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Cbd oil for pain management anxiety levels

Cannabidiol in Anxiety and Sleep: A Large Case Series

Cannabidiol (CBD) is one of many cannabinoid compounds found in cannabis. It does not appear to alter consciousness or trigger a “high.” A recent surge in scientific publications has found preclinical and clinical evidence documenting value for CBD in some neuropsychiatric disorders, including epilepsy, anxiety, and schizophrenia. Evidence points toward a calming effect for CBD in the central nervous system. Interest in CBD as a treatment of a wide range of disorders has exploded, yet few clinical studies of CBD exist in the psychiatric literature.

Objective

To determine whether CBD helps improve sleep and/or anxiety in a clinical population.

Design

A large retrospective case series at a psychiatric clinic involving clinical application of CBD for anxiety and sleep complaints as an adjunct to usual treatment. The retrospective chart review included monthly documentation of anxiety and sleep quality in 103 adult patients.

Main Outcome Measures

Sleep and anxiety scores, using validated instruments, at baseline and after CBD treatment.

Results

The final sample consisted of 72 adults presenting with primary concerns of anxiety (n = 47) or poor sleep (n = 25). Anxiety scores decreased within the first month in 57 patients (79.2%) and remained decreased during the study duration. Sleep scores improved within the first month in 48 patients (66.7%) but fluctuated over time. In this chart review, CBD was well tolerated in all but 3 patients.

Conclusion

Cannabidiol may hold benefit for anxiety-related disorders. Controlled clinical studies are needed.

INTRODUCTION

The Cannabis plant has been cultivated and used for its medicinal and industrial benefits dating back to ancient times. Cannabis sativa and Cannabis indica are the 2 main species.1 The Cannabis plant contains more than 80 different chemicals known as cannabinoids. The most abundant cannabinoid, tetrahydrocannabinol (THC), is well known for its psychoactive properties, whereas cannabidiol (CBD) is the second-most abundant and is nonpsychoactive. Different strains of the plant are grown containing varying amounts of THC and CBD. Hemp plants are grown for their fibers and high levels of CBD that can be extracted to make oil, but marijuana plants grown for recreational use have higher concentrations of THC compared with CBD.2 Industrial hemp must contain less than 0.3% THC to be considered legal, and it is from this plant that CBD oil is extracted.3

Many different cultures have used the Cannabis plant to treat a plethora of ailments. Practitioners in ancient China targeted malaria, menstrual symptoms, gout, and constipation. During medieval times, cannabis was used for pain, epilepsy, nausea, and vomiting, and in Western medicine it was commonly used as an analgesic.4,5 In the US, physicians prescribed Cannabis sativa for a multitude of illnesses until restrictions were put in place in the 1930s and then finally stopped using it in 1970 when the federal government listed marijuana as a Schedule I substance, claiming it an illegal substance with no medical value. California was the first state to go against the federal ban and legalize medical marijuana in 1996.6 As of June 2018, 9 states and Washington, DC, have legalized recreational marijuana, and 30 states and Washington, DC, allow for use of medical marijuana.7 The purpose of the present study is to describe the effects of CBD on anxiety and sleep among patients in a clinic presenting with anxiety or sleep as a primary concern.

CBD has demonstrated preliminary efficacy for a range of physical and mental health care problems. In the decade before 2012, there were only 9 published studies on the use of cannabinoids for medicinal treatment of pain; since then, 30 articles have been published on this topic, according to a PubMed search conducted in December 2017. Most notable was a study conducted at the University of California, San Diego’s Center for Medicinal Cannabis Research that showed cannabis cigarettes reduced pain by 34% to 40% compared with placebo (17% to 20% decrease in pain).8 In particular, CBD appears to hold benefits for a wide range of neurologic disorders, including decreasing major seizures. A recent large, well-controlled study of pediatric epilepsy documented a beneficial effect of CBD in reducing seizure frequency by more than 50%.9 In addition to endorphin release, the “runner’s high” experience after exercise has been shown to be induced in part by anandamide acting on CB1 receptors, eliciting anxiolytic effects on the body.10 The activity of CBD at 5-HT1A receptors may drive its neuroprotective, antidepressive, and anxiolytic benefits, although the mechanism of action by which CBD decreases anxiety is still unclear.11 CBD was shown to be helpful for decreasing anxiety through a simulated public speaking test at doses of 300 mg to 600 mg in single-dose studies.12–14 Other studies suggest lower doses of 10 mg/kg having a more anxiolytic effect than higher doses of 100 mg/kg in rats.15 A crossover study comparing CBD with nitrazepam found that high-dose CBD at 160 mg increased the duration of sleep.16 Another crossover study showed that plasma cortisol levels decreased more significantly when given oral CBD, 300 to 600 mg, but these patients experienced a sedative effect.17 The higher doses of CBD that studies suggest are therapeutic for anxiety, insomnia, and epilepsy may also increase mental sedation.16 Administration of CBD via different routes and long-term use of 10 mg/d to 400 mg/d did not create a toxic effect on patients. Doses up to 1500 mg/d have been well tolerated in the literature.18 Most of the research done has been in animal models and has shown potential benefit, but clinical data from randomized controlled experiments remain limited.

Finally, the most notable benefit of cannabis as a form of treatment is safety. There have been no reports of lethal overdose with either of the cannabinoids and, outside of concerns over abuse, major complications are very limited.19 Current research indicates that cannabis has a low overall risk with short-term use, but more research is needed to clarify possible long-term risks and harms.

Given the promising biochemical, physiologic, and preclinical data on CBD, a remarkable lack of randomized clinical trials and other formal clinical studies exist in the psychiatric arena. The present study describes a series of patients using CBD for treatment of anxiety or sleep disturbances in a clinical practice setting. Given the paucity of data in this area, clinical observations can be quite useful to advance the knowledge base and to offer questions for further investigation. This study aimed to determine whether CBD is helpful for improving sleep and/or anxiety in a clinical population. Given the novel nature of this treatment, our study also focused on tolerability and safety concerns. As a part of the evolving legal status of cannabis, our investigation also looked at patient acceptance.

METHODS

Design and Procedures

A retrospective chart review was conducted of adult psychiatric patients treated with CBD for anxiety or sleep as an adjunct to treatment as usual at a large psychiatric outpatient clinic. Any current psychiatric patient with a diagnosis by a mental health professional (psychiatrist, psychiatric nurse practitioner, or physician assistant) of a sleep or anxiety disorder was considered. Diagnosis was made by clinical evaluation followed by baseline psychologic measures. These measures were repeated monthly. Comorbid psychiatric illnesses were not a basis for exclusion. Accordingly, other psychiatric medications were administered as per routine patient care. Selection for the case series was contingent on informed consent to be treated with CBD for 1 of these 2 disorders and at least 1 month of active treatment with CBD. Patients treated with CBD were provided with psychiatric care and medications as usual. Most patients continued to receive their psychiatric medications. The patient population mirrored the clinic population at large with the exception that it was younger.

Nearly all patients were given CBD 25 mg/d in capsule form. If anxiety complaints predominated, the dosing was every morning, after breakfast. If sleep complaints predominated, the dosing was every evening, after dinner. A handful of patients were given CBD 50 mg/d or 75 mg/d. One patient with a trauma history and schizoaffective disorder received a CBD dosage that was gradually increased to 175 mg/d.

Often CBD was employed as a method to avoid or to reduce psychiatric medications. The CBD selection and dosing reflected the individual practitioner’s clinical preference. Informed consent was obtained for each patient who was treated and considered for this study. Monthly visits included clinical evaluation and documentation of patients’ anxiety and sleep status using validated measures. CBD was added to care, dropped from care, or refused as per individual patient and practitioner preference. The Western Institutional Review Board, Puyallup, WA, approved this retrospective chart review.

Setting and Sample

Wholeness Center is a large mental health clinic in Fort Collins, CO, that focuses on integrative medicine and psychiatry. Practitioners from a range of disciplines (psychiatry, naturopathy, acupuncture, neurofeedback, yoga, etc) work together in a collaborative and cross-disciplinary environment. CBD had been widely incorporated into clinical care at Wholeness Center a few years before this study, on the basis of existing research and patient experience.

The sampling frame consisted of 103 adult patients who were consecutively treated with CBD at our psychiatric outpatient clinic. Eighty-two (79.6%) of the 103 adult patients had a documented anxiety or sleep disorder diagnosis. Patients with sole or primary diagnoses of schizophrenia, posttraumatic stress disorder, and agitated depression were excluded. Ten patients were further excluded because they had only 1 documented visit, with no follow-up assessment. The final sample consisted of 72 adult patients presenting with primary concerns of anxiety (65.3%; n = 47) or poor sleep (34.7%; n = 25) and who had at least 1 follow-up visit after CBD was prescribed.

Main Outcome Measures

Sleep and anxiety were the targets of this descriptive report. Sleep concerns were tracked at monthly visits using the Pittsburg Sleep Quality Index. Anxiety levels were monitored at monthly visits using the Hamilton Anxiety Rating Scale. Both scales are nonproprietary. The Hamilton Anxiety Rating Scale is a widely used and validated anxiety measure with 14 individual questions. It was first used in 1959 and covers a wide range of anxiety-related concerns. The score ranges from 0 to 56. A score under 17 indicates mild anxiety, and a score above 25 indicates severe anxiety. The Pittsburg Sleep Quality Index is a self-report measure that assesses the quality of sleep during a 1-month period. It consists of 19 items that have been found to be reliable and valid in the assessment of a range of sleep-related problems. Each item is rated 0 to 3 and yields a total score from 0 to 21. A higher number indicates more sleep-related concerns. A score of 5 or greater indicates a “poor sleeper.”

Side effects and tolerability of CBD treatment were assessed through spontaneous patient self-reports and were documented in case records. Any other spontaneous comments or complaints of patients were also documented in case records and included in this analysis.

Data Analysis

Deidentified patient data were evaluated using descriptive statistics and plotted graphically for visual analysis and interpretation of trends.

RESULTS

The average age for patients with anxiety was 34 years (range = 18–70 years) and age 36.5 years for patients with sleep disorders (range = 18–72 years). Most patients with an anxiety diagnosis were men (59.6%, 28/47), whereas more sleep-disordered patients were women (64.0%, 16/25). All 72 patients completed sleep and anxiety assessments at the onset of CBD treatment and at the first monthly follow-up. By the second monthly follow-up, 41 patients (56.9%) remained on CBD treatment and completed assessments; 27 patients (37.5%) remained on CBD treatment at the third monthly assessment.

Table 1 provides means and standard deviations for sleep and anxiety scores at baseline and during the follow-up period for adults taking CBD. Figure 1 graphically displays the trend in anxiety and sleep scores over the study period. On average, anxiety and sleep improved for most patients, and these improvements were sustained over time. At the first monthly assessment after the start of CBD treatment, 79.2% (57/72) and 66.7% (48/72) of all patients experienced an improvement in anxiety and sleep, respectively; 15.3% (11/72) and 25.0% (18/72) experienced worsening symptoms in anxiety and sleep, respectively. Two months after the start of CBD treatment, 78.1% (32/41) and 56.1% (23/41) of patients reported improvement in anxiety and sleep, respectively, compared with the prior monthly visit; again, 19.5% (8/41) and 26.8% (11/41), respectively, reported worsening problems as compared with the prior month.

How To Use CBD To Help Alleviate Anxiety

Dr. Bindiya Gandhi is an integrative medicine physician with expertise in functional and holistic medicine based in Atlanta, Georgia.

Commissions we earn from partner links on this page do not affect our opinions or evaluations. Our editorial content is based on thorough research and guidance from the Forbes Health Advisory Board.

Table of Contents

  • CBD for Anxiety
  • How to Use CBD for Anxiety
  • CBD Dosage for Anxiety
  • Potential Risks and Side Effects

While delta-9-tetrahydrocannabinol (THC) can have a bad rap for being intoxicating and anxiety-inducing, cannabidiol (CBD) can actually be used to relieve anxiety. Research supports this benefit, with several studies reinforcing the positive effects CBD can have on various anxiety conditions. In fact, 51% of U.S. adults who use CBD do so to help alleviate their anxiety, according to a recent Forbes Health survey of 2,000 U.S. adults conducted by OnePoll.

CBD isn’t yet legally cleared as an anxiolytic, or anxiety relief medication. Therefore, it’s up to you—and, ideally, a doctor who specializes in cannabis administration—to determine whether CBD is a safe treatment for your anxiety.

Here’s what the science says regarding CBD’s anxiolytic properties, along with experts’ dosage guidelines and advice on how to take CBD safely.

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CBD for Anxiety

The Food and Drug Administration (FDA) has yet to approve any CBD-based medications for anxiety. However, many studies indicate the substance can be an effective anxiolytic.

CBD for Generalized Anxiety

In 2011, a small trial-tested CBD on participants with generalized social anxiety disorder (SAD) and healthy control patients undergoing a simulated public speaking test (SPST), which is a common anxiety testing method [1] Bergamaschi MM, Queiroz RH, Chagas MH, et al. Cannabidiol reduces the anxiety induced by simulated public speaking in treatment-naïve social phobia patients. Neuropsychopharmacology. 2011;36(6):1219-1226. . Compared to a placebo, CBD significantly reduced anxiety and discomfort in the participants with SAD. In fact, their reduced anxiety levels were comparable to those of the control participants.

Eight years later, a 2019 test compared the efficacy of three CBD doses (150 milligrams, 300 milligrams and 600 milligrams) and a placebo in men taking an SPST [2] Linares IM, Zuardi AW, Pereira LC, et al. Cannabidiol presents an inverted U-shaped dose-response curve in a simulated public speaking test. Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999). 2019;41(1):9-14. . Compared to a placebo, 300 milligrams of CBD significantly reduced participants’ anxiety during the speech, but the 150-milligram and 600-milligram doses did not. These results highlight how dosage can be highly variable and that more CBD isn’t necessarily more effective.

Meanwhile, another 2019 study tested CBD in much lower doses than most other clinical studies—some participants consumed 25 milligrams a day while others consumed 50 milligrams or 75 milligrams a day [3] Shannon S, Lewis N, Lee H, Hughes S. Cannabidiol in Anxiety and Sleep: A Large Case Series. Perm J. 2019;23:18-041. . Researchers thought higher doses might be too expensive for participants to maintain in their normal lives and that low doses would still prove effective. Indeed, anxiety decreased within the first month for most participants and remained low. Sleep quality also improved, although it fluctuated more than anxiety. Only three patients reported side effects.

CBD for Anxiety and Depression

In 2020, researchers tested the effects of CBD oil at varying doses across 397 patients with a variety of ailments [4] Gulbransen G, Xu W, Arroll B. Cannabidiol prescription in clinical practice: an audit on the first 400 patients in New Zealand. BJGP Open. 2020;4(1):bjgpopen20X101010. . Participants with non-cancer pain or mental health-related symptoms experienced significant improvement in anxiety and depression, as well as in their abilities to complete their usual activities. The use of CBD oil suggested significant pain relief in these groups as well.

CBD for PTSD and Phobia Therapy

A small 2019 study of 11 patients found that, when consumed orally and administered alongside routine psychiatric care, CBD decreased patients’ posttraumatic stress disorder (PTSD) symptom severity [5] Elms L, Shannon S, Hughes S, Lewis N. Cannabidiol in the Treatment of Post-Traumatic Stress Disorder: A Case Series. J Altern Complement Med. 2019;25(4):392-397. .

Other studies suggest CBD can reduce PTSD symptoms when consumed with THC [6] Bitencourt RM, Takahashi RN. Cannabidiol as a Therapeutic Alternative for Post-traumatic Stress Disorder: From Bench Research to Confirmation in Human Trials. Front Neurosci. 2018;12:502. . When taken together, the two compounds create what’s known as the “entourage effect,” where THC enhances the effects of CBD as CBD tempers the effects of THC, resulting in a more well-rounded experience [7] Ferber SG, Namdar D, Hen-Shoval D, et al. The “Entourage Effect”. Terpenes Coupled with Cannabinoids for the Treatment of Mood Disorders and Anxiety Disorders. Curr Neuropharmacol. 2020;18(2):87-96. .

Some studies also suggest CBD can enhance the effects of exposure therapy—which assists patients in dissociating certain cues with a fear response—and cognitive behavioral therapy [8] Das RK, Kamboj SK, Ramadas M, et al. Cannabidiol enhances consolidation of explicit fear extinction in humans. Psychopharmacology (Berl). 2013;226(4):781-792. [9] Blessing EM, Steenkamp MM, Manzanares J, Marmar CR. Cannabidiol as a Potential Treatment for Anxiety Disorders. Neurotherapeutics. 2015;12(4):825-836. .

How to Use CBD for Anxiety

Without clear FDA guidance, optimal CBD use for anxiety varies from person to person. You may find one method works better for you over another. You can consume CBD in the following forms:

  • Oils and tinctures, which come in dropper bottles and are consumed by mouth
  • Gummies, which are chewable, sweet and often fruit-flavored
  • Sprays, which come in bottles with a nozzle to be sprayed in the mouth
  • Capsules, softgels or tablets, which are taken individually by mouth like a pill
  • Vapes, which heat CBD oil without igniting it, resulting in an inhalable vapor
  • Flowers, which are dried hemp plants that are typically ignited and smoked
  • Creams and gels, which introduce CBD topically (through the skin) as a more localized treatment

You may have to try different forms to determine what works best in addressing your anxiety. For instance, when it comes to the absorption of CBD in your bloodstream, vaping and smoking are more effective than edibles like gummies.

CBD Dosage for Anxiety

You also have to find the right CBD dosage for your anxiety. Experts suggest starting small and working your way up depending on how your body reacts.

Many clinical trials jump right to testing high doses. Successful doses evaluated for anxiety relief specifically include:

  • 600 milligrams in patients with SAD in a speech simulation [10] Bergamaschi MM, Queiroz RH, Chagas MH, et al. Cannabidiol reduces the anxiety induced by simulated public speaking in treatment-naïve social phobia patients. Neuropsychopharmacology. 2011;36(6):1219-1226.
  • 300 milligrams in male patients in a speech simulation [11] Linares IM, Zuardi AW, Pereira LC, et al. Cannabidiol presents an inverted U-shaped dose-response curve in a simulated public speaking test. Revista brasileira de psiquiatria (Sao Paulo, Brazil : 1999). 2019;41(1):9-14.

However, other trials suggest much lower doses are also quite effective in treating anxiety.

  • 25 to 75 milligrams for generalized anxiety and/or sleep problems [12] Shannon S, Lewis N, Lee H, Hughes S. Cannabidiol in Anxiety and Sleep: A Large Case Series. Perm J. 2019;23:18-041.
  • 33 to 49 milligrams a day for PTSD, in addition to routine psychiatric treatment [13] Elms L, Shannon S, Hughes S, Lewis N. Cannabidiol in the Treatment of Post-Traumatic Stress Disorder: A Case Series. J Altern Complement Med. 2019;25(4):392-397.

Another study involving hundreds of patients noted success with doses from 40 milligrams to 300 milligrams a day, further supporting the idea that CBD dosage varies significantly, depending on a person’s symptoms and physiology.

Potential Risks and Side Effects

The World Health Organization deems CBD a safe and generally well-tolerated substance. Studies report very few adverse effects, if any.

However, taking CBD while on other medications may pose a risk, as these substances may interact and cause unwanted effects, such as weight gain, drowsiness, upset stomach and change in appetite.

Cheryl Bugailiskis, M.D., a cannabis specialist at Heally, a telehealth platform for alternative medicine, also warns people with preexisting liver injuries and people taking medications that can cause liver injuries should practice caution when using CBD.

CBD for chronic pain: The science doesn’t match the marketing

If you ask health care providers about the most challenging condition to treat, chronic pain is mentioned frequently. By its nature, chronic pain is a complex and multidimensional experience. Pain perception is affected by our unique biology, our mood, our social environment, and past experiences. If you or a loved one is suffering from chronic pain, you already know the heavy burden.

People are looking for novel, nonaddictive ways to treat pain

Given the ongoing challenges of chronic pain management coupled with the consequences of the opioid epidemic, pain management practitioners and their patients are searching for effective and safer alternatives to opioids to alleviate pain. With the legalization of marijuana in many states and resulting cultural acceptance of this drug for recreational and medical use, there has been an increased interest in using cannabis for a myriad of medical problems, including pain.

Cannabis (most commonly obtained from the Cannabis indica and Cannabis sativa plants) has three major components: cannabinoids, terpenoids, and flavonoids. While there are over a hundred different cannabinoids, the two major components are tetrahydrocannabional (THC) and cannabidiol (CBD). Historically more attention has been paid to the psychoactive (euphoric “getting high”) component of the cannabis plant, THC; there have been fewer scientific studies on the medical use of CBD, a non-psychoactive component of the plant.

What’s the thinking behind using cannabis for chronic pain?

CBD is emerging as a promising pharmaceutical agent to treat pain, inflammation, seizures, and anxiety without the psychoactive effects of THC. Our understanding of the role of CBD in pain management continues to evolve, and evidence from animal studies has shown that CBD exerts its pain-relieving effects through its various interactions and modulation of the endocannabinoid, inflammatory, and nociceptive (pain sensing) systems. The endocannabinoid system consists of cannabinoid receptors that interact with our own naturally occurring cannabinoids. This system is involved in regulating many functions in the body, including metabolism and appetite, mood and anxiety, and pain perception.

What’s the research that CBD works in humans?

Given its promising results in animal models, along with its relative safety, non-psychoactive properties, and low potential for abuse, CBD is an attractive candidate to relieve pain. Unfortunately, there is a lack of human studies about the effectiveness of CBD. However, there is an abundance of commercial advertisements about the magical effects of CBD, and it is frequently presented as a cure-it-all potion that will treat everything including diabetes, depression, cancer, chronic pain, and even your dog’s anxiety!

So far, pharmaceutical CBD is only approved by the FDA as adjunct therapy for the treatment of a special and rare form of epilepsy. Currently, CBD alone is not approved for treatment of pain in the United States. But a combination medication (that contains both THC and CBD in a 1:1 ratio) was approved by Health Canada for prescription for certain types of pain, specifically central neuropathic pain in multiple sclerosis, and the treatment of cancer pain unresponsive to optimized opioid therapy. There is currently no high-quality research study that supports the use of CBD alone for the treatment of pain.

Why is CBD presented to the public this way, when it is not without risks?

Given the rapid change in the legality of cannabis coupled with the increased appetite for something new, and driven by unprecedented profit margins, the advertising for cannabinoids in general and CBD in particular has gone wild. The FDA is very clear that it is illegal to market CBD by adding it to a food or labeling it as a dietary supplement. And it warns the public about its potential side effects, as it’s often advertised in a way that may lead people to mistakenly believe using CBD “can’t hurt.” CBD can cause liver injury, and can affect the male reproductive system (as demonstrated in laboratory animal studies).

Most importantly, CBD can interact with other important medications like blood thinners, heart medications, and immunosuppressants (medications given after organ transplantation), potentially changing the levels of these important medications in the blood and leading to catastrophic results, including death. Also, more information needs to be gathered about its safety in special populations such as the elderly, children, those who are immunocompromised, and pregnant and breastfeeding women.

Many of the CBD products on the market are unregulated

In fact, the FDA has issued several warning letters to companies and individuals that market unapproved new drugs that allegedly contain CBD. The FDA has tested the chemical content of cannabinoid compounds in some of the products, and many were found to not contain the levels of CBD the manufacturers had claimed they contain.

Beware of powerful testimonials

Finally, there is anecdotal wisdom, when experiences by patients and health professionals have positive results. While the experience or medication could be beneficial, that doesn’t mean it is going to work for everyone. That’s because each and every person is unique, and what works perfectly for one patient could have no effect on another patient. This is especially true for pain, where many other factors (our mood and stress level, our environment and other medical conditions, and our previous experiences) can affect the perception of pain. Please be careful, and keep in mind that some of these incredible-sounding testimonials are merely marketing materials meant to lure consumers to buy more products, as the CBD market is expected to hit $20 billion by 2024.

The bottom line: Don’t make CBD your first or only choice for pain relief

If you or someone close to you is considering trying CBD, I would recommend Dr. Robert Shmerling’s advice about the dos and don’ts in choosing an appropriate product. Until there is high-quality scientific evidence in humans, it is difficult to make a recommendation for the regular use of CBD in chronic pain management.

About the Author

Shafik Boyaji, MD , Contributor

Dr. Boyaji earned his medical degree from University of Aleppo, Syria. He completed an Internal Medicine residency at Michigan State University and an Anesthesiology residency at the Brigham and Women’s Hospital. Currently he is in fellowship … See Full Bio

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Comments

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