Guinevere Gets Sober

Recovery news, reviews and stories, by Jennifer Matesa.

Tag: Percocet (page 1 of 2)

Dear G: Am I An Addict?

So I’m responding to two emails I received in the past week: one from a stranger, and one from a friend.

This is gonna be a long post, so get your iced coffee and your orange-chocolate-chip biscotto (my favorite) and sit down.

The Stranger has been prescribed Percocet (oxycodone), OxyContin (also oxycodone), and the antidepressant Cymbalta (duloxetine) for the past six years.

The Friend has been taking a teensy dose of Klonopin, a benzodiazepine—an addictive class of drugs used as sedatives and muscle relaxants—for the past year.

Both of them asked me for advice.

(Before I go on, I have to remind y’all that I’m not a doctor. I just share experience here—please take what you need and leave the rest.)

The Stranger seems more confused than the friend. The Friend, who has seen his share of addicted folks but is not in any program of recovery and never before thought he was addicted to anything, reached out to me because he knows I write about addiction. And he knows I don’t bullshit.

The Stranger writes:

I think I’m an addict? Am I? Am I not? Why is it even important to know if I am or not? Well, to me it’s important because I am having a HECK of a time coming off these meds.

This person has been tapering off 60mg OxyContin plus 40mg Percocet—a total of 100mg oxycodone, which truthfully is not that big a habit. It’s not a tiny habit, a tiny habit is two or three Percocet (15mg) per day, but getting off 100mg oxycodone is eminently doable, even if you’ve been taking Oxy for six years.

So let me tell you about some of the things I’ve learned about how to tell whether you’re an addict.

Obsession

It doesn’t matter how much we use, or how we use, or when we use (only after noon, only after 5 p.m., only after work, only after we put the kids to bed, etc.). It matters what the drug-use does to our minds.

Quitting 15mg versus quitting 100mg is like the difference between somebody who drinks two glasses of wine every evening and someone who drinks a bottle. Is the person who drinks just two glasses—but who cannot do without those two—NOT an alcoholic because she only drinks two? No. It’s what the two does to her. It’s how she thinks of those two glasses when she’s not drinking them, as well as when she is.

(BTW heavy drinking, for women, is usually defined as more than one drink per day every day.)

Both these people can quit their habits. The person who drinks only two glasses might have a harder time quitting because she thinks, “I’m only drinking two.” Or the person who drinks a bottle might have a harder time because her body has become more physically dependent and she’ll get sicker when she quits.

If they both stick it out, they’ll start to see benefits. It takes time. It takes a lot of days of sheer commitment not to pick up, and that itself takes a lot of support. For which I’d say, yeah, try a 12-step program, but give it a real shot: get a sponsor, take the steps, do what you’re told. If you’re really powerless over your drugs, wave the white flag (Step 1). If that doesn’t work, there are other ways of getting sober, but I know best what has worked for me and that’s what I talk about here.

Getting Our Drugs

Alcoholics can just go to the store and buy their drugs. We drug-addicts usually have to lie and cheat to get ours. Alcoholics wind up doing weird stuff AFTER they’ve bought and taken their drugs. For example, how do you hide all those empties—they clink when you try to drag them to the curb or the recycling bin, etc. … Drug-addicts usually aren’t faced with these kinds of questions (unless you’re shooting, which leaves tracks that you have to hide). Our questions are more about how to get the drugs in the first place.

If we’re using illegal shit, we have to commit felonies to buy it.

If we’re using legal shit, we also usually have to commit felonies to buy it.

I committed I don’t know how many felonies to get my drugs. A lot. More than 10. Enough, probably, to warrant a prison sentence, because I committed them over and over, over time. They all expired this summer, which made me feel free, in a sense, but in another sense I can never make up for having committed them in the first place. I talked to a lot of people about how to make amends for having committed felonies that put doctors and pharmacists and my own family in danger. They all said, Change your behavior and stop doing it. Tell other people not to do it. So:

Don’t. Change. Dates. On. Scripts. It’s fucking dangerous and can hurt more people than yourself.

The Stranger is not yet committing felonies. But she’s doctor-shopping. She’s been to four doctors other than her regular doctor to get drugs to supplement her regular scripts. More and more states are enacting doctor-shopping laws.

//

The green Watson-387 hydrocodone tabs I used to chew when I was becoming an addict. Bitterness on the tongue.

The green Watson-387 hydrocodone tabs I used to chew when I was becoming an addict. Bitterness on the tongue.

Let me tell you a story. When I started using legal drugs, I didn’t think I was an addict and I thought the amount of drugs I was being prescribed (45mg hydrocodone per day?—or something like) would last me frigging forever. I had spent the past two or three years trying to make thirty 10mg Watson-387 hydrocodone tablets last an entire month, and I’d always run out, because, of course, I Was In Pain, and the pain needed to be treated. When I scored ninety 15mg caps per month, I saw a road paved with those white-caps stretching to the horizon and thought life was finally perfect and I would be taken care of forever.

What happened was, in two months I needed 60mg per day.

By the end of that year I was being prescribed 150mg per day—ten 15mg caps. I would get a delivery of 300 15mg capsules each month. A delivery. The Man would come and deliver them. Personally, I think this qualifies as an official “shitload” of drugs, but just wait:

By the end of the next year another 120mg morphine (in the form of Kadian, a long-acting capsule) had been added to that, and in another six months I was given extra fentanyl lollipops. Pharmaceutical Tootsie-Pops. No: Dum-Dums, really. By that time I was a stone junkie, although I still had trouble believing I was, because I was still doing my life. Opioids don’t disable you the way alcohol and, say, meth do: I didn’t look drunk because I wasn’t drunk. I was just on a shitload of drugs, and when I ran out, I was incapacitated in every way.

And toward the end I always ran out.

Running Out

“When I would run out of the meds early,” The Stranger says.

People who don’t have problems taking their meds don’t run out. People who do have problems taking their drugs do run out.

“But I hate being high!!!”

“I LIKE feeling normal and sober!” she writes.

Oh, sweetheart, pleeeze. I hated being “high” too. I just wanted to be normal. I just wanted to have energy when I wanted, be relaxed when I wanted, be accepted.

“I never drink (hate the stuff!) or smoke marijuana, and I’ve never done any hard drugs.”

Solidarity, sistah. <fistbump> I am a Top-Shelf White-Collar Addict all the way.

By the time I detoxed five years ago, I hadn’t seriously drunk alcohol in more than a decade. I “hated the stuff.” And I’ve never done any street drugs. Ever. Never smoked cigarettes, let alone weed. Never danced topless on any frat bars, never stripped for the dudes, never screwed around. I’ve never woken up in anyone’s bed I didn’t actually have a relationship with.

By the end I had a kid, for chrissake, and I Took Care Of Him, and I did a good job, not the best job I could have done, because I was a stone junkie.

If you like feeling sober, then quit sooner rather than later. You will only feel more and more sober. The feeling of extra energy I got from pills was fake energy. If you can exercise at all, your body will soon start producing its own endorphins and you’ll heal.

But you will not start to heal until you quit putting extra opioids into your body.

Anxiety and Fear

One of the most helpful things I’ve ever heard was from my first sponsor, who told me that I needed to call anxiety by its right name: fear. “Because anxiety can be medicated,” she said.

But you don’t go to the doctor and ask for pills because you’re having fear.

The Stranger mentions fear over and over again in her email. It’s a signal of addiction.

The Friend’s email had none of that fear. He was balls-out about his concern: “I believe I have become addicted.” Which is the thing that made me think he wasn’t addicted: we addicts tend to keep second-guessing ourselves. Even when we ask for help, it’s usually: “I think I MIGHT be addicted,” or, “Am I addicted?”

But who am I to know for sure? I don’t know how much fear or obsession he has or whether he’s running out of his tiny dose of Klonopin each month and changing dates on scripts to get more. (I’m pretty sure he’s not committing that felony; after speaking with him, I don’t think he’s even running out.)

This is one of the aspects of addiction that needs a lot more research. If we’re going to treat addiction as an illness, we need clear diagnostic criteria so that it’s not a matter of self-diagnosis or self-identification.

Pregnancy

I’m not a doctor, and I’m not an addictions specialist, but I’m a mom and a woman and I wrote a book on pregnancy for which I did more than a little research, and my mind is made up about this: if at all possible, unless the mother’s life is threatened (which is to say, unless she’s already on a load of heavy drugs and gets pregnant and can’t detox without endangering herself and the pregnancy), women ought to get off their drugs if they want to get pregnant.

There are a lot of studies starting to come out about the “benefits” of buprenorphine over methadone in pregnancy, but most of those are for heroin addicts and/or methadone-maintenance patients who are already pregnant.

The Stranger has tapered down to 30mg of oxycodone per day. I hope that, before she gets pregnant—which she says she wants to do—she’ll quit entirely.

Because motherhood is damned hard work. And it’s best to do it sober. It is the single thing I wish I could go back and change: I wish I’d been entirely sober for my kid’s childhood.

Please don’t miss your kid’s.

The boy, age 3.

The boy, age 3.

If this helped you, the best thing you can do is pass it on via the little social buttons below.

Also, please visit my new site: Recovering the Body.

Prescribing Opiates For Mood Disorders

A reader called “Rapture” wrote the other day, in response to one of my most popular posts (“Chewing Vicodin Was the Start of My Problem”):

I struggle with how to think about my use of narcotics. When I have a supply of them, I take them as they would be prescribed–I suffer from PTSD and find relief in narcotics, but no doctor supplies them for psychological pain, even though the mind/body split was discounted ages ago. 

So when i have them I take 4 10/325 percs a day; if I have vicodin 7.5/325 I might take 6. That’s it. I started doing this maybe 10 years ago by taking one darvon/darvocet with a 1 mg ativan that I am prescribed for my PTSD–I was gang raped as a young child. Over the years I realized that I simply FELT BETTER if I took one every 6 hours.

Much of my stress comes from not being able to find a doctor willing to prescribe me the pills. I have been taking a reasonable dose for 10 years and am not about to try to increase it. Sometimes I just don’t understand how people can take so much and get so addicted because I can barely find enough pills to buy.

I don’t know whether I’m an addict and I don’t really care. I just don’t understand why I can’t find a doctor who will understand that I need these to feel like myself. I am in my early 40s, I have a wonderful family, am a PhD at a large research University–I am a responsible citizen and completely functional, actually more functional on the pills than the awful days I don’t have any.

“Rapture”: I’m sorry to hear about what happened to you in childhood.

There are two ways I think about what Rapture describes.

The first is by using the medical model: I feel “bad,” I must “need something” to make me feel “normal.” When presented with a problem, the medical model usually looks to a drug or a device. Something external to oneself. 

There are folks who believe in such a phenomenon as “endorphin deficiency syndrome” or EDS. The idea is that some folks are just born with a hampered ability to produce endorphins, the body’s natural opiates. I haven’t seen literature that proves such a condition exists. It’s a theory at this point, and in the U.S. it’s not widely accepted (it’s hardly accepted at all) because of the ideology that “narcotics,” as Rapture calls them, are evil—”drugs are bad” and “narcotics” tempt people into becoming “evil junkies.” That’s the American narrative.

In reality, there’s nothing “evil” about addiction, except, in my opinion, the horror of the experience itself. Addiction is an illness that involves genetic predisposition activated by adverse stresses, usually in childhood, and by chronic exposure to chemicals that ease the feeling of stress. Rapture has one thing right: the drug is not the problem—the drug is the solution. It only becomes a problem when it stops “working.”

Which leads me to the second way I think about Rapture’s experience—through my own, which raises a few red flags.

Percocet tablets. Rapture takes four of these per day to feel better.

Red Flag No. 1: Tolerance. Apparently the starting drug, 10 years ago, was Darvocet (which contains propoxyphene, a weak opioid) and the dose was 1 tablet per day. Over time this increased to 4 Percocet (or “percs,” as Rapture calls them: pet names, in my experience, are a sign that we have become emotionally attached to our drugs) or “maybe” 6 Vicodin, and “that’s it,” Rapture writes. So why shouldn’t Rapture be able to get an above-board script for these drugs?—after all, Rapture writes, while taking them, “I simply FELT BETTER.” And then Rapture asks for people’s thoughts.

Well, gosh.

I can only offer my own experience. I spent maybe four years taking one or two 10mg Lorcet each day, to “feel better.” Lorcet is a Vicodin equivalent. It was prescribed to me for migraine and intractable chronic daily headache, and I wasn’t about to increase my dose because of the same reason Rapture states: I could hardly ever get any more than that.

When I got more than that, I took more. When I got 60 tablets per month, I took at least two per day. I had pain, and I also had depression, and I simply FELT BETTER on the drugs. I slept better; I worked better (I could work for five or six hours in one spot, without moving—this is what I expected of myself). And just like Rapture, “much of my stress” came from the uncertainty of my supply.

When I had intractable pain all over my body in 2002, I visited a pain clinic and received my first prescription for 15mg hydrocodone, compounded as a single agent (no Tylenol!), to be taken four times per day. I thought surely I’d survive forever on this amount. It seemed an ungodly amount of medication. And in the beginning, it lasted the whole month. Then, gradually, my body built a tolerance, because it was undergoing chronic exposure to these drugs. Tolerance is always a problem with “narcotics.”

Red Flag No. 2: Self-monitoring. Tolerance is one problem. The constant monitoring of how I felt, and whether I “needed something,” was the other.

When I detoxed, it took me ages to get past the constant evaluation of how I felt, and whether I needed something, which started with taking that one pill every four hours. Is it wearing off yet? Do I need to take another one? This so eroded my ability to think and feel independently that I’m still getting over it. I no longer continually evaluate how I feel… But I still have a tendency to look outside myself for “the fix” to whatever it is that I’m feeling.

Red Flag No. 3: Criminality. And then there’s the problem of buying the Percocet or Vicodin on the street. Or stealing them. Or forging scripts. Or however Rapture is getting them. … When I committed crimes to get drugs, this made me a thief and a liar. In active addiction I constantly told myself that I needed to operate outside the bounds that applied to everyone else, because my case was “special.” … I get the feeling, from what Rapture writes, that this is also Rapture’s way of thinking. I can only speak for myself: it led me down a pretty dark road.

I don’t believe that people have to be off all drugs of any class to be totally “clean.” (I don’t even usually call myself “clean,” because I don’t like the implication that those who take drugs are “dirty.”) I buy that some folks might need to take some sort of medication indefinitely to do their lives productively.

I’m just not sure opioids are the best solution—they’re no kind of solution for me, anyhow. 

There are other ways of boosting endorphin production in the body. They usually involve taking care of our bodies, minds and spirits. Search on “endorphins” in this blog—or start at this post, about insomnia (a sign of depression). And there are reliable, evidence-based ways of dealing with PTSD.

I really want to know what others think about what Rapture is asking: Why shouldn’t folks who “feel better” on opiates be able to buy them legally? Please comment below, or email me.

Lindsay Lohan’s doing Adderall, Ambien, and Dilaudid

So, I never imagined myself to be the kind of writer who documents the lives of celebrities, but this is an interesting case that illustrates a trend happening all over the country.

Lindsay Lohan’s probation report was released today and it says she’s taking five powerful prescription drugs: Adderall (for attention-deficit disorder); Ambien (for insomnia); Zoloft (for depression); Trazodone (for depression and insomnia); and—get this—Dilaudid, prescribed after she had her wisdom teeth out in early June.

Dilaudid is a Schedule II opioid painkiller that’s roughly four times more powerful than morphine. In other words, it’s some heavy shit, and dentists and oral surgeons don’t usually prescribe heavy shit for that kind of pain. Where I come from, they usually write for a few Tylenol #3 or Vicodin with no refills and tell you to give your gums the good old saltwater rinse. Prescribing Dilaudid for post-wisdom-tooth extraction pain is like sending in the A-bomb for the proverbial anthill.

Asking for Dilaudid for that kind of thing?

If you’re Lindsay Lohan, you can probably get what you want. You can be persuasive one way or another.

More and more people are taking drugs they’re getting from a variety of doctors, and mixing them with each other, and with alcohol. The belief is rampant that because a drug is prescribed by a doctor—because it is a prescription drug—it’s not dangerous.

The belief is that the Real Dangerous Drugs are the ones that Homeless Junkies shoot under the bridge.

Actually?—the Real Dangerous Drugs are the ones in your medicine cabinet. They’re pure and they’re quality-controlled to do their jobs.

One job of morphine, by the way, is to treat “dyspnea,” or the labored breathing that people experience when they’re dying. The “death rattle.” Because morphine—all opioids, actually—slow down your breathing.

And you take too much of any opioid, and/or mix it with other stuff like Ambien, Valium, or alcohol, and your breathing can stop (this is what, for example, Heath Ledger did).

The strength and reliability of these drugs is one reason prescription drug abuse is the most rapidly growing drug problem in this country. According to a statement by the International Narcotics Control Board earlier this year, 6.2 million Americans are abusing prescription drugs. Many of these people are doing things like taking painkillers such as Dilaudid for toothache, mixing them with Adderall (speed) and Ambien (major downer) and knocking those back with a cocktail at, say, the MTV Music Awards.

You mix too many chemicals like this and yes—you will wind up depressed and anxious, with insomnia, and some physical pain, plus maybe gastric reflux. This sends you to the doctor, who gives you more pills (Trazodone, Zoloft, Nexium… all of which Lindsay, according to her probation report, is taking).

Lindsay, Lindsay… who since 2004 has had how many cosmetic-surgery procedures?—and did each one come with its subsequent painkiller prescription? I’ve known addicts who would get teeth pulled unnecessarily so they could get pills; in L.A. it’s just as easy (maybe easier) to go to your plastic surgeon.

Unfortunately it looks as though Lindsay will be able to keep getting her drugs while she’s in jail, because they’re prescribed by a doctor. Hopefully, for her sake, once she reaches rehab, that’ll change.

Two sane voices talk about addiction

So many people need help with alcoholism or addiction—the National Institute on Alcohol Abuse and Alcoholism estimates 17.6 million Americans abuse alcohol and/or are alcohol-dependent; and the International Narcotics Control Board estimates that 6.2 Americans were abusing prescription drugs in 2008.

But so much misinformation prevails about addicts and addiction. Part of what I want this blog to do is help weed out fact from fiction, and offer sane voices speaking about this problem.

Dr. Steven Scanlan—outpatient detox doctor

Thanks to my friend Sluggo at ODR for this link to this podcast featuring Steve Scanlan, MD, a board-certified psychiatrist and addiction-medicine physician who practices office-based opiate detox in Boca Raton, Fla. Scanlan is interviewed in this podcast about the use of Suboxone, a relatively new synthetic opiate that is not only FDA-approved to detox addicts from opiates but is also increasingly being used as a “maintenance” drug in the manner of methadone, with a high dose that is said to block cravings but causes all sorts of side-effects.

Scanlan’s conviction—one borne out by scads of anecdotal evidence—is that Suboxone is best used as a short-term detox tool, prescribed for no more than three weeks and at the lowest dose possible, preferably under 2mg. Refreshing to hear this sane truth spoken, when I’ve heard about so many addicts on 24 or 36 or even 48mg of Suboxone, unable to cut back because of the drug’s super-glue binding power.

At the top of my list of things I admired were these bald-faced statements: he tells patients he will help them detox once, and if they fail they need to seek inpatient treatment—so he’s not a revolving door; that they need to work for sobriety; and that he does not wish to make a ton of money in his business. That he sees physicians all around him using suboxone as a marketing tool, rather than a detox tool, and this doesn’t help addicts. He spoke in plain language. I heard the program working in him. This is what Getting Sober does: it cleans up distortion and allows us to see and act clearly. Man, I so appreciated it.

Scanlan said two more sane things in this interview:

1. Physician opinions of addicts: most physicians have a “low opinion” of addicts and dislike treating us—something both physician and patient know but never articulate to each other. canlan himself is a addict recovering through the 12 steps. He understands addicts are not Bad People but rather struggling with an illness and in need of help.

2. Sobriety success rates—rehab v. 12 steps: Scanlan said the average rate of sobriety after one year for rehabs is 3 percent—and that for those who complete a thorough fifth step (“Admitted to God, to ourselves, and to another human being the exact nature of our wrongs”) in AA/NA it’s 60 percent. Like to know where he got that second number—if it’s viable, it’s a great one.

Michael Douglas, actor

Yeah I never thought I’d be touting a celebrity in this blog, but truth can come from the most unexpected places.

Michael Douglas’s 30-something kid, Cameron, was busted last year for selling drugs in a Manhattan hotel. He pleaded guilty and was finally sentenced to 5 years in prison. They’d been expecting 10 years.

What was sane about Douglas’s commentary on the Today Show this morning was that he took some responsibility for his son’s problem—but not all the responsibility. Like Scanlan, he also understood that his son was not an evil person.

“This disease, as you look at it, certainly the family has a lot to do with it,” Douglas said. “The fact is, with all the mistakes and the disease that Cameron has, he’s a great young man.”

Douglas talked humbly and directly about the strains of addiction that run throughout his family’s genetics and behavior. He spoke about his own stint in rehab, and he evinced a measure of gratitude that his kid is still alive:

My son has not been sober for this length of time since he was 13 years old. So he was going to be dead, or somebody was gonna kill him. So he has a chance to start a new life, and he knows that.

Getting ready for work: Chewing Vicodin

I didn’t plan on writing about Michael Jackson again, but the news today (via the Associated Press, see story) is pretty shocking:  Jackson paid a physician to administer the anesthetic propofol intravenously every night for two years so he could get a full night’s sleep.

On the one hand, it’s appalling; on the other, predictable. I did the same sort of thing myself. And I’m hardly unique: I’m a 44-year-old white middle-class American addict.

What’s predictable is the fact that Jackson was so desperate for sleep.  If he was taking as many drugs every day as they say he was (two heavy-duty opioids, a benzodiazepine, a muscle relaxant, and more), he was definitely screwing up his body’s ability to regulate its sleep-wake cycles, also called “circadian rhythms.”

When I made it into detox last year, I was taking 100mcg/hr fentanyl—usually more, because I sometimes took more than prescribed. That’s roughly equivalent to 400mg morphine. (To give you some perspective, after routine surgery, patients are usually given 5mg Percocet, which is about equal in strength to morphine.  I was taking about 80 times that, every day.)

Fentanyl is the strongest opioid available by prescription. It’s commonly used for cancer patients. I was prescribed it for migraine and fibromyalgia.

Any opioid addict will tell you that addiction wrecks your sleep.

Morphine was named after Morpheus, the god of sleep, and heroin addicts have made the image of the “nod” a cliché.  But there’s another side to opioids that many non-addicts don’t realize: a spike in blood-levels can give you extra energy.

I started taking Lorcet 10mg for headaches about eight or nine years ago. (Lorcet is the same as Vicodin: it contains hydrocodone and Tylenol.) I was given 30 per month—an amount that seemed enormous then. So I took about one per day. As soon as I discovered I could get refills a bit earlier than exactly 30 days, I started taking maybe one-and-a-half per day. Here’s why: on Lorcet, I could Get Everything Done.

I could get up at 6 with my son, get breakfast, do the dishes, get him dressed, get myself dressed, get his lunch packed and get him out the door to daycare, and I was showered and in my chair ready to work by 9.

I could work at a computer for hours and never move. I could get an amazing amount of work done in the half-day I had to do it. I could get my son, put him down for a nap, get more work done, get him up, clean the house, get dinner, and after dinner, weed the garden or do other chores.

For someone like me, that level of control was central to my ability to feel like I could survive in this world.

About 18 months or two years into my run with Lorcet, I was taking two tablets per day (and facing the consequences: I’d face several days per month when I was out of medication). Because, as with any drug that results in dependence, after 18 months at the same dose, the effects of one tablet weren’t as powerful. So I increased the dose—not under supervision. Just on my own. Because, of course, I knew best.

So I could “function.”

Many addicts take drugs so they can function.  For us, it was a solution.  For many years, I reasoned—rationalized—that I wasn’t an addict because I had a common image of addiction: Real Junkies lay around on the couch, eating Doritos and watching soap operas.

I was Working.  I was Productive. Just like Michael Jackson. Right?

The press often mentions that Jackson was taking all these drugs to “prepare” himself for the 50 London shows he’d signed for.  As if it is a truth universally acknowledged that a celebrity musician—or anyone—needs drugs as part of his “preparation” for his work. Even the press continues to enable him in his death.

My habit of “preparing” for my work each day was to chew a pill or two before I even got out of bed.  I chewed them to maximize their effects: most addicts discover that taking drugs in some manner “not as prescribed” is the best way to manipulate their effects. The practice led me into a deep well, out of which I’ve climbed step by step in the past nine months. I’m seeing the light, and for that I’m grateful.

What’s shocking is that there is a health professional on the face of this earth who would be so greedy for money and so interested in exploiting his association with a celebrity that he or she would agree to carry out something so harmful one time, much less over the course of two years.  Not only did the practice apparently finally kill Jackson, but also the drug itself had to be stolen: propofol, an anesthetic designed for hospital use, is not available by prescription.

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