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Treatment, self-help and other responses to addiction or dependence, changing consumption patterns, detox, residential treatment, self-help programs, pharmacotherapy, talking therapies

Pharmacotherapy/medication-assisted treatment

NOTE: Quotes are presented word for word apart from minor editing for readability and clarity. Identifying details have been removed. Square brackets show text that has been added, e.g. ‘I want to maintain [my current level of drug use]’. Ellipses within square brackets […] show where text has been removed, e.g. ‘Counselling was good but […] I would have liked more information about other treatment options’.

Many of the people interviewed for this website talk about changing their patterns of alcohol and other drug use by seeking formal treatment (see also other subsections under Creating change: treatment, self-help and other responses). One of the treatments commonly discussed is pharmacotherapy or medication-assisted treatment. In Australia, pharmacotherapies are available for the treatment of dependence on opioids, alcohol and nicotine. At present no pharmacotherapies are approved to treat dependence on methamphetamine, cocaine or cannabis. The aims of pharmacotherapy treatment, and how it is delivered, differ depending on the drug of concern. In the case of alcohol dependence, it is generally intended to prevent drinking and control or reduce ‘cravings’. Pharmacotherapy for people diagnosed with opioid dependence goes by several different names: Opioid Pharmacotherapy Treatment (OPT – used here), Opioid Replacement Therapy/Treatment (ORT), Opioid Pharmacotherapy Program (OPP) or Opioid Substitution Therapy/Treatment (OST). It involves replacing the opioid normally consumed, such as heroin, with a legally prescribed opioid.

Beyond reducing other opioid use and preventing physical symptoms associated with opioid withdrawal, OPT is associated with people staying in treatment, reduced overdose risk, reduced risk of HIV and hepatitis C transmission, and general improvement in mental health and well-being. Some of these health improvements relate both to the use of pharmacotherapy and the fact that when in treatment people may connect with health and welfare agencies better. In this sense, OPT is also thought to aid ‘social reintegration’, ease the economic burden of illicit consumption, allow better access to employment and reduce harms associated with injecting. There is little doubt that opioid pharmacotherapy is the most effective treatment for opioid dependence. The term ‘medication-assisted treatment of opioid dependence’ (MATOD) refers to treatments for opioid dependence that combine medication (pharmacotherapy) with access to counselling and health and social services.

The three main opioid pharmacotherapy medications currently used in Australia are methadone (or Biodone®) syrup, buprenorphine (Subutex®) sublingual tablets and combination buprenorphine and naloxone (Suboxone®) sublingual film. Methadone is a synthetic opioid initially developed for the treatment of pain. It is an opioid agonist, which means it is designed to bind to the receptors in the brain which otherwise take up heroin or other opioids and give an opioid effect. Buprenorphine is also a synthetic opioid initially developed for the treatment of pain. Buprenorphine is a partial opioid agonist: it is also designed to bind to opioid receptors in the brain. Buprenorphine has a ‘ceiling effect’ which means that its psychoactive effect reaches a maximum level that doesn’t increase even with increasing doses. Buprenorphine can be longer acting in the body than methadone, depending on the dose, and can allow some clients to dose every second day rather than daily. Combination buprenorphine and naloxone (Suboxone®) treatment combines the partial opioid agonist buprenorphine with naloxone. Naloxone is an opioid antagonist: it is intended to reverse the effects of opioids. Combination buprenorphine/naloxone is a sublingual film designed to be absorbed under the tongue. When taken under the tongue (or sublingually), only the buprenorphine is absorbed, and the medication has an opiate effect. If the medication is injected, the naloxone is absorbed and the medication can produce withdrawal effects. The addition of naloxone to buprenorphine was intended to discourage the injecting of treatment medication.

Some of our participants had experience of OPT and one participant, Phoenix, undertook pharmacotherapy for alcohol dependence. Of those who undertook OPT, most went on methadone maintenance treatment (MMT). Others had buprenorphine (Subutex®) or combination buprenorphine and naloxone (Suboxone®). Some tried more than one type of opioid pharmacotherapy treatment. While each type has benefits and drawbacks, our participants describe a number of general benefits of pharmacotherapy. Its effectiveness in preventing or easing withdrawal symptoms and reducing ‘craving’ for the drug are two commonly mentioned benefits. Several say that pharmacotherapy helped them cut down or stop taking heroin or other non-prescribed opiates altogether, while others say it helped them manage their consumption in relation to work and other commitments.

Negative experiences and disadvantages were also described. These include the side-effects of some opioid pharmacotherapies, long waiting times at some clinics or chemists, lack of access to takeaway or non-supervised doses, the cost of OPT (as dosing fees are not subsidised by the Pharmaceutical Benefits Scheme) and limited availability especially outside major cities. Some describe experiences of stigma and discrimination when accessing OPT. Despite these issues, many comment on the value of OPT and the difference it makes in their lives. Importantly, many of the disadvantages described are related to the delivery of OPT, rather than the medications themselves, which many of our participants find very helpful.

Read on to find out more about people’s experiences of accessing and undertaking different medication-assisted treatments.

Read more...

Opioid pharmacotherapy treatment (OPT)

This section begins by presenting experiences of accessing treatment. Experiences of treatment with specific opioid pharmacotherapies are discussed next. We begin with accounts of methadone maintenance treatment (MMT), the first opioid pharmacotherapy treatment to be introduced in Australia (in the 1970s). We then present experiences of treatment with buprenorphine (Subutex®), which was introduced in Australia in 2001. Lastly we present experiences of treatment with buprenorphine naloxone (Suboxone®), which was introduced in Australia in 2005 but is now more widely prescribed than buprenorphine.

Accessing treatment

Australia has a significant demand for OPT and many of our participants, keen to commence treatment and access its benefits, describe difficulty accessing treatment. They often persevere for some time and travel long distances to secure access to treatment. In Australia, pharmacotherapy is delivered through dedicated, government-funded clinics, private clinics, community pharmacies and GP prescribers. Most states and territories have a combination of government-funded clinics, community pharmacies and GP prescribers. A few of our participants say they find it especially hard to access OPT outside major cities. Having to queue for a long time to get their dose from a prescribing clinic or chemist was a concern for several people. It was suggested that clinics employ more clinical staff to cope with the demand and reduce waiting times. In most states in Australia, doctors must apply for approval to prescribe OPT before they can prescribe, but some states (e.g. Victoria, South Australia, New South Wales) are granting exemptions to increase the number of buprenorphine-prescribing doctors to facilitate access to treatment.

Affording OPT on top of other regular expenses was also an issue in some cases. In Australia OPT consumers have to pay a ‘program’ or ‘dispensing’ fee to the prescribing chemist or clinic – this can be an additional $15 to $90 per week and is not subsidised by Medicare. Research has found that dispensing fees can be a significant financial burden for pharmacotherapy clients on fixed incomes or welfare support and contribute to people prematurely dropping out of treatment due to financial stress. Experiences of stigma and discrimination when accessing OPT at chemists or clinics were also described and in some cases, this discouraged people from seeking or continuing treatment.

Despite these issues, many stress the value of OPT and describe the difference it makes in their lives. As Nick (M, 50, not working due to illness, heroin) puts it:

I’m on methadone as well, which is, you know, to get off heroin. But I am not on a very large dose. If you haven’t got methadone to back you up, where it takes away the withdrawals, there is no other choice but to use the drug to feel normal, which is a shame […] The best way to stop using heroin […] is methadone and Suboxone and Subutex and all those things that they have got available now […They’re very helpful in] managing withdrawal symptoms.

Josie (F, 38, not working due to illness, heroin) makes a similar point:

The methadone does make a difference […] Now I only use [heroin] once a week or whatever, but I’m not chasing and trying to do anything I can to get on […The methadone] doesn’t take [the withdrawals] away but it does make a difference. It’s bearable, you know. It sort of gives you that calm feeling […] I need to either have my methadone or my gear [heroin] to get me going for the day.

Grace (F, 58, works in manufacturing, heroin) and her partner find it hard to access OPT in their local town so they travel to the nearest major city for it. (Played by an actor)

We tried to get a doctor [in our local town to prescribe treatment] but apparently there was only one and he’s really hard to get in to see. So that’s why we just keep [seeing our regular prescribing doctor in the nearest major city]. It was just easier to ring up, make an appointment and he can see you in the next couple of days […] But I can’t really tell you much about [this town because…] when I did ring a couple of times [they said] ‘You have to wait. I can give you an appointment in a month or three weeks’. I can’t remember exactly, but yeah, it was like, I’m not waiting that long.

Rachel (F, 50, works in the health sector, heroin) supports her family on a single income and finds it hard to afford MMT on top of her other expenses. (Played by an actor)

I pay the bills and I’m lucky to have $100 left, you know [With] that I’ve got to feed the family, I’ve got to get transport […] I think that we would have this [financial] pressure even if we didn’t have [to pay for heroin] because we’re a single income family. Even though I earn good money, it’s still [not enough] Mind you, I say I earn good money but I was earning the same amount of money in the 90s and the rent’s [gone up since then…] When we move out of this place, I don’t know where we’re going to move to because I just look at the rent and I just can’t see anywhere that we can afford […] I have to pay for [my partner’s] medication. He has a lot of medication and that’s $30 or $40 a ‘hit’, and he’s on about seven different medications. My [child] is on two different medications. Plus the methadone, so there’s all that. So if the methadone was free, God that would help!

Some people such as Amy below find the highly structured dosing arrangements help them manage their use and remain ‘committed’ to treatment, while others question them. For example, several point out that supervised dosing and restrictions on takeaway doses mean they have to visit the chemist every day to get their medication. This disrupts work and family commitments, and limits opportunities for travel. Those working full-time note that limited dispensing hours mean they have to get their medication dose from a chemist after work hours. A few say they avoid telling their employers that they are on treatment for fear of being judged or even losing their jobs (see also Work, study & making ends meet).

Amy (F, 52, studying, heroin) finds the structured dosing arrangements help her to avoid skipping doses.

Going to a chemist you sort of have to be committed and you do have to actually appear. There’s rules around [it]: you can’t miss three days and things like that […] But the longer you are on [OPT] the more takeaway [doses] you get. But the more takeaways you get, the more you can abuse it, because you can not take [the dose…] So for a couple of months I actually went to the chemist more often because I felt it was better for me. I’d have less opportunity to muck around […] I need be on [Suboxone] because I couldn’t be going to school. I couldn’t manage my life without it. If I wasn’t on Suboxone I […] couldn’t afford to use every day. And, you know, you couldn’t afford to because your habit would be going up and up and up.

OPT helped Harry (M, 52, works in arts, heroin) fit his heroin consumption around his work but he found the dosing arrangements restricted his freedom of movement.

I had to [go on methadone] because at the time I was working a full-time job in a place that required a lot of shift work and a lot of hours per week. And I couldn’t even financially […] maintain the heroin and the job. So I had to go on methadone […] I didn’t know what journey that was going to be and it turned out 10 years on methadone and a horrible period of withdrawal from it. But it […] was, you know, maintenance. It wasn’t treatment to get you off [heroin] obviously. It was maintenance. And so it just made sure you could continue to go to work and not necessarily use heroin every day. So there was 10 years of that until I finally got away from the methadone and now my opinion of methadone is fairly low. I wouldn’t ever go back on it again. It wasn’t as though it wasn’t convenient or useful. It was the rigmarole, the process that you had to go through. And also that it bound you to a particular location.

When David (M, 25, unemployed, heroin) was on MMT, he didn’t tell his employer because he was concerned about being judged or even fired.

[I never talked to my boss about going to the chemist…] I just didn’t want him looking at me as a druggie […] I always had to [get my methadone dose] before work or after work. And with getting there on time and just a lot of hassle just to make it to the chemist, I thought to myself, it’s not worth it [trying to get my dose during work hours… I thought if I told my boss he would] just look at me different and I know I’m better than that […I was] scared to get sacked or discriminated against.

Related to these concerns about restricted dosing arrangements, some participants mention the importance of access to takeaway doses.

Grace (F, 58, works in manufacturing, heroin) values the convenience of takeaway doses.

[The prescribing chemist that my partner and I go to is] really good because we can get takeaway doses. And we’re allowed five, I think, a week […] but we sort of just pace it out to average probably three takeaways […] Sometimes we’ll just get two. And they’re not open on Saturday or Sunday so we’ve got to keep that in mind too, to always have the weekend sort of covered […] But it suits. It’s no hassle because you can get the takeaways.

Kate (F, 36, works in health sector, prescription drugs) explains how she manages her OPT dosing in relation to her work commitments.

I have my opioid substitution therapy. I actually don’t take all of it in the morning. I just take enough to hold me through the day and I’ll take the rest at night or as I just finish work. So it sort of spaces out, because I’m able to do that. I’m in a privileged position with regards to my doctor and stuff and I only have to go into the chemist once a week. And it’s just over seven years of doing it, that I’ve worked out that it works for me […] The [clinic where I get OPT is] very good and over the years, since I’ve been so stable […] my doctor […has] been very flexible about [giving me] takeaways.

While access to OPT is generally valued highly, a concern for some participants is encountering stigma and discrimination at chemists and clinics when accessing treatment (see also Dealing with stigma & discrimination). Some describe experiences in which healthcare professionals treated them differently from other clients, with several commenting that they feel like staff ‘look down on’ them. As David (M, 25, unemployed, heroin) explains in relation to his experience of accessing MMT:

Just at the chemist, I feel like they are looking down on us. They don’t treat us [like] a normal patient. Like, we’d go in there for a prescription [and we] are always second best. Like [the staff will] push you to the side or push you back, and deal with their people first and then deal with the ‘druggies’. That’s what we look like [to them].

Grace (F, 58, works in manufacturing, heroin) describes negative experiences when she and her partner accessed OPT or sought medical care at the chemist. (Played by an actor)

Well just recently [my partner and I] stopped going to the doctor and the chemist because our prescription had run out so I can’t go back to the chemist and pick up the Suboxone. And we were feeling really, really crook, both of us […] And we went and saw this [pharmacist] and she was actually not the one who’s usually there. I mean, all we wanted was some Valium or something like that, you know, just to get through for a few more days* […] and she virtually said, ‘Get out’ […] She was horrible.

[…]

A lot of chemists [are] fantastic […] but some just treat you [differently to other clients…] We’d have to stand outside the door. We weren’t allowed in the shop. I think they were scared somebody was going to shoplift something. I think that was the reason. And we’d have to wait outside the door until they’d call us in, ‘You can come in now […] lord of the drugs’ [laughs] Not all of them, but I can think of one who was really shocking.

* Note: A prescription is needed for pharmacists, doctors and other authorised medical practitioners to dispense Valium®. They cannot legally dispense it without one.

Methadone

Most of those interviewed who had experience of OPT had undertaken methadone maintenance treatment (MMT). MMT involves replacing the opioid usually consumed (e.g. heroin, oxycodone, morphine) with the legally prescribed opioid, methadone. MMT can prevent opioid withdrawal and help people cut down or stop taking other opioids. It is also associated with other health improvements. Some of our participants describe positive experiences of MMT and say it’s effective in treating withdrawal symptoms and managing ‘cravings’. Others say it supports efforts to cut down or stop consumption altogether. A few say it helps them manage their consumption and avoid spending too much on drugs.

Barry (M, 40, unemployed, heroin) says that being on MMT helps him manage his work commitments and avoid getting sick from not taking heroin.

I’ve been on and off methadone most of this time […] since I started [taking heroin] really. I’d start and I’d go berserk, and that would affect my work. So […] I said to [my GP…] ‘You know, I need to go on methadone because I want to keep my job’. So that’s where the methadone sort of started. And it helped. And then, you know, I got clean off that and had a big relapse a while later […] But the only reason I’ve gone back on methadone this time was because I was working […] I could not afford to get sick [from heroin withdrawal] and miss work […] I just couldn’t […] afford to do that. I had to keep going because work was the thing that kept me going.

According to Misja (M, 40, not working due to illness, heroin and cannabis), being on MMT is the ‘only thing’ that prevents him from taking heroin.

This is my seventh time on the methadone program and every time […] when I’m with a woman and I split up with them, I just go back to my old ways. And now that I’m getting older, I’m not [keen to repeat that]. I’m trying really hard not to stuff my relationship up with my missus. And, you know, I’d like to keep that relationship and possibly have kids with her but I don’t ever want to go back on the heroin. So [if] worst comes to worst, when I get off the methadone, if there is a chance that I do go back to the heroin, I will get back on the program again. Like, [go] on the methadone program again to stop me from doing it because it’s the only thing that stops me from doing it.

For Kate (F, 36, works in health sector, prescription drugs) being on OPT helps her avoid the financial cost of taking heroin.

I’ve been on opiates for nearly 20 years now, 19 on and off, and whenever I haven’t had them in my system except for a few […] periods [of several months], I have returned to them. So if I’ve got something that’s feeding that [opioid] receptor as well as blocking it, and is doing what it does for me, and it’s not costing me any time or minimal time, minimal effort, minimal money […] then I’ll just stick with it, because it’s working. And it’s a lot cheaper than having that risk of going back to, you know, putting $50 to $100 [of heroin] up my arm every day.

Rachel (F, 50, works in the health sector, heroin) was told to begin MMT when she became pregnant. She has been on it since then and finds it helps her manage her heroin use. (Played by an actor)

Then I got pregnant and I had to go onto [methadone]. The doctor basically said to me, ‘If you don’t go onto methadone today, you will not be taking your baby home from the hospital’ […] So the methadone helped a lot, except my partner wasn’t on methadone and […] he didn’t want me to go on [it]. He was saying, ‘You’re going to be on it for years and years’. And I said, ‘No I won’t. As soon as the baby is born, I’ll get off it’ […] Of course, I’m still on it years later […but] being on methadone is really good [It…] made all that chaos make sense. Because of methadone I am able to be a functional drug user […] When you are [taking heroin] every day […] you’ve got all the financial worries […] so you have to manage it, which is why we have methadone. It helps with all of that.

Some people describe negative or mixed experiences of MMT, and comment on its disadvantages. These include unpleasant side-effects and the difficulty some experience when reducing their dose or stopping treatment.

Grace (F, 58, works in manufacturing, heroin) says that MMT helped her to stop taking heroin but she later found it hard to reduce her dose. (Played by an actor)

I loved the methadone at first. When [my partner and I] first went on it, it was great. We didn’t touch [heroin for…] a long time but then it took us a long time to get off [methadone] I can’t remember how long […] The first time [getting off it] was all right but I don’t think we’ve ever properly completed it without using [heroin] you know, because once you get [to a] really low dose, just a couple of [milligrams], well then you start […] feeling [ill…] I’ve always thought, ‘Oh, I’ll just be on it for a few weeks and then I’ll be able to cut down’. I found it really hard to cut down quickly and I found myself stuck on it, but that’s me. You hear of other people who can do it in a couple of weeks or a month or two, but I was stuck on it for a year.

Nick (M, 50, not working due to illness, heroin) describes some unpleasant side-effects of methadone and says the obligatory daily supervised dosing limits his ability to travel.

My teeth, I lost every single tooth in my mouth [from time on methadone maintenance treatment]. These are falsies […] It’s a synthetic heroin, to tell you the truth. And it dries your mouth out, as you can see. The reason you lose your teeth is because you get no saliva to protect the enamel on your teeth.*

[Also] you’re restricted in your travel. I suppose, you can get takeaway doses but you can only get five at most. So to go on a holiday, you have to […] try and get methadone for the entire stay of the holiday or you don’t go. We have a nickname and we call them ‘liquid handcuffs’ because you have to go to that chemist to get your dose otherwise, you know, you couldn’t function.

* Note: Methadone, like heroin and other opioids, decreases saliva production, which encourages bacterial growth and can lead to dental problems. It is possible that years of heroin use and methadone maintenance treatment affected Nick’s dental health, leading to the issues he describes.

Buprenorphine (Subutex®)

A few participants had tried treatment with buprenorphine and describe it as having similar benefits to other opioid pharmacotherapies. These include preventing or easing ‘withdrawal’ symptoms, reducing the desire for the drug and relieving pain. Some say it helped them cut down or stop altogether. As Zadie (F, 33, works in health sector, heroin) puts it, ‘I realised that I just needed to stop [taking heroin]. I know that’s going to involve being sick for a week or two [but] I didn’t have time to be sick for a week or two […] I needed to go to work […] So I went to a doctor and got on [buprenorphine] which got me over that period. In two weeks, I was fine. I wasn’t using any more’. Others say that they found it difficult to reduce their dose of buprenorphine in order to eventually stop treatment.

Sean (M, 48, works in education, OTC painkillers) describes his experience of gradually reducing his buprenorphine dose. (Note: strong language) (Played by an actor)

I think I ended up going and seeing this psychiatrist […] and he suggested that I go on buprenorphine […] He started me on four [milligrams] and then I quickly went up to six to eight to 10 and I think it was 10 or 12 [milligrams] that I stayed on […] I think the most I’ve ever heard of anyone being on is 32 milligrams so 12 is kind of a middling dose, I guess. It’s such an odd drug […] but it was amazing […] I just didn’t have any withdrawals [from stopping Nurofen Plus…] I guess I was on buprenorphine then for [a few years] so I just came off [it…] I had a shitty time [coming off it] Even though I had kind of reduced and done it slowly, I was still staggered by how difficult it was coming off. I think the lowest the chemist could do was like one milligram I think, but even though I’d done it really slowly and not really felt it as I was coming down […] going from 1 milligram to nothing […] just made me realise what a powerful drug [buprenorphine] is even in really small doses.

Buprenorphine naloxone (Suboxone®)

Some of our participants had undertaken treatment with combination buprenorphine and naloxone (Suboxone®). As with methadone and buprenorphine, those who undertook combination buprenorphine and naloxone treatment say it’s helpful in preventing or easing withdrawal symptoms experienced on stopping heroin. Others say it helps them manage their use and avoid taking larger amounts over time. For some, being on combination buprenorphine and naloxone treatment means they don’t experience the desired effect from consuming opioids such as heroin and oxycodone, and this helps them cut down or stop altogether.

Helen (F, 53, Australian, not working due to injury, heroin) says that Suboxone® gives her a very long-lasting opioid effect and discourages her from taking heroin. (Played by an actor)

At the moment I’m on Suboxone so there’s not much point [in] using heroin until you haven’t had [Suboxone] for a couple of days […Taking] Suboxone means that if you are going to use [heroin] you really have to plan it, which means you are inevitably either going to use less or jump off the [Suboxone treatment] program. And it has such a long-lasting effect that, you know, even the fourth day you don’t feel that awful. Whereas if you miss a day of methadone, you start feeling uncomfortable and feeling like you’ve got to have a shot [of heroin…] I think [being on Suboxone] I’ll probably end up not using at all because once you’ve got Suboxone in your system, you’re really talking a week before you’d get the same effect from a shot [of heroin] that you did before. And by then you’d have been kicked off your program. So like I’m already finding that […] it’s starting to become pointless [taking heroin].

While Helen and others say that being on Suboxone® discourages them from taking heroin, some of our participants, such as Amy below, say it doesn’t stop them taking heroin altogether. Instead, it helps them to manage their consumption.

Amy (F, 52, studying, heroin) says that taking Suboxone® helps her keep her heroin consumption at an affordable level but it doesn’t prevent her taking it altogether.

I couldn’t manage my life without it. If I wasn’t on Suboxone I […] couldn’t afford to use every day and, you know. You couldn’t afford to because your habit would be going up and up and up […] Going on Suboxone, you can still use now and again so my experience has been that it doesn’t really stop me using […] I think ultimately […I want to stop using]. But I think that Suboxone gives me the opportunity to […] stabilise my life. I think that if I continue on this course, I will probably be on the Suboxone that whole two years. I wouldn’t even dream of trying to come off it because the two times that I have, I just [gone back to heroin …] Whatever it is that makes me bust, all those reasons I’ve brought up, I haven’t […] got ways to manage that stuff.

Pharmacotherapy for alcohol dependence

One of our participants, Phoenix (M, 48, works in media, alcohol and prescription painkillers) undertook pharmacotherapy for alcohol dependence. He was treated with a medication called acamprosate (Campral®) and says it curbed the desire (or ‘craving’) for alcohol and helped him stop drinking altogether.

Phoenix (M, 48, works in media, alcohol and prescription painkillers) had pharmacotherapy for alcohol dependence and says it took away the ‘cravings for alcohol’.

So [my counsellor] actually insisted I go and spend some time in […] the detox unit at […] the hospital […] And I spent nine days in there. I didn’t have any contact with my wife and kids for the [first] five or six or something. They put me on Campral, acamprosate, which took away the cravings for the alcohol. I came out of there and I’ve never experienced anything like that in my life. It still confuses me. Just that absence of the need to go to the pub. It was gone but because it was only a detox not a rehab, there was no follow-up […] I had nothing to do with this new information. My wife and I got back together again at that point and we had ten years sober […] I did Campral probably for maybe 18 months, I think. I’m not sure actually how long, but yeah, 12-18 months, I think, so a fair while.

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