Opioid Treatment Among Pregnant Women

New frontier of risk

Study finds sharp rise in opioid treatment among pregnant women

April 23, 2014 | Popular

By Alvin Powell, Harvard Staff Writer

A recent study by a group of Harvard-affiliated researchers found a sharp increase in the use of opioid painkillers among a large group of pregnant women between 2000 and 2007.

The increase means that more than one in five women receiving Medicaid — which pays for 40 percent of U.S. births — took codeine, oxycodone, or another opioid sometime during their pregnancy, a troubling trend particularly because opioids have been implicated in potentially fatal birth defects in fetuses.

The research team included scientists and physicians from the Harvard School of Public Health as well as Brigham and Women’s Hospital and Massachusetts General Hospital, both Harvard affiliates.

Rishi Desai, a Harvard Medical School research fellow working in the Division of Pharmacoepidemiology and Pharmacoeconomics at Brigham, was the lead author. The Gazette talked to him about the research and its implications.

GAZETTE: Your study in Obstetrics and Gynecology revealed some disturbing information on medication use during pregnancy. Can you describe the findings?

DESAI: The main finding of our study was that 21.6 percent of the 1.1 million Medicaid-enrolled pregnant women included in our cohort were exposed to some kind of opioid painkiller during the duration of their pregnancy. In 2000, the overall prescription rate of these medications at any time during pregnancy was 18.5 percent. That went up to 22.8 at the end of 2007, so we saw a sharp rise in a relatively short amount of time. We need to evaluate the fetal safety of these medications because right now we have very limited information, yet their use has been increasing.

GAZETTE: Was that finding expected or unexpected?

DESAI: The magnitude was surprising, but we were expecting to see some rise because several studies have documented a similar trend in the general population. What goes on in the general population is pretty much reflective of any specific subpopulation you study, and pregnant women were our subpopulation of interest.

GAZETTE: Can you tell us a little bit about the medication itself? What is an opioid? What do we know about them and their potential impact on fetuses?

DESAI: Opioids have been around for a long time. These are painkilling medications such as codeine, hydrocodone, and oxycodone. There are many, but those are the ones that are more commonly used. These are controlled substances, which means the FDA has recognized them as being potentially habit-forming. These agents are basically used for pain control in the general population. Pregnancy is one of the conditions in which pain complaints are fairly common, especially back pain and abdominal pain.

One of the reasons we decided to do this study was research published in 2013 that highlighted concerns about the safety of the fetus when this medication is used. That study saw an increase in neural-tube defects in fetuses exposed to these medications in the first trimester. Another study in 2011 saw similar signals. So that signal has been replicated twice — both times in observational settings, so it’s an association and not causation, but it’s the same signal in two different studies. We were interested in looking at this from a public-health point of view. How many potential fetuses are we talking about?

GAZETTE: What is a neural-tube defect?

DESAI: The CNS [central nervous system] organs, brain and spinal cord, are formed from the neural tube in a developing fetus during the first trimester of pregnancy. Any malfunction in this process results in incomplete development of the CNS, which is potentially fatal for a newborn. It’s a very serious condition. The absolute risk of neural-tube defects is small, but the earlier studies reported doubling of this risk after first-trimester opioid exposure compared to non-exposure.

GAZETTE: You saw a 4 percent increase in use of opioids among pregnant women during the study period. Is there an epidemic of pain among pregnant women or is something else going on? What’s driving this?

DESAI: It is difficult to attribute this trend to any single factor. Obviously, there’s more recognition of pain and the need to control pain overall. Increase in the use of these agents in the general population has been well documented in various studies in the past. Our study was based on prescribing and dispensing data, so we don’t have any idea how big a factor abuse is. Our data represent filled prescriptions of opioids, so we are viewing this use as medicinal in nature.

GAZETTE: The study shows regional differences. Can you address that?

DESAI: We did see some sizable differences across states and regions. The South had the highest and the Northeast had the lowest. That could be due to a combination of several things. Underlying prevalence of pain conditions might be different in different regions and practice patterns of the physicians themselves might be different. We do know from past research that there is a huge regional variation when it comes to prescription medication [patterns].

GAZETTE: Do you have any words of wisdom for a woman who is pregnant and considering getting a prescription for some of these compounds?

DESAI: Absolutely. There has to be a discussion around the risk-benefit profile of any medication you use. If the pain is not so severe, I think physical therapy or [another alternative] could help. We are not saying these agents should not be used at all. For instance, with cancer pain or serious joint pain, these agents do work. We know that. It would be best to at least have a discussion with your physician whenever you are thinking of getting medication for your pain.

GAZETTE: What next steps are important?

DESAI: We are in the process of looking at various safety signals among fetuses after exposure to opioid agents, so I think that is the next step. This is really important and an active area of investigation. We hope to contribute more to it.

Prescribing Mushrooms for Anxiety

The Atlantic

A New York University research team is using hallucinogenic experiences to help patients come to terms with their mortality.T

“Some of the things I’m about to say might not make sense,” began O.M., a 22-year-old cancer survivor. He had the far-off look in his eyes that I recognized from so many of the other study participants. They sound like travelers, struggling to describe exotic foreign lands to the people left back home. That struggle is a sign that the treatment has worked. Ineffability is one of the primary criteria that define a mystical experience.

“I was outside of my body, looking at myself,” O.M. continued, “My body was lying on a stretcher in front of a hospital. I felt an incredible anxiety—the same anxiety I had felt every day since my diagnosis. Then, like a switch went on, I went from being anxious to analyzing my anxiety from the outside. I realized that nothing was actually happening to me objectively. It was real because I let it become real. And, right when I had that thought, I saw a cloud of black smoke come out of my body and float away.”
The encounter with the black smoke was just one of many experiences that O.M. had that day. As his mind, “like a rocket,” traversed vast expanses, his body never left the comfortable and well-worn couch at the Bluestone Center for Clinical Research in Midtown Manhattan. The athletic first-year medical student is one of 32 participants in a New York University study examining the hallucinogen psilocybin as a treatment for cancer-related anxiety.
For O.M., that anxiety had been crippling. Diagnosed with Hodgkin’s Lymphoma at the age of 21, the then-pre-med student at first refused to accept reality. “I’m pretty domineering,” he laughed. “I told the nurses, ‘I can’t have this right now.’ I thought I could negotiate with cancer.” That domineering spirit served O.M. well through six rounds of chemotherapy. He even looked forward, he insisted, to the debilitating side-effects of his cancer-killing infusions. Enduring them gave him a sense of agency. He could withstand the punishment; his cancer could not. Only when the treatments ended, with his cancer in remission, was O.M. consumed by a feeling of abject helplessness. The fight was over. From that day on, all he could do was wait to see whether the cancer would return.
“When I first met him, he had calluses all over his neck,” explained research manager Gabrielle Agin-Liebes. “He would constantly feel his lymph nodes as a habit, to see if they had grown. Even as he was talking to you, his hand would be up there feeling his neck. Ironically, that would make the lymph nodes swell up even more.”
“He had one of the highest ratings on the anxiety scale that we had seen: 21 out of 30,” Gabrielle continued. “To qualify for the study you only need an eight. The day after his first dosing session, he dropped to zero, and for seven months he’s stayed there. Zero anxiety.” The black cloud had carried it all away.

In the years after World War II, hallucinogen-aided therapy was a rapidly growing field.

Psilocybin, found naturally in more than 200 species of mushrooms, has a long history of use by humans. Called “flesh of the gods” by the Aztecs, the mushrooms were widely consumed in religious ceremonies by pre-contact indigenous cultures throughout the Americas.  Cave paintings in Spain and Algeria suggest ritualized ingestion dating back as far as 9,000 years. Brutally suppressed by Christian authorities on both sides of the Atlantic, indigenous psilocybin use was nearly eradicated until the late 195o’s when Western psychiatry rediscovered it.
In the years after World War II, hallucinogen-aided therapy was a rapidly growing field. Conditions as diverse as alcoholism, drug addiction, post-traumatic stress disorder, and anxiety were treated. In the quarter century that followed, 40,000 patients were given psilocybin and other hallucinogens such as DMT, LSD, and mescaline. More than 1000 research papers were produced. The results were very promising, though as the NYU study’s principal investigator Dr. Stephen Ross explained, much of the research lacked proper oversight. “They didn’t understand set and setting in the beginning. Patients would be injected with LSD, put in restraints, and somebody would come back hours later. They were put in very drab clinical environments. Then you had people like Timothy Leary and his group over at Harvard who were using the drugs themselves, using them with famous people, and recklessly promoting psychedelics within American culture.”
The government soon took notice. As paranoia grew within the Nixon Administration over the rise of a drug-fueled counterculture, regulation became a priority. Creeping legislation culminated in the Controlled Substances Act of 1970. The law created five schedules of increasing severity under which drugs were to be classified. Psilocybin was rushed into the most restrictive Schedule I, alongside MDMA, marijuana, and heroin. The classification was reserved for drugs that, by definition, have a “high potential for abuse,” “no currently accepted medical use,” and a “lack of accepted safety.” The act signaled the end of psychedelics research in America for nearly 25 years.

Dr. Stephen Ross

The research made a slow comeback starting in the mid-90’s, but the stigma remains. “The only thing I learned about psychedelics in psychiatry training is that they were toxic,” Dr. Ross explained. “We were told that they cause psychosis. I’d also heard the old urban legends: that they cause chromosomal damage, and that if you take seven hits of LSD you go insane. But, I knew nothing about their history in psychology and in mental health, which had been considerable.”
The soft-spoken psychiatrist first came to NYU under a fellowship to do research on drug addiction. In his search for novel treatments for intractable conditions, Ross stumbled upon a decades-old study in which LSD had been used to successfully cure alcoholism. “I was shocked,” he admitted. “As a Schedule I drug, I assumed that LSD must be very addictive. But that simply wasn’t true. It does not behave like an addictive drug by any measure. I was even more shocked to find out that Bill Wilson, the founder of Alcoholics Anonymous, got sober from a psychedelics-induced mystical experience. He was so impressed that he actually wanted to introduce it into the bylaws of AA.”
As for the toxicity Dr. Ross had been warned about in medical school, “There are simply no known long-term toxic effects from taking serotonergic hallucinogens,” he explained. “From a medical perspective, psilocybin is a remarkably safe compound.”
The Drug Enforcement Agency takes a different view.
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Consistent with similar studies involving psilocybin, approximately three-fourths of the participants rate their experience with the drug as being one of the top five most significant events of their lives.
I asked Dr. Ross how a medication taken only once can have such an enduring effect. “One way to think of it,” he replied, “is that these experiences are profoundly memorable. When something really bad happens, PTSD can occur. It activates the amygdala where emotional memories are formed. Symptoms can last for years. Dramatic negative events can create symptoms for long period of time, and it seems that way with very positive experiences too. In my own life, I think about the birth of my kids. It was a profound event that caused great changes in my life. I think these psychedelic events are similar to that.”
I sat across the table from O.M., examining his perfectly normal neck. He smiled as he demonstrated the way he used to palpate his lymph nodes – fingers curling expertly into position behind his left ear like those of a virtuoso violinist. “Now, in medical school, I’m learning to palpate other people’s lymph nodes,” he added. “I’m the best.”
His hands dropped easily back onto the table, resting peacefully there before him. It was hard to imagine that this man had ever been sick.
“At the hospital they gave me Xanax for anxiety,” he said. “Xanax doesn’t get rid of your anxiety. Xanax tells you not to feel it for awhile until it stops working and you take the next pill. The beauty of psilocybin is: it’s not medication. You’re not taking it and it solves your problem. You take it and you solve your problem yourself.”
Full article
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Study Finds Recreational Cannabis Use Is Associated With Abnormalities In The Brain

April 16, 2014 | by Justine Alford

photo credit: Wikimedia Commons.

A study investigating recreational marijuana use in young adults has found that users had differences in two areas of the brain, the amygdala and the nucleus accumbens, when compared with non-users. The study has been published in The Journal of Neuroscience.

Cannabis, or marijuana, is the most commonly used illicit drug in the United States, but relatively few studies have investigated how it affects the brain. Although some animal studies have demonstrated changes in regions of the brain involved in learning and memory, attention and decision-making after exposure to the main psychoactive component of cannabis (THC), only a handful of similar studies exist in humans. The few studies that have been carried out also show contrasting results, which may be due to differences in methodologies. They also usually focus on heavy users as oppose to occasional users.

In this study, scientists used high-resolution MRI to scan the brains of 20 marijuana users and 20 non-users, between the ages of 18-25. The scans were used to collect data on gray matter density, brain volume and morphology. They matched the participants on age, sex, race and years of education. The marijuana users reported that they used the drug at least once a week, but were not dependent. The non-users had never used it more than 5 times in their lifetime. They also corrected for things like alcohol consumption as the users reported that they drank more alcohol than the non-users.

The researchers found that the marijuana users, compared with the non-users, had structural abnormalities in gray matter density, volume and shape of two areas of the brain; the nucleus accumbens and amygdala. These regions have been implicated in reward and aversion and therefore likely play a role in addiction. They are also involved in the euphoria associated with the rewarding effects of drugs.

The researchers also found that some of the abnormalities were exposure dependent. Finally, the researchers also suggested that cannabis use may be associated with a disruption of neural organization in the nucleus accumbens and amygdala, but this is speculation.

These data therefore suggest that recreational marijuana use in young adults may lead to alterations in the core reward structures. It's important to remember, however, that correlation does not imply causation- the study can infer an association but not a definitive cause. The number of participants was also small and the study did not investigate whether cannabis use affected cognition as well as brain morphology. Therefore although this particular study is important, it also lays the foundations for further in-depth research into this interesting area. 

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Society for Neuroscience

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Female Athletes Punished for Hormonal Abnormality

The Opinion Pages|OP-ED CONTRIBUTORS

The Trouble With Too Much T

By KATRINA KARKAZIS and REBECCA JORDAN-YOUNGAPRIL 10, 2014

Amanda Lanzone

In 2009, the South African middle-distance runner Caster Semenya was barred from competition and obliged to undergo intrusive and humiliating “sex testing” after fellow athletes at the Berlin World Championships questioned her sex. Ms. Semenya was eventually allowed to compete again, but the incident opened the world’s eyes to the process of sex testing and the distress it could bring to an athlete who had lived her whole life as a girl. When an endocrinologist, a gynecologist and a psychologist were brought in to determine whether the teenager was really a woman, she simply asserted, “I know who I am.”

From 2011, major sports governing bodies, including the International Olympic Committee, the Fédération Internationale de Football Association and the International Association of Athletics Federations, instituted new eligibility rules that were intended to quell the outrage over the handling of the Semenya case. Instead, as recent cases attest, they may have made things worse.

Rather than trying to decide whether an athlete is “really” female, as decades of mandatory sex tests did, the current policy targets women whose bodies produce more testosterone than is typical. If a female athlete’s T level is deemed too high, a medical team selected by the sport’s governing bodies develops a “therapeutic proposal.” This involves either surgery or drugs to lower the hormone level. If doctors can lower the athlete’s testosterone to what the governing bodies consider an appropriate level, she may return to competition. If she refuses to cooperate with the investigation or the medical procedures, she is placed under a permanent ban from elite women’s sports.

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Pop Stars Are Sippin' On Patron, And Teens Are Bingeing

Original Article

Pop Stars Are Sippin' On Patron, And Teens Are Bingeing

by MAANVI SINGH

April 09, 2014 3:52 PM ET

Shots, shots, shots, shots! Redfoo and Sky Blu keep the Ciroc vodka flowing in the music video for their party anthem "Shots."

Ke$ha says that to start the day she'll brush her teeth with a bottle of Jack Daniel's whiskey. Nicki Minaj likes to "have a drink, have a clink" of Bud Light. And the party-rockin' hip-hop duo LMFAO like Ciroc, and they love Patron. "Shots, shots, shots, shots everybody!"

All that name-checking of alcohol brands encourages teens to drink, researchers say. Adolescents who liked songs like these were three times as likely to drink, and were twice as likely to binge than their peers who didn't like those songs.


Don't think music can make you want to drink? Try our remix.
Researchers from the University of Pittsburgh surveyed more than 2,500 young people and asked them whether they liked or owned 10 randomly selected top 40 singles that referenced alcohol.

The kids who most enjoyed those hits were also the most likely to drink and binge, even after controlling for age and parental alcohol use. Only 8 percent could recall the specific brand names mentioned in the songs, but they were even more likely to drink than the rest.

The findings were published Tuesday in Alcoholism: Clinical and Experimental Research.

"It is unclear how much very specific information adolescents do or do not get from popular music," says Dr. Brian Primack, an associate professor of medicine at the University of Pittsburgh and the study's lead author. But, he says, it's clear that the music adolescents are listening to does have some impact on their drinking habits.

Parents and peers' drinking habits can also influence young people, previous research has shown. But seeing people drink in real life is a lot different than seeing them drink in a music video, Primack tells Shots. In real life, you see the negative side effects of drinking. But most musicians don't talk about hangovers and addiction, he says.

Of course, this study only shows that listening to certain types of music is associated with young people's drinking habits. It doesn't show that one causes the other. While it could be that the music is encouraging young people to drink, it might also be that young people who drink are more likely to listen to songs about parties and alcohol.


This isn't the first time researchers have looked at alcohol references in popular music. In December, researchers from Boston University and Johns Hopkins University combed through Top 40 hits from 2009 through 2011 and found that about a quarter referenced alcohol.

The most name-dropped brands of alcohol were Patron tequila, Hennessy cognac, Grey Goose vodka and Jack Daniel's whiskey. And that's not a coincidence, says David Jernigan, the director of Hopkins' Center on Alcohol Marketing and Youth, and one of the researchers behind that study.

"There are some really lucrative deals being made between artists and particular brands," Jernigan tells Shots. Rapper and producer Sean Combs is a paid spokesperson for Ciroc vodka. Grey Goose sponsored a 2011 music tour featuring rappers like Lil Jon, the study points out, while Jack Daniel's sponsored a party celebrating top Nashville singers and songwriters. Many of these brands also sponsor musicians' album release parties and music festivals, according to the study.

"For at least some of these artists, promoting alcohol has become part of their business models," Jernigan says. Reversing that trend may be one way to reduce young people's exposure to alcohol in music.

The tobacco industry, for example, is banned from paying for product placements in movies. Jernigan says that kind of regulation is unlikely to happen with alcohol in the music industry. But he hopes the companies can be persuaded to exercise restraint.

And he says teaching kids to beware of what they hear and see in the media couldn't hurt.

We here at Shots listened up and made a very unscientific remix of recent songs celebrating alcohol. Take a listen, and let us know if it puts you in the mood to take some shots.

Uruguay Wants to Give Marijuana to Prisoners

BY MIKE ADAMS · WED APR 09, 2014

 
 
 
 
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Pot for convicts? A leading Uruguay health official told the United Nations last week that the country is interested in experimenting with medical marijuana to treat prisoners suffering from cocaine addiction.

"Jail is not a very suitable place for someone to safely overcome drug addiction," said public health sub-secretary, Leonel Briozzo, during a U.N. meeting last Thursday. Briozzo said it is crucial for Uruguay to explore "new strategies for drug addiction treatment… And in that sense, we harbor a possible hope that medical marijuana can play a role in this as well."

Ever since the turn of the new millennium, an inexpensive drug known as “Paco,” which is considered the bologna of cocaine derivatives, has been wreaking havoc on the dope fiends of Uruguay. The drug is extremely inexpensive -- approximately 30 cents per hit -- and can be smoked similar to American welfare favorites like crack cocaine. Paco has since created an epidemic in South American countries, including Argentina, Brazil and Uruguay, with a high percentage of the people incarcerated in those areas forced to conquer their addictions behind bars.

Although there is not a lot of research outlining the effects of treating hardcore drug addicts with medical marijuana, countries like Colombia have thrown caution to the wind and are currently exploring it as an option. Members of the International Drug Policy Consortium say the marijuana method is not about pot taking the place of harder, more dangerous drugs, but rather to help alleviate some of the anxieties associated with withdrawals.

Other Latin American countries are also considering using marijuana to help addicted prisoners, but as Coletta Youngers with the IDPC points out, "They Uraguay [sic] are in a unique situation. Because of the legal markets they have much greater freedom."

Mike Adams writes for stoners and smut enthusiasts in HIGH TIMES, Playboy’s The Smoking Jacket and Hustler Magazine. You can follow him on Twitter @adamssoup and on Facebook/mikeadams73.

Addicts shoot up in safe haven in Canada

By Natasha Maguder, CNN

updated 9:48 AM EDT, Fri April 12, 2013

Legal high but is it safer?

STORY HIGHLIGHTS

• Safe haven in Vancouver allows drug addicts to shoot up safely and without fear of arrest
• Controversially, InSite does not require addicts to try to kick their habits
• Supreme Court ruled it should stay open as it was giving access to medical care
• InSite is the only legal safe haven facility in North America

Watch "World's Untold Stories: Shooting up legally" on CNN International on Friday April 12 at 11.30 ET, Saturday 9 a.m. ET and 4.30 p.m. ET, and Sunday at 5.30 a.m. and 11.30 p.m.

Vancouver, British Columbia (CNN) -- Heroin, cocaine and amphetamines are the kind of street drugs you expect to find in the shady corners of any city, hiding away from the glare of law enforcement.

But in one small space in downtown Vancouver addicts openly inject their fixes -- as medics watch on.

This is InSite, North America's only legal safe drug injection center. A banner outside reads "InSite saves lives."

It's a facility where drug addicts can bring and use their drugs and not risk arrest.

Some of the addicts line up two or three times a day to use one of the 12 injection booths.

Shooting up legally

One of the first users of the day is Steve. The center opens at 10 a.m. and then runs steadily for 18 hours until4 a.m. Approximately 800 people use the booths every day.

Steve gives his alias to the receptionist -- all InSite users have an official alias to protect their identity -- and moves into the injection room.

He takes a seat and calmly begins to prepare his hit of heroin. He uses the clean needle and sterile equipment provided by InSite.

The white powder is mixed with water in a spoon, gently heated with a candle, before being drawn into the syringe, and injected into the inside of Steve's elbow. It's not for the squeamish. There's quite a lot of blood.

With fluorescent lighting and lots of mirrors, the atmosphere is clinical, even as the room fills with drug addicts focused on one task only -- feeding their addiction.

Medical staff are on hand and watching closely. If needed they can help addicts find the right vein to shoot up into -- something which can be tricky for long-term users. But their main job is to step in when a user overdoses.

Steve has overdosed here three times.

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The drug legislation dilemma

Featuring:

UK drug policy is “disastrous” says Open University Visiting Professor and former government advisor David Nutt. In a lecture at the OU the professor called for scientists to have greater input to the control of illegal substances.

By: The OpenNews Team (Other Open University departments, The Open University), Professor David Nutt (The Open University)

• Published on: Friday 21st February 2014

Copyrighted imageA menace to society?Our current policies to control drugs and alcohol are having ‘disastrous results’, because they are made by politicians rather than scientists.

This is the hard-hitting view put forward by The Open University’s recently appointed Visiting Research Professor of Social Policy and Criminology, David Nutt.

In his first lecture at the OU’s Walton Hall campus in January, the former head of the Government’s Advisory council for the Misuse of Drugs said: “There is no correlation between harms of drugs and control.”

He added: “We currently have a decision-making process about drugs based on political expediency. I am sure we could do much better if scientists took over.”

Professor Nutt and colleagues have developed a Cause of Harm Index compiled by scientific experts (see below), which compares the harms done to individuals and to society by individual drugs, including tobacco and alcohol.

By this measure alcohol is more harmful than most of the drugs which are now currently illegal and responsible for the deaths of 8,000 people in the UK each year.

By contrast drugs like cannabis, ecstasy and mephedrone, which the scientific evidence suggests are all much less dangerous, are much more strictly controlled. Mephedrone was recently made illegal despite evidence that it may have encouraged a drop in consumption of a much more harmful drug, cocaine.

But current drugs legislation also discourages medical research which holds out hope for relieving suffering, Professor Nutt said.

He heads a team investigating a promising new drug treatment for cluster headaches, an intractable condition which causes its victims so much agony that some commit suicide.

But because the drug in question is psilocybin, classed as a Schedule 1 drug (the most restricted) it has taken his team eighteen months to clear the regulatory hurdles before they can start work.

Other Schedule 1 drugs may offer hope to sufferers from alcohol addiction, depression, post-traumatic stress disorder and other serious conditions. But with regulatory hurdles including a licence that costs £6000 a year “almost no-one researches these drugs”, Professor Nutt said.

Ironically, Schedule 1 drugs are not necessarily the most dangerous – heroin at Schedule 2 is less restricted than cannabis which is Schedule 1. They classed as such because they are currently seen to have no medical use.

The Hippie's Disappointment

This is a video about using cannabis, without any psychoactive effects, to treat pediatric epilepsy. It's a little cheesy, as most TED talks are.
https://www.upworthy.com/think-marijuana-is-for-stoners-meet-a-6-year-old-girl-who-might-just-disagree-with-you-on-that?c=reccon1