No matter where you turn these days, it’s common to find people fixated on their next dose. At family gatherings, it’s not unusual to find someone hidden in the corner of their room, or even taking the bold step of using in front of family members. It has become ubiquitous among all socioeconomic groups, classes, races and religions, and it is no longer limited to income, or geographical location. People are willing to spend anything to get their next fix, and what started out as occasional use has mushroomed out of control to even multiple times an hour. People that at one time were in control of their lives now find themselves addicted to the point that their habit is disruptive to their personal life, their family relationships, and enjoying simple pleasures. Some can’t even complete a bathroom trip without reaching for their next jolt! In traditional cases, rapid dopamine influx affects the nerve cells in the central nervous system. Of course, in this case it’s just the opposite, as your cells strip away dopaminergic pleasures. Naturally, what I’m talking about is cell phone usage.
It occurred to me while observing people (including myself) at a dinner table, in a meeting, or with my grandson, that my cell phone was doing just that. I see people crossing the street oblivious to traffic, texting while driving, or distracted from entire conversations because a text must be answered within 1- minute of receiving one, or something popped up on Twitter or Instagram. So, it occurred to me to ask some very practical question in comparison to opioid usage…
- What is the death toll from cell phone usage?
- What is the revenue from smartphone manufacturers and/or service providers compared to Big Pharma?
- Is there a cell phone epidemic, and if so how does it compare to opioids?
- What has the government done to enforce controls on cell phones compared to opioids?
- How have cell phones affected society compared to opioids in terms of addiction?
- Should the CDC place similar restrictions on cell phones as they have for prescribed opioids?
- Should cell phones be treated as a controlled substance?
- Should cell phones require a REMs program of sorts and be dispensed with requirement for counseling?
- And finally, is there a naloxone equivalent that can reverse a cell phone overdose?
I decided to engage a true millennial, Dr. Mena Raouf to collect some data and put this in perspective. Here’s what he has to share…
Out of the world’s 7 billion people, 6 billion own a cell-phone, which is surprising considering that 4.5 billion people have access to a working toilet and 5.3 billion have access to electricity.1,2 More people have access to a cellphone than running water, indoor plumbing, or consistent electricity. Wait a second, more people have access to cell phones than electricity – How are they charging their phones?
It is safe to say that we have a cellphone “epidemic”. Most people now check their smartphones 150 times a day, which is once every 6 minutes, including sleep hours.3 Approximately 46% of smart phone users say “they couldn’t live without their phone” and 60% of U.S. college students consider themselves to have a cell phone addiction. In one study, one-in-three participants would rather give up sex than their cellphone. Another study found that 35% of people think of their cellphone when they wake up while 10% of people think of their significant others.
How does one become addicted to their cellphone you may ask? One cannot shoot up an app, inject an emoji, snort an Instagram filter, or pop some signal bars? When we hear the word “addiction”, we immediately think of opioids, alcohol, stimulants, etc. However, addiction does not have to involve a substance or a drug and can be behaviors associated with pathological pursuit of reward such as gambling or sex. Addiction is a chronic disease of the brain reward, motivation, memory, and related circuitry. Characteristics of addiction include inability to consistently abstain, impairment in behavior control, and craving.4
A 2016 NIH study found that DSM-5 criteria for substance use disorder can be applied to effectively identify cell phone addiction.5 A breakdown of the symptomology for cell phone and substance use disorder is available HERE! (hyperlink or include the picture below)
The cell-phone “epidemic” has inspired new pathologies such as:5
- Nomophobia :No-Mobile-Phobia
- FOMO: Fear of Missing out
- Textaphrenia: false sensation of receiving text message that leads to constantly checking the device
- Ringxiety: false sensation of receiving a call that leads to constantly checking the device
- Textiety: compelling urge to respond immediately to a text message upon receiving
A millennial like myself might say “cell-phones connect people and improve communication so what is wrong with having a cellphone epidemic”? Nevertheless, here are some of the individual and societal harms from excessive cellphone use:
- Motor vehicle accidents: Cellphone use while driving leads to 1.6 million crashes every year leading to 330,000 injuries and over 3000 deaths.6 Texting while driving is 6x more likely to result in an accident than driving drunk.7 Texting while driving has reached an epidemic. A 2010 study found that nearly half US adults admit reading or sending a text message while driving and nearly one in three 16- or 17- year olds admitted texting while driving.
- Pedestrian injuries: A study of pedestrians in midtown Manhattan found that 42% of drivers that enter traffic during a “Don’t Walk” signal were using their cellphone.8 No surprise, a 2013 study found 10-fold increase in injuries related to pedestrians using cell phones from 2005 to 2010.9
- Loss of work productivity: the average worker spends 5 hours on their cell-phone for non-work related activities. 10
- Impaired sleep: smartphone screens emit blue light and decreases melatonin production – a hormone involved in regulation of sleep/wake cycle
- Myopia epidemic (near sightedness): There has been a 35% increase in people developing myopia since 1997 when cellphones were launched.11
- Pain: if you are reading this blog while looking down at your phone, there is a force equivalent to having a 60-lb weight or an 8-year old child on your neck.12 One can only predict a parallel rise in disorders of the cervical spine, maybe a new diagnosis “Text neck” will arise.
Let’s shift back to the presumed opioid epidemic and continued efforts to limit opioid prescribing.
The rise in opioid prescription overdose deaths in 2010 to over 16,000 cases has sparked major policy changes to reduce opioid prescribing by placing “morphine equivalent daily dose” cutoffs or other means. The CDC released its Guidelines for Opioid Prescribing in March 2016 with recommendations against prescribing more than 90 mg morphine equivalent daily dose for chronic non-cancer pain. Insurance companies have placed morphine equivalent dose restrictions. Despite these efforts, opioid overdose deaths continued to rise.13 Legitimate chronic pain patients are facing difficulties obtaining and filling their prescriptions and some resort to buying opioids off the street to avoid withdrawal.
There is no doubt that opioids have been liberally prescribed with lack of risk assessment and mitigation strategies. Opioids are not for everyone with chronic pain and should never be first line options. For a carefully selected subset of the population whom other options are not viable, opioids may provide relief and help restore their quality of life.
Similar to cell-phones, opioids are can be a double-edged sword. For individuals with intractable pain, opioids may provide relief, functional improvement, and help restore quality of life. For other individuals, opioids are abused and can lead to morbidity and mortality. Simply placing ubiquitous morphine equivalent limitations is not the answer and this has been evident by continued rise in overdose deaths despite reductions in opioid prescribing.
For cell-phone users with personal or business emergencies, cell-phone could be a lifeline, but overuse and addictive behaviors have led to harm and death as noted above. Cell phones can restore quality of life that connects various persons to loved ones or friends, but can also distract from important direct human contact.
Is the answer to the opioid epidemic is continued efforts to limit prescribing? Then for the cell-phone epidemic, do you think cellphone carriers should have a maximum daily tweet dose? Should local agencies enforce a Snap Chat equivalent daily dose? Should the CDC place restrictions on Instagram posts? Should cell phones be Schedule II Narcotics because of a high abuse potential? Should Apple and other Cell Phone manufacturers be sued for the “cell-phone epidemic” by various state agencies?
Cell phone usage and patients requiring long-term opioids have an important correlation. Proper doses and disciplined usage of cell phones and opioids could be lifesaving. And for chronic pain patients, these worlds may overlap. Cell phones can actually connect patients with chronic pain syndromes that are unable to leave their home (possibly due to Draconian abrupt drops in their opioid dose) with the outside world because they are trapped in their body and in their home. Cell phones could be a lifeline to emergency services if a patient falls and can’t get up, if there is an opioid overdose emergency, or a call to the suicide prevention hotline due to unrelenting pain.
No matter how you slice it, cell phones may prove to be similarly addicting compared to opioids. We wonder what would happen if regulatory agencies abruptly cut-off cell phone use, reduced the maximum allowable daily cell phone dose, or set up a cell phone state monitoring program. Would there be a black market for cell phones? Would people kill for cell phones? Would the cost of prescription cell phones increase as the street value decreased? Would phone manufacturers be encouraged to develop abuse deterrent cell phones, the dose of which needs to be used gently over 8-12 hours instead of immediate release bursts?
Perhaps Drake had the foresight to understand the lifeline between human touch, pain and cell phone access in his song Hotline Bling…
You used to call me on my cell phone
Late night when you need my love
Call me on my cell phone
Late night when you need my love
I know…
There is much to think about here. We encourage you to comment and share your thoughts.
Dr. Mena Raouf, PharmD, BCPS. is currently completing PGY-2 Pain and Palliative Care residency at the Stratton VA Medical Center in Albany, NY. Dr. Raouf received his PharmD from Albany College of Pharmacy and Health Sciences and completed a PGY-1 residency at the VA Tennessee Valley Healthcare System in Nashville, TN.
Reference:
- http://www.un.org/apps/news/story.asp?NewsID=44452#.WmojHDYUkdU
- https://newsroom.cisco.com/press-release-content?articleId=1741352
- https://www.nytimes.com/2017/01/09/well/live/hooked-on-our-smartphones.html?_r=0
- American Society of Addiction. Definition of Addiction. [Webpage on the internet]. Available from: https://www.asam.org/resources/definition-of-addiction. Accessed January 25, 2018.
- De-Sola Gutiérrez J, Rodríguez de Fonseca F, Rubio G. Cell-Phone Addiction: A Review. Frontiers in Psychiatry. 2016;7:175.
- National Center for Statistics and Analysis. Distracted Driving: 2015, in Traffic Safety Research Notes. DOT HS 812 381. March 2017, National Highway Traffic Safety Administration: Washington, D.C.
- Wilms, Todd. It Is Time For A ‘Parental Control, No Texting While Driving’ Phone. Forbes Business, September 18, 2012.
- Nasar JL, Troyer D. Pedestrian injuries due to mobile phone use in public places. Accid Anal Prev. 2013 Aug;57:91-5.
- https://www.theaustralian.com.au/life/smombies–zombies-on-smartphones–are-walking-into-accidents/news-story/8836ae43fbc574ea8a2053567b599561
- https://www.inc.com/melanie-curtin/in-an-8-hour-day-the-average-worker-is-productive-for-this-many-hours.html
- http://www.dailymail.co.uk/health/article-2394611/Have-got-screen-sightedness-Smartphones-causing-sight-problems-soar-warns-eye-surgeon.html
- Hansraj KK. Assessment of stresses in the cervical spine caused by posture and position of the head. Surg Technol Int. 2014 Nov;25:277-9.
- National Institute on Drug Abuse. Opioid Overdose Death Rates. September 2017. [Webpage on the internet]. Available from: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed January 25, 2018.
I agreed we are all cell phone addicted ! Should have to over come on this.
Oddly, the three lawyers whom AG Jeff Sessions put to work defending him in the lawsuit, “Washington v Sessions” that’s up for oral arguments Feb 14th, actually dreamed up an argument to counter every last one of the excellent points Drs Raouf and Fudin make here. US Attorney Joon H Kim and Assistant US Attorneys Samuel Dolinger and Rebecca Tinio go on for some 68 maddening pages, explaining just exactly how the Government can choose to exhaust mountainous efforts on molehill-sized problems while exerting zero effort to solve what appear to be serious problems. Those with the nerve to read their argument may find it laid out in excruciating detail, at http://www.scribd.com/document/362505122/Washington-v-Sessions-de-37-Governments-Motion-to-Dismiss#download although I caution the reader that reading this may make one angry enough to litigate, and perhaps angry enough to think about how citizens can go about having lawyers disbarred.
Before getting to the answer to Drs Raouf and Fudin’s excellent points, the three lawyers first waste 21 pages trying to explain that the Government can do anything it wants and that if it wants to do something wrong, and has a good reason to do it, or even has a horrible reason to do it, the courts must stand aside and let the Government do as it wishes. According to the learned lawyers, only if the Government randomly does stuff for no reason at all, should the courts step in and attempt to restrain the action. This would seem to contradict the entire purpose of having law courts that try criminal cases, because in criminal cases the Government intends to punish somebody for either a good reason (the person’s guilty) or for a bad reason (the guilty party paid off a Government employee to blame his crime on somebody else), Normally we citizens benefit from having law courts to sort out the difference between cases brought against guilty people, and cases that guilty people paid off crooked cops to bring against innocent people so that the guilty people could commit more crimes and keep splitting the loot with the crooked cops who protect them. (John Dillinger ran such a racket in the 1920’s and did so well at it, that when booze got re-legalized, he switched to bank robbery and kept right on splitting the loot with a crooked Illinois police chief, who always engaged Mr Dillinger in a car chase and always let Mr Dillinger get away. It was the Dillinger case that persuaded Congress to make bank robbery a federal crime, and Hoover’s FBI finally ended all of Mr Dillinger’s robberies for fun and profit.) Generally that’s the entire reason why there are law courts, and I really don’t know how attiorneys Kim, Dolinger and Tinio managed to get through law school and pass the bar exam without ever learning about that. Absolutely law courts inquire into the reasons why the Government does something. But as if that weren’t enough, Kim, Dolinger and Tinio than announce a radical new concept of law that they babble on about from Pages 22-28, called “Fundamental Rights”. This “Fundamental Rights” notion says that Freedom never really existed. What we Americans mistake for Freedom, is actually a matter of the Government conquering people and their land and taking absolute, dictatorial, despotic control over everything, and then doling out small concessions of freedom to a few select people. If there isn’t an express grant of a “fundamental right” to do something, written out on a piece of paper from the Government, that freedom doesn’t really exist, and the Government can take Freedom away from us whenever it wants to take it back, and it can give that Freedom away to someone else if it likes. This, too, sounds more like a law book from Kim Il Sung’s North Korea or Mussolini’s Italy than from a US lawyer explaining US law, and a great many people who swore an oath to protect and defend the Constitution against all enemies foreign and domestic, will have trouble imagining how this could have been written by a loyal American citizen.
But if one reads those 28 pages of sheer nonsense, one then runs up against one of Kim, Dolinger and Tinio’s next weird arguments. Supposedly, the Government is free to pick and choose which problems it wants to work on, first.
Just because the office is on fire, the Government workers in the office have no obligation to call firemen to put the fire out. If they think it more important to go out and take an earthworm census, they’re free to do that, argue the 3 lawyers. If, on returning to find their offices burnt to the ground, they may ask taxpayers to build them a new office, and may keep a perfectly straight face while so doing. It’s not up to the Court, assert the 3 lawyers, to ask the Government workers why the bleep they let their offices burn down. The Government is free to set it’s own priorities and the Court must not interfere.
Frankly, none of these 3 lawyers should ever talk like this in a hospital emergency room, because if the ER physician does not personally know them, and they start talking like this and telling the medical staff that they have important Government jobs, the ER physician is liable to commit them for 72 hours for psychiatric observation, on suspicion of delusional behavior.
What prompted the writing of these 68 pages of gobblety-gook, is a lawsuit by former NFL Super Bowl winner Marvin Washington, who paid the Department of Health and Human Services for the rights to use a Government patent on an Alzheimer’s drug that three NIH researchers tested on mice. The drug, a cannabis derivative, prevents a toxin that forms during Alzheimer’s disease and in traumatic brain injuries, from killing healthy brain cells.
Mr Washington bought the patent rights and then sought permission to run an FDA Phase I clinical trial on volunteer human patients. His efforts hit a snag, when DEA refused him permission to manufacture more of the drug, which the NIH researchers had used up by testing it on mice. Mr Washington’s lawyers got curious on just exactly how it was, that the DEA could veto an FDA clinical trial, read the law, and discovered to their surprise, that there was no law giving DEA this power. Instead, 44 years ago, DEA was given temporary authority to prohibit cannabis, mescaline, and diacetylmorphine, pending a review by the Surgeon General. But DEA never asked the Surgeon General to review the evidence, hold hearings, and make a ruling. So Mr Washington sued the DEA, and is asking the court to remove the authority to prohibit cannabis, from the DEA’s powers. DEA agents may, in their capacity as private citizens, petition the Surgeon General to regulate cannabis, but if the court rules for Mr Washington, DEA will no longer have any authority to interfere with FDA trials. As Mr Washington reads the law, it’s up to FDA to test drugs, and if there’s potentially an addiction issue, FDA may refer the drug to the Surgeon General and ask that it be scheduled as some sort of controlled substance, as a condition of licensing a drug company to make the drug. DEA, which is the only federal law enforcement agency that hires people who only hold high school diplomas, is not qualified to practice medicine nor supervise doctors, if Mr Washington’s reading of the law is correct. It’s up to the Surgeon General to schedule controlled substances, and DEA’s entire job is to arrest people who steal or divert controlled substances…not to write regulations on why substances are to be controlled.
The chronic pain community will get a crack at this case very soon. Mr Sessions is not about to give up, if the court rules against him and orders the lawsuit to proceed to pretrial. Almost certainly he will appeal the ruling, because it’s pretty much an open-and-shut case, if it goes to trial, that DEA has operated outside it’s authority for 44 years. Conceivably every conviction on federal charges of possessing cannabis would be thrown open for re-trial, because DEA lacked authority in those cases. Cannabis restriction would revert to a state-law power, and 26 states that already legalize it for some uses, would no longer be challenged by federal authorities. Mr Sessions won’t give that up without a fight, so almost certainly there will be an appeal, to the Second Circuit and then to the Supreme Court. In those appeals, we patients are free to retain lawyers and file Amicus Curiae briefs, telling the judges our side of the story.
Would the CDC Guidelines for Opioid Prescribing have any influence at all, were it not for DEA agents posing as patients and haunting doctor’s offices? Doctors would ignore the Guidelines and practice medicine as they should. The worry doctors have, is that a DEA snoop who lies about having pain and comes to them seeking treatment, will prosecute them, and will try to used those CDC Guidelines as a basis for arguing that his prescribing practices were not up to par.
Since that decision is outside DEA’s responsibility, it is up to the FDA and the Surgeon General to make any necessary rules on high-dose opioid therapy. But a DEA that imagines itself free to make the rules up as it goes along, can do great harm to patients who require opioids when no other drug works.
Mr Washington is primarily interested in head injuries. He doesn’t understand why opioids are necessary and he has said some things about opioids and the people who need them, that quite frankly are unhelpful. As Amicus Curiae, we patients can correct these errors and inform the court about the rest of the harm DEA has done, by trying to practice medicine without any qualifications for it. We need to make our case in court, because no matter how ridiculous our opponents are, the courts won’t be told of it, unless we go to the court and explain that the DEA is making ridiculous choices.
Dude, you forgot cellphone thumbs
Not to mention “Text Claw” and “Cell Phone Elbow” !
http://www.toi-health.com/blog/post/Effects-of-smartphones-on-our-Fingers-Hands-Elbows.aspx
First, charge money in causing, while studying, the “problem”. Then, charge money in order to “solve” it.
As the perversely mindless ethics our highly evolved society of moralistic luminaries married to jingoistic jack-booted cultural dinosaurs hurtles forward at light speed towards global environmental, if not nuclear, destruction and annihilation of our own, as well as other, species, based upon nothing more than vaguely understood amorphous immediate emotional gratifications, where the collective glorification of modern feudalism rests upon effectively executed debasement, control, and sustained enslavement of the ruled, we applaud the glorious ineluctable march of pernicious progress mandating/implementing the following:
Science abandoning all aspects of intellectual honesty in favor of theocratically inspired fear-mongering;
Politics abandoning all aspects of objectivity/fairness in favor of deranged lounge-lizard dictatorial rule;
Medications/procedures capitalizing upon placebo effects and more dangerous than non-interventions;
Analgesics devoid of u-opioid-receptor agonism that induce so much sundry neuro-biological chaos in other receptor systems, that, in abject chemical misery, patients might perhaps “forget about their pain”;
Cigarettes limited to micro-doses of Nicotine (stuffed instead with highly profitable corporate bullcrap);
Beverages limited to micro-doses of Ethanol (stuffed instead with highly profitable corporate bullcrap);
Processed foods stripped of nutritional value and piled full of toxic garbage ensuring high profit-margins;
Personal portable wonder-widgets that “connect” our ever lamer intellects and evermore vacuous souls to Corporate/State sponsored thought-police surveillance networks wherein the populace pays big $$$ for the dubious privilege of living under what Orwell (in “1984”) predicted would become tyrannical rule;
A lifetime installed Fake President and Sycophant Congress cravenly encumbered by criminal oligarchs worldwide, while wrapping themselves in phony patriotic flags and spouting patriarchal theocratic rants.
.
What brilliant beings we are to exemplify such high-minded, humane principles of “forward thinking” and “integrity”! (Seemingly often) speciously invoked, psychiatric memes such as “biopsychosocial”, “patient centered care”, “acceptance strategy” and “mindfulness therapy” become rhetorical stigmata with which physicians strategically “brand” patients via what they choose to say/do in relation to patients’ reported pains, engendering patients’ ongoing psychological, as well as their own financial, dependence. Such a quantity of life over quality of life modus operandi is a profitable as well as defensive medicine – but does not serve to represent the interests of, or to act on the genuine behalf of competent and informed adults.
“Insofar as the biologist or physician chooses to act as a scientist, he has an unqualified obligation to tell the truth; he cannot compromise that obligation without disqualifying himself as a scientist. … Insofar as the biologist or physician chooses to act as a social engineer, he is an agent of the particular moral and political values he espouses and tries to realize or of those his employer espouses and tries to realize.”
Thomas Szasz; “The Theology of Medicine: The Political-philosophical Foundations of Medical Ethics”, “The Moral Physician”, Syracuse University Press, 1977
https://books.google.com/books?id=ybCoL-fQR4IC&source=gbs_navlinks_s
A wry, funny, but also serious look at an untenable situation. Dr. Fudin, I really appreciate your humor.
But – this madness must stop. Let doctors treat patients and keep the government out of practicing medicine.
I think it’s time to ban all cell phones EXCEPT FOR THOSE WHO ARE TRULY ADDICTED. Those people have special needs to which we should all cater. They should be given housing, free cell phone service, counseling, and free passes for any violations, because they are special snowflakes with an illness. The rest of us will have our cell phones removed, even if we’ve never overused them, because a few people do have a real problem with self-control and we should all go without because of them.
Meanwhile, the people who really needed their cellphones, like first responders, doctors, or parents who are just trying to get through their day and function properly, will have to use pen and paper to pass messages via carrier pigeon, or just give up trying to communicate.
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Great blog, very humorous. But it’s really not funny – at all. This national crisis is a failing of wisdom and mercy, and is now an absolute tragedy. Think of those who have literally shot themselves, shortening their lives unnecessarily and leaving loving families behind, all because they were denied basic pain relief. Relief which we have readily available, that is effective and inexpensive. They are DEAD because other people were reckless and thrill seeking, or sought to deal with emotional situations through illegal substances.
The US has lost its collective mind, the CDC has lost all integrity and repsect, and our citizens are dying while those who are addicted get billions of dollars thrown at them, while neither ever changes.
CDC is greatly to blame for co-opting legitimate, legal, medicinal use of analgesics with overdoses to try to co-opt and conflate the two.
What this blog does illustrate is that self-control is available to all of us. Those with addictions may need help, but stopping illigale drugs is still something they ultimately need to do for themselves. They really need to stop using medications other people need for legitimate medical purposes. They are killling innocent people, through their abuses.
Thank you Nate. I would say more, but I am too road weary from living in the midst of this. And at this point I fear that nearly everyone has drank the “cool aide”. It helps to know there are a few folks out there who get it.
I know we are all so weary, and all that is happening is so unfair. It does seem as though the addiction industry is trying to confuse everyone with the idea that exposure to an opioid for pain leads directly to heroin addiction. There is virtually no evidence for that, but this is a PR campaign, not an evidence-based narrative. We have to stay strong and keep speaking up. One place to do it is the following: we need to submit comments here. Also, Watch the live stream this Tuesday as advocates all speak out on this topic. Hang in there, people are fighting for us,
https://www.fda.gov/NewsEvents/MeetingsConferencesWorkshops/ucm583543.htm
No more cellphone usage we r all addicted, that’s next, wait 4 it! U think l’m over reactingNOT! The govt took r much needed medicines away & seemed 2 enjoy doing just that. Good God our govt would take our eyes out & tell us that we look better without them!
This is an EXCELLENT Article that draws very cogent analogies between two very divergent challenges.
Respectfully, we would simply add the following Disorders and Syndromes which are undoubtedly marked for inclusion in the DSM-6 and will most certainly be included as headliner Topics at the first FDA Cellphone Steering Committee Meeting:
– CIAD: Cellphone-Induced Anxiety Disorder;
– CDD: Cellphone Dependence Disorder; and,
– ICWS: Iatrogenic Cellphone Withdrawal Syndrome.
We thank you for drawing public attention to this CRITICAL challenge confronting WEthePEOPLE.
Professional regards,
TheButterflyProtocol™
butterflyprotocol@gmail.com
@emergVictorious
CDC needs to get on the this, STAT!!