefits to society."

Justice Policy Institute, "Substance Abuse Treatment and Public Safety," (Washington, DC: January 2008), p. 2.
http://www.justicepolicy.org/i...

51. Substance Use Treatment in State and Federal Prisons

"The percentage of recent drug users in State prison who reported participation in a variety of drug abuse programs rose from 34% in 1997 to 39% in 2004 (table 9). This increase was the result of the growing percentage of recent drug users who reported taking part in self-help groups, peer counseling and drug abuse education programs (up from 28% to 34%). Over the same period, the percentage of recent drug users taking part in drug treatment programs with a trained professional was almost unchanged (15% in 1997, 14% in 2004).

"Participation in drug abuse programs also increased among Federal inmates who had used drugs in the month before their offense, from 39% in 1997 to 45% in 2004. While there was no change in percentage of these inmates who had undergone drug treatment with a trained professional (15% in both years), the percentage taking part in other drug abuse programs rose from 32% in 1997 to 39% in 2004."

Mumola, Christopher J., and Karberg, Jennifer C., "Drug Use and Dependence, State and Federal Prisoners, 2004," (Washington, DC: Bureau of Justice Statistics, Dept. of Justice, Oct. 2006) NCJ-213530, p. 8.
http://www.bjs.gov/content/pub...

52. Risk of Death and Other Adverse Events from Anesthesia-Assisted Rapid Opioid Detoxification (AAROD)

"Government agencies and professional societies,* including the American Society of Addiction Medicine, have recommended against using AAROD in clinical settings (9). There is insufficient knowledge regarding how widely AAROD is used in the United States and the frequency of AAROD-associated adverse events in community practice settings. At least seven deaths occurred following AAROD among 2,350 procedures performed in one practice during 1995–1999.†
"The New York City clinic investigation revealed that AAROD was performed on 75 patients during January–September 2012 and was associated with two deaths and five additional adverse events requiring hospitalization, a serious adverse event rate of 9.3%. No standard protocol exists for AAROD; however, the clinic’s practice was consistent with AAROD use described elsewhere (7). All events occurred after and in close temporal proximity to AAROD. Although a common mechanism linking these events to AAROD is not evident, the events are consistent with previously proposed mechanisms of AAROD-associated adverse events, including electrolyte disturbance, catecholamine release, altered cardiopulmonary functioning, acute lung injury, and other physiologic effects associated with administration of high doses of opioid antagonists under general anesthesia (10). Given the ongoing epidemic of prescription opioid dependence, further increases in the demand for substance use disorder services are to be expected. AAROD has substantial risks, including a risk for death, and little to no evidence to support its use. Safe, evidence-based treatments of opioid dependence (e.g., MAT [Medication-Assisted Treatment]) exist and are preferred (2)."


* Additional information available at http://www.nice.org.uk/. Care Med 2000;28:969–76.
† Additional information available at http://njlaw.rutgers.edu/colle....

"Deaths and Severe Adverse Events Associated With Anesthesia-Assisted Rapid Opioid Detoxification - New York City, 2012," Mortality and Morbidity Weekly Report (Atlanta, GA: Centers for Disease Control, Sept. 27, 2013), Vol. 62, No. 38, p. 780.
http://www.cdc.gov/...
http://www.cdc.gov/mmwr/pdf/wk...

53. Harm Reduction Interventions

"Harm-reduction services for problematic drug users usually address the associated harms and risk behaviours, such as injecting, with a holistic approach that focuses on the nature and severity of the behaviours and problems experienced by the individual, rather than on a specific substance. Therefore, in response to the elevated health risks associated with problem drug use, including polydrug use, harm-reduction services are generally provided on a case-by-case basis and often according to professionals’ own work experience. Furthermore, harm-reduction interventions usually operate within a broader local prevention strategy that combines other types of services such as outreach work and opioid substitution treatment, which contribute to the reduction of risks and health problems experienced by problem polydrug users. Evidence of the effectiveness of harm-reduction interventions has been reported in other EMCDDA publications (EMCDDA, 2008a) and will be reviewed in a forthcoming monograph on harm reduction."

European Monitoring Centre for Drugs and Drug Addiction, "Polydrug Use: Patterns and Responses" (Lisboa, Portugal: 2009), p. 25.
http://www.emcdda.europa.eu/at...

54. Portion of US Healthcare Spending Used For Substance Use Treatment

"In 2003, an estimated $21 billion was spent on drug and alcohol addiction treatment. This represents 1.3 percent of all health care spending for that year."

"Defining the Addiction Treatment Gap" Open Society Foundations (New York, NY: Open Society Foundations, November 2010), p. 5.
http://www.opensocietyfoundati...

55. Estimated Unmet Treatment Need in the US, 2010-2013

"• In 2013, among the 20.2 million persons aged 12 or older who were classified as needing substance use treatment but not receiving treatment at a specialty facility in the past year, 908,000 persons (4.5 percent) reported that they perceived a need for treatment for their illicit drug or alcohol use problem (Figure 7.10). Of these 908,000 persons who felt they needed treatment but did not receive treatment in 2013, 316,000 (34.8 percent) reported that they made an effort to get treatment, and 592,000 (65.2 percent) reported making no effort to get treatment. These estimates were stable between 2012 and 2013.

"• The rate and the number of youths aged 12 to 17 who needed treatment for an illicit drug or alcohol use problem in 2013 (5.4 percent and 1.3 million) were lower than those in 2012 (6.3 percent and 1.6 million), 2011 (7.0 percent and 1.7 million), 2010 (7.5 percent and 1.8 million), and 2002 (9.1 percent and 2.3 million). Of the 1.3 million youths who needed treatment in 2013, 122,000 received treatment at a specialty facility (about 9.1 percent of the youths who needed treatment), leaving about 1.2 million who needed treatment for a substance use problem but did not receive it at a specialty facility.

"• Based on 2010-2013 combined data, commonly reported reasons for not receiving illicit drug or alcohol use treatment among persons aged 12 or older who needed and perceived a need for treatment but did not receive treatment at a specialty facility were (a) not ready to stop using (40.3 percent), (b) no health coverage and could not afford cost (31.4 percent), (c) possible negative effect on job (10.7 percent), (d) concern that receiving treatment might cause neighbors/community to have a negative opinion (10.1 percent), (e) not knowing where to go for treatment (9.2 percent), and (f) no program having type of treatment (8.0 percent).

"• Based on 2010-2013 combined data, among persons aged 12 or older who needed but did not receive illicit drug or alcohol use treatment, felt a need for treatment, and made an effort to receive treatment, commonly reported reasons for not receiving treatment were (a) no health coverage and could not afford cost (37.3 percent), (b) not ready to stop using (24.5 percent), (c) did not know where to go for treatment (9.0 percent), (d) had health coverage but did not cover treatment or did not cover cost (8.2 percent), and (e) no transportation or inconvenient (8.0 percent) (Figure 7.11)."

Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014, pp. 94-95.
http://www.samhsa.gov/data/NSD...
http://www.samhsa.gov/data/NSD...

56. Treatment Admissions in the US with Marijuana as a Primary Substance, 2014

"• Marijuana/hashish was reported as the primary substance of abuse by 15 percent of TEDS admissions aged 12 and older in 2014 [Table 1.1b].
"• The average age at admission for primary marijuana/hashish admissions was 26 years [Table 2.1b], although the peak age at admission for both genders in all race/ethnicities was about 16 to 17 years [Figure 12]. Thirty-two percent of marijuana/hashish admissions were under age 20 (vs. 8 percent of all admissions combined), and primary marijuana/hashish abuse accounted for 78 percent of admissions aged 12 to 14 and 76 percent of admissions aged 15 to 17 years [Table 2.1c].
"• Non-Hispanic Whites accounted for 44 percent of primary marijuana/hashish admissions (30 percent were males and 14 percent were females), and non-Hispanic Blacks accounted for 31 percent (24 percent were males and 8 percent were females) [Table 2.3b].
"• Twenty-four percent of primary marijuana/hashish admissions had first used marijuana/hashish by age 12 and another 30 percent had first used it by age 14 [Table 2.5b].
"• Primary marijuana/hashish admissions were most likely to be referred by the court/criminal justice system (52 percent). Primary marijuana/hashish admissions were less likely than all admis-sions combined to be self- or individually referred to treatment (18 vs. 37 percent) [Table 2.6b].
"• More than 4 in 5 marijuana/hashish admissions (86 percent) received ambulatory treatment; among all admissions combined, 3 in 5 (61 percent) received ambulatory treatment [Table 2.7b].
"• Sixty-three percent of primary marijuana/hashish admissions reported abuse of additional sub-stances. Alcohol was reported by 37 percent [Table 3.8]."

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2004-2014. National Admissions to Substance Abuse Treatment Services. BHSIS Series S-84, HHS Publication No. (SMA) 16-4986. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016, pp. 21-22.
https://www.samhsa.gov...
https://www.samhsa.gov...

57. Effectiveness of Heroin-Assisted Treatment [HAT] and Overview of Research

"A few key conclusions and discussion points regarding the state and future of HAT (heroin-assisted treatment) can be offered based on the above review of completed or ongoing studies.

"First, although the basic goal of the different HAT studies is similar, each of the studies is distinct in key aspects, thus limiting direct comparisons and meta-analyses.40 Although this might be a desirable goal for science, it should be noted that heroin addiction and its consequences occur in distinct real-life environments (including unique cultural and system factors), and interventions need to be devised, measured, and evaluated within these to have authentic relevance for policy and practice.33,41

"Second, the discussed studies above have demonstrated in several different contexts that the implementation of HAT is feasible, effective, and safe as a therapeutic intervention.21,24,26,30 This should not be seen as a conclusion that could be taken for granted because many observers expected disastrous consequences from the provision of medical heroin prescription.

"Third, even within the contexts of relevant methodological constraints, e.g., the Swiss study relying purely on prospective observational data, and most of the other RCTs comparing HAT outcomes against a control intervention (MMT), which participants have previously either rejected by choice or proven to be ineffective, 32,42 the reviewed HAT studies have demonstrated rather robust and consistently positive therapeutic outcomes on the various indicators chosen for a population of high-risk heroin addicts for whom currently no effective alternative therapies are available. Clearly, this demonstrated effectiveness is at this point limited to short-term outcomes, and long-term examinations ought to follow (albeit Swiss follow-up data present initial positive evidence in this regard).43 It may very well emerge that HAT's main long-term benefit does not materialize through life-long maintenance, but by stabilizing and readying many of its patients for other simpler therapeutic interventions or even abstinence.

"Fourth, also given the current expansion and diversification of alternative oral opioid maintenance therapies (e.g., buprenorphine and morphine) and considering the complex logistics (on both providers and patients_ ends), high costs, and sociopolitical controversy around (especially injection) HAT, the most sensible role of HAT is likely that of an exceptional 'last resort' option for heroin addicts who cannot be effectively attracted into or treated in other available therapeutic interventions.44,45 Granted the above, the primary emerging challenge for science—rather than conducting new and more HAT effectiveness studies—is to provide evidence-based guidelines on how to effectively match existing heroin addict profiles and needs with existing treatment options. This challenge has recently been complicated—in at least some jurisdictions—with the increasing diversification of heroin into poly-opioid (e.g., prescription) use profiles.46

"Finally, after extensive HAT research efforts over the past decade, the principal onus of action has shifted from the scientific to the political arena in the jurisdictions under study.12,18 Despite the overall positive results of completed HAT trials undoubtedly justifying some role of HAT in the addiction treatment landscape, authorities in only two countries, Switzerland and the Netherlands, have decisively acted on this issue.34"

Benedikt Fischer, Eugenia Oviedo-Joekes, Peter Blanken, Christian Haasen, Jurgen Rehm, Martin T. Schechter, John Strang, and Wim van den Brink, "Heroin-assisted Treatment (HAT) a Decade Later: A Brief Update on Science and Politics," Journal of Urban Health: Bulletin of the New York Academy of Medicine, (2007) Vol. 84, No. 4, pp. 559-560.
http://www.ncbi.nlm.nih.gov/pm...

58. Treatment - 3-16-10

"Domestic enforcement costs 4 times as much as treatment for a given amount of user reduction, 7 times as much for consumption reduction, and 15 times as much for societal cost reduction."

Rydell, C.P. & Everingham, S.S., Controlling Cocaine, Prepared for the Office of National Drug Control Policy and the United States Army (Santa Monica, CA: Drug Policy Research Center, RAND Corporation, 1994), p. xvi.
http://www.rand.org/pubs/monog...

59. Funding Barriers

"Despite the many factors that contribute to the gap, the Panel agrees with many in the field that inadequate funding for substance abuse treatment is a major part of the problem. Over the last decade, spending on substance abuse prevention and treatment has increased, albeit more slowly than overall health spending, to an estimated annual total of $12.6 billion in 1996 (McKusick, Mark, King, Harwood, Buck, Dilonardo, and Genuardi, 1998). Of this amount, public spending is estimated at $7.6 billion (McKusick, et al., 1998). The public spending includes dollars from Medicaid and Medicare, as well as other Federal funds from the Department of Defense, the Department of Veterans Administration, the Department of Justice, and the Substance Abuse Prevention and Treatment (SAPT) Block Grant. The SAPT Block Grant provides Federal support to addiction prevention and treatment services nationally through State and local governments. Private spending includes individual out-of-pocket payment, insurance, and other nonpublic sources, and is estimated at $4.7 billion (McKusick, et al., 1998)."

US Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, "Changing the Conversation: Improving Substance Abuse Treatment: The National Treatment Plan Initiative; Panel Reports, Public Hearings, and Participant Acknowledgements" (Washington, DC: SAMHSA, November 2000), p. 12.
http://permanent.access.gpo.go...

60. Public vs. Private Insurance

"One of the main reasons for the higher outlay in public spending is the frequently limited coverage of substance abuse treatment by private insurers. Although 70 percent of drug users are employed and most have private health insurance, 20 percent of public treatment funds were spent on people with private health insurance in 1993, due to limitations on their policy (ONDCP, 1996b). In the view of the Panel, private insurers should serve as the primary source of coverage, with public insurance serving as the safety net."

US Dept. of Health and Human Services, Substance Abuse and Mental Health Services Administration, "Changing the Conversation: Improving Substance Abuse Treatment: The National Treatment Plan Initiative; Panel Reports, Public Hearings, and Participant Acknowledgements" (Washington, DC: SAMHSA, November 2000), p. 12.
http://permanent.access.gpo.go...

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