Position statement (FnimH 2010-01)
Inhalant abuse
L Baydala; Canadian Paediatric Society, First Nations, Inuit and Métis Health Committee
Français en page 449
L Baydala; Canadian Paediatric Society, First Nations, Inuit and
Métis Health Committee. Inhalant abuse. Paediatr Child Health
2010;15(7):443-448.
Inhalant abuse – also known as volatile substance abuse, solvent abuse,
sniffing, huffing and bagging – is the deliberate inhalation of a volatile
substance to achieve an altered mental state. Inhalant abuse is a
worldwide problem that is especially common in individuals from
minority and marginalized populations, and is strongly correlated with
the social determinants of health. It often affects younger children,
compared with other forms of substance abuse, and crosses social and
ethnic boundaries. Inhalants are pharmacologically diverse products
that are selected for their low price, legal and widespread availability,
and ability to rapidly induce euphoria. Chronic abuse is associated
with serious and often irreversible effects. Widespread screening and
early referrals to treatment programs have resulted in significant
improvements in the mental, physical and social conditions of those
affected. The present statement reviews critical aspects of inhalant
abuse, highlighting new information and data that pertain to
Aboriginal children and youth, and provides recommendations for
treatment and prevention.
Key Words: Abuse; Inhalant; Solvent; Volatile substance
I
nhalant abuse, which is also known as volatile substance
abuse, solvent abuse, sniffing, huffing and bagging, is the
deliberate inhalation of a volatile substance to achieve an
altered mental state. It often affects younger children, compared with other forms of substance abuse, and crosses social
and ethnic boundaries. Inhalant abuse is a worldwide problem that is especially common in individuals from minority
and marginalized populations, and is strongly correlated
with the social determinants of health (1). The present
statement reviews critical aspects of inhalant abuse, highlighting new information and data that pertain to Aboriginal
children and youth, and provides recommendations for
treatment and prevention. It replaces the previous Canadian
Paediatric Society statement published in 1998 (2).
EPIDEMIOLOGY
Lack of recognition, social stigma, changing trends and
apparent regional differences, along with differences in survey methods, make accurate reporting of inhalant abuse
epidemiology difficult. The Canadian Addiction Survey
(3) – a randomized telephone survey – noted that 1.3±0.3%
L Baydala; Société canadienne de pédiatrie, comité
de la santé des Premières nations, des Inuits et des
Métis. L’abus de substances volatiles.
L’abus de substances volatiles, également connu sous le nom d’abus de
substances inhalées, d’abus de solvants, de sniffing (ou snifage – reniflage à
partir d’un contenant), de huffing (inhalation d’un linge imprégné) ou de
bagging (inhalation dans un sac placé autour de la bouche et du nez),
désigne l’inhalation délibérée d’une substance volatile pour altérer l’état
mental. L’abus de substances volatiles est un problème mondial
particulièrement courant au sein des populations minoritaires et
marginalisées, et il a une forte corrélation avec les déterminants sociaux de
la santé. Par rapport aux autres formes de consommation de drogues, il
touche souvent les enfants plus jeunes et traverse les frontières sociales et
ethniques. Les substances volatiles sont des produits volatils diversifiés sur
le plan pharmacologique, sélectionnés pour leur faible coût, leur légalité et
leur grande disponibilité, de même que pour leur capacité à induire
l’euphorie rapidement. La consommation chronique s’associe à des effets
graves et souvent irréversibles. Un dépistage généralisé et un aiguillage
rapide vers des programmes thérapeutiques assurent une amélioration
importante de l’état mental, physique et social des personnes qui y
recourent. Le présent document de principes analyse les aspects cruciaux
de l’abus de substances volatiles, fait ressortir de nouveaux renseignements
et de nouvelles données à l’égard des enfants et adolescents autochtones et
contient des recommandations en matière de traitement et de prévention.
of Canadians 15 years of age and older reported lifetime use
of inhalants in 2004, compared with 0.8±0.2% in 1994.
Inhalants are legal, inexpensive and easy to obtain, all of
which may account for the higher abuse potential among
young children. In a 2007 United States (US) face-to-face
survey (4), 1.1% of youth aged 12 to 13 years had used
inhalants in the past month, and 66.3% of respondents
12 years of age and older were children when they first
abused inhalants. Notably, 10.7% of respondents reported
inhalants as their first drug of abuse. Both the American
and Canadian surveys excluded the homeless and incarcerated; thus, the prevalence of inhalant abuse may be even
higher. Research also varies in the categorization of different substances and which ones qualify as ‘inhalants’.
In a self-administered survey of youth from the US, fewer
students from the same class cohort claimed to have ever
abused inhalants in later years (5). These findings may have
occurred because some students who were abusing inhalants
may have left school or forgotten their inhalant experiences
when questioned later. Or, perhaps older students considered
inhalant abuse to be less socially acceptable and were,
Correspondence: Canadian Paediatric Society, 2305 St Laurent Boulevard, Ottawa, Ontario K1G 4J8. Telephone 613-526-9397,
fax 613-526-3332, websites www.cps.ca, www.caringforkids.cps.ca
Paediatr Child Health Vol 15 No 7 September 2010
©2010 Canadian Paediatric Society. All rights reserved
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CPS Statement: FNIMH 2010-01
TABLE 1
Categories, examples and chemicals present in commonly abused inhalants
Category
Examples
Chemicals
Other terms
Aliphatic, aromatic and
halogenated
hydrocarbons
Hair spray, air fresheners, deodorants
Butane, propane, fluorocarbons
Fuels including cigarette lighters
Gasoline, propane, benzene, butane
Paint/polish removers, paint thinners,
felt-tip markers, correction fluids, glues
and rubber cements
Trichloroethane, trichloroethylene, toluene,
hexane, acetone, methylene chloride,
ethyl acetate
Medusa, moon gas, poor man’s pot, air
blast, discorama, hippie crack, chroming,
gladding, whiteout
Varnishes, lacquers, resins, lacquer
thinners
Benzene, xylene
Dry cleaning fluids, spot removers,
degreasers
Dimethyl ether, hydrofluorocarbons,
hydrocarbons
Computer/electronics cleaning sprays
Hydrocarbons
Vegetable oil cooking sprays
Diethyl ether, halothane, enflurane, ethyl
chloride
Medical anesthetics
Trichloroethane, tetrachloroethylene, xylene
Nitrous oxide
Whipping cream aerosols, balloon tanks,
anesthetics
Nitrous oxide
Volatile alkyl nitrites
Angina medications, ‘room odourizers’,
videocassette recorder head cleaners,
synthesized products
Amyl nitrites, butyl nitrites, cyclohexyl nitrite, Medusa, moon gas, pearls, boppers,
isopropyl nitrite, other nitrites
snappers, poppers, amys, bolt, quicksilver,
rush, climax, aroma of men, hardware,
locker room, thrust
therefore, more reluctant to report its use. The perception of
inhalants as ‘kid’s drugs’ (along with the use of the generic
and innocuous-sounding term ‘glue sniffing’ for inhalant
abuse) has been described. This perception may explain the
epidemiological trends of inhalant abuse and deserves consideration by health care professionals (6).
Inhalant abuse is more common in school dropouts,
those who have been physically or sexually abused or neglected, the incarcerated and the homeless, as well as among
Aboriginal communities (1,7,8). Differences among other
ethnic groups and between sexes are more ambiguous.
Inhalant abuse is more prevalent among rural communities,
as well as isolated communities with high rates of unemployment, poverty and violence (1). It is also correlated with
reduced family support or deviant family environments,
poor school performance, poor self-esteem and suicidality,
psychiatric conditions, other substance abuse, and substanceabusing family and peers (1,8). Inhalant abuse is an international problem that is closely linked with the social
determinants of health. Children and youth from different
social backgrounds initiate inhalant use for different reasons; for example, in the developing world, inhalant abuse
is often done to relieve symptoms of hunger (9).
ABUSED CHEMICALS AND PRODUCTS
Inhalants are pharmacologically diverse volatile products
that are frequently selected for their low price, legal and
widespread availability, and ability to rapidly induce
euphoria. A grouping by pharmacology and patterns of
abuse has resulted in three categories: aliphatic, aromatic or
halogenated hydrocarbons; nitrous oxide; and volatile alkyl
nitrites (10,11) (Table 1). The most commonly abused substances reported to US poison centres from 1996 to 2001
were gasoline (41%), paint (13%), propane/butane (6%),
air fresheners (6%) and formalin (5%). The majority of
inhalant-related deaths were caused by gasoline (45%), air
fresheners (26%) and propane/butane (11%) (12).
444
Laughing gas, shoot the breeze, whippets,
buzz bomb
IMMEDIATE EFFECTS
‘Sniffing’ or ‘snorting’ involves the direct inhalation of
fumes, ‘bagging’ from a plastic or paper bag, ‘huffing’ from a
rag or cloth soaked in the substance held over the mouth or
nose, ‘glading’ from air freshener aerosols, and ‘dusting’
involves the direct spraying of aerosol cleaners into the
mouth or nose (10,11). Often, several deep inhalations are
needed to achieve full euphoric effects. Rapid pulmonary
absorption and lipid solubility mean that the brain is rapidly
affected (13). The greatest concentration of inhalant can be
obtained through ‘bagging’ and ‘huffing’; thus, these methods of abuse are preferred (14).
Initial effects are similar to those of anesthetics: stimulation, disinhibition and euphoria. These sensations may
be followed by hallucinations and then a general depression including slurred speech and disturbed gait, dizziness,
disorientation, and drowsiness or sleep within seconds to
minutes (13). Rebreathing when ‘bagging’ potentiates the
intoxication by causing hypercapnia and hypoxia (15).
Further drowsiness and headache can persist for hours
because of residual intoxication. Tiredness and sleep often
limit the degree of intoxication (13). Inhalants have a
wide range of effects on neurotransmitter release and
receptors, with a few similar cellular actions as those of
other depressants such as benzodiazepines, alcohol and
barbiturates (16).
Volatile alkyl nitrites, such as those indicated for angina,
have vasodilatory effects, resulting in hypotension and syncope and sensations of warmth and flushing. ‘Poppers’ and
their sensations have been associated with dance clubs and
sexual activity; they have also been used for their sphincter
relaxation effect and penile engorgement in young men for
anal sex, with links to increased HIV transmission (17).
Inhalants of various types have been reported to cause freezing
and burning of the face and upper aerodigestive tract (18).
Respiratory arrest due to central nervous system depression has been reported in at least one case, and sudden
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CPS Statement: FNIMH 2010-01
cooling of the larynx (by direct spraying of aerosols) has
been suggested to cause fatal vagal depression (19). Likely
due primarily to cardiac arrhythmia, ‘sudden sniffing death
syndrome’ is the leading cause of death among inhalant abusers. Inhalants disrupt myocardial electrical propagation – an
effect heightened by hypoxia – increasing the risk of arrhythmia. Inhalants also sensitize the heart to adrenaline; sudden
sniffing death can occur when a user is startled during inhalation (such as being caught inhaling) or in vivid hallucinations (19). Deaths and injuries from acute abuse often result
from dangerous behaviour (eg, drowning, falls or jumps,
burns or hypothermia) due to disinhibition and feelings of
invincibility, while aspiration and suffocation, especially
when ‘bagging’, can also be fatal (10).
TABLE 2
CRAFFT Screening Tool
LONG-TERM EFFECTS
Chronic abuse has been shown to have drastic and irreversible neurological and neuropsychological effects, likely due
to damage of myelin and neuronal membranes by lipophilic
chemicals (15). More concentrated in neural tissue than in
blood, these chemicals can cause cortical atrophy and
lesions visible with neuroimaging. Inhalants have been
known to result in brainstem dysfunction and a variety of
motor, cognitive and sensory deficits (20). Signs may
include irritability, tremor, ataxia, nystagmus, slurred speech,
decreased visual acuity and deafness (13).
Inhalant abuse can cause cardiomyopathy with distinct
electrocardiographic changes (21). Dyspnea, emphysemalike abnormalities and other pulmonary debilitations, distal
renal tubular acidosis and hepatitis can be caused by inhalant abuse (22). Hydrocarbons can result in bone marrow
toxicity (causing aplastic anemia and leukemia) (23), while
volatile nitrites have been implicated in immune impairment and the replication of HIV and Kaposi’s sarcoma, and
the creation of carcinogenic nitrosamine and methemoglobin as metabolites (13).
Women who are occupationally exposed to solvents
have more menstrual disorders, and preeclampsia and spontaneous abortions are more common in pregnant women
who abuse inhalants (24). Teratogenic effects secondary to
maternal exposure to inhalants may lead to ‘fetal solvent
syndrome’ with associated congenital neurological defects
including microcephaly and cognitive impairments (25).
Signs of neonatal withdrawal include high-pitched cry, and
disturbed sleep and feeding (26).
Inhalant abuse is associated with poor school performance, criminal behaviour, abuse of other substances, social
maladjustment, low self-esteem and suicidality (1,4).
Causality of these phenomena has not been established;
they may be as much predecessors or a direct cause of inhalant abuse.
legal, making their purchase and storage less conspicuous.
Abusers may have unusually large caches of inhalants, perhaps stored in atypical places (such as under a child’s bed).
Chronic users may have clear physical signs: odour on the
breath that can linger for hours, stains, paint, glitter and/or
odour on skin or clothing. Presentation may also include
perioral dryness or pyodermas, the ‘huffer’s rash’ (may be
yellow in nitrite abusers) or even facial, oral/nasal or
esophagopharyngeal freezing or burning, sometimes with
secondary edema of lips, oropharynx and trachea (13).
Other obvious signs may be manifestations of neuropsychological impairment (such as confusion, moodiness or irritability) and pulmonary toxicity (including wheezing,
emphysema and dyspnea) (13,15,27). Severe toxicity may
be detected with more pronounced central nervous system
depression such as ataxia, tremor and nystagmus (27,28).
Friends and family may suspect heavy abuse by noticing
poor hygiene, weight loss, fatigue, nosebleeds, conjunctivitis, muscle weakness, nausea, apathy, poor appetite and
gastrointestinal complaints, changes in school attendance
or psychological/psychiatric changes (27,28). High prevalence of mood, anxiety and personality disorders has been
correlated with inhalant abuse, and should be considered in
both detection and subsequent treatment.
Analysis for urinary metabolites of certain solvents (benzene, toluene, xylene and chlorinated solvents) may be
conducted to ensure treatment compliance, but generally
routine urine screening and other laboratory tests do not
detect inhalant abuse (10,29). Although it may be the most
valuable tool in inhalant abuse detection, screening is seldom performed by health care providers (30). Health professionals are advised to consider a screening tool such as
the CRAFFT questionnaire (Table 2), and to be aware of
appropriate techniques in its administration including private interviews as well as involving family members in
assisting with collecting a more complete history (30-32).
Additionally, family, peers, teachers, counsellors and others
should be made aware of the signs of inhalant abuse and
how to refer children and youth who may be at risk.
Widespread screening for youth and the incarcerated has
resulted in successful referrals to treatment programs (33),
while the Screening, Brief Intervention, and Referral to
DETECTION
The signs of inhalant abuse are often more subtle than with
other abused substances. Effects are experienced rapidly and
disappear quickly (11), and only small amounts of a substance
are required. Furthermore, abused products are typically
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C
Have you ever ridden in a Car driven by someone (including
yourself) who was “high” or had been using alcohol or drugs?
R
Do you ever use alcohol or drugs to Relax, feel better about
yourself, or fit in?
A
Do you ever use alcohol or drugs while you are by yourself, Alone?
F
Do you ever Forget things you did while using alcohol or drugs?
F
Do your Family members or Friends ever tell you that you should
cut down on your drinking or drug use?
T
Have you ever gotten into Trouble while you were using alcohol or
drugs?
Two or more “yes” answers indicate a potential substance use problem and
the need for further assessment. Reproduced with permission from reference 51. © Canadian Medical Association
445
CPS Statement: FNIMH 2010-01
Treatment (SBIRT) pilot program in the United States
resulted in 22.7% of 459,599 patients screening positive for
some degree of involvement in, or risk of, substance abuse.
Early referrals to treatment programs have resulted in significant improvements in the physical, mental and social
conditions of those affected (34).
INTERVENTION AND TREATMENT
Inhalant abusers may not seek medical attention, except in
cases of related injury or serious illness. Effective treatment
is not available for acute inhalant intoxication and withdrawal, apart from extra-vigilant and supportive care (35).
Management may include the use of antiarrhythmics or
beta-blockers to stabilize the myocardium and avoid overstimulation by catecholamines; sympathomimetics should
be avoided (19). Hypotension is common and cardiopulmonary status must be monitored, along with mental
status (11,35). Skin and clothing may require decontamination (35). Patient history from peers and family must be
taken, an assessment of the patient’s neurological status is
critical, and laboratory investigations to screen for liver,
kidney and heart damage are important (13). Withdrawal
may influence treatment; varying manifestations have been
reported, such as nausea, anorexia, sweating, tics, sleep disturbance and significant changes to mood (13,28,36).
Inhalant abusers are younger and suffer greater social
dysfunction than abusers of other substances. Therefore,
inhalant-specific treatment programs are required, and
should include time for detoxification, use of a peer-patient
advocate system, development of strengths and skills, and
appropriate transition back into the community (37).
Considerations for other substance dependencies, or the
presence of psychiatric or physical disorders, must be made and
co-current conditions should be treated. Early treatment –
assisted by early detection by widespread screening – and
extended treatment periods improve outcomes (35,38).
Families of inhalant abusers are often dysfunctional, and
family therapy and social family contracting with parental
reinforcement and enforcement of the youth’s appropriate
behaviour may also be effective in treatment. Finally, referring health professionals should make themselves available
during and following treatment to encourage and facilitate
the uptake of parenting, parent support and youth social
skills programs that may reduce the risk of relapse (39).
PREVENTION
Almost unequivocally, prevention is considered the most
effective strategy in combating inhalant abuse. Prevention
methods must aim to reduce the social acceptability of
abuse and should be comprehensive and community based,
involving not only abusers and family members, but also
peers, schools and retailers (9).
Involving the producers of abused legal products in inhalant
abuse prevention interventions has had mixed results.
Legislation in three American states was abandoned after difficulty in finding suitable additives to make substances unpleasant to abusers, and compulsory labelling of constituent
446
chemicals in inhalants has made products likely to be abused
easier to identify (40). Australia has had some success in
replacing harmful components in products, mostly driven by
environmental requirements (41). Retailers and manufacturers
can also partner in prevention education (40).
Preteens are at risk of inhalant abuse; therefore,
evidence-based in-school primary prevention education
must begin early to ensure that its messages have been
delivered before – not in the midst of – youth inhalant
abuse (6). Office-based brief interventions including a
5 min to 10 min session outlining the risks associated with
substance use have been found to be effective in reducing
alcohol, marijuana and tobacco use (42). However, similar
strategies have not been shown to be effective for inhalant
abuse, in which perceptions of harm are more strongly correlated with social networks than with future intent to use
inhalants (43). Availability and use of inhalants by peers
correlate with inhalant abuse, with many youths reporting
abuse at friends’ homes and on school property (44). In
addition, inhalant abuse is correlated with poverty, hunger,
illness, low education levels, unemployment, boredom and
feelings of hopelessness (45). Thus, it is clear that prevention must also address the influence of social factors including the social determinants of health. Intersectoral action
that includes partnerships among community agencies, the
private sector and government is required to disseminate
information and education on inhalant abuse, and develop
policies that address inhalant abuse prevention (40,46).
CONSIDERATIONS FOR ABORIGINAL
CHILDREN AND YOUTH
Several studies (47) have found higher rates of inhalant abuse
in some Aboriginal populations (in particular Inuit and First
Nations communities, but with no studies specific to Métis).
Importantly, however, as with the abuse of other substances,
these higher rates are likely due to socioeconomic status and
not inherent to the populations’ ethnicities (45,48). In some
communities, it has been reported that inhalant abuse is
denied or normalized – although media reporting of abuse
may have skewed views of its prevalence (49). Health disparities, reduced access to services and socioeconomic factors
may contribute to these higher rates. The unique social and
health contexts, as well as the widespread nature of inhalant
abuse in some communities, has led to the development of
culturally specific treatment programs.
The National Youth Solvent Abuse Program (NYSAP),
was founded between Health Canada and First Nation communities to increase youths’ ability to deal with adversity
and access to support through stronger cultural identity
(50). Treatment is long term and residential (creating a safe
place that is separate from the home community), and aims
to involve spiritual components in healing – a critical component of program success. Clients are encouraged to find
and use supports in their communities and schools, and
family participation is required. The success of the program
continues to grow because it establishes proactive outreach
services to prevent inhalant abuse, considers other abused
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CPS Statement: FNIMH 2010-01
substances in its treatment of inhalant abusers, and continues to incorporate research on the outcomes of its treatment and prevention efforts.
CONCLUSION AND RECOMMENDATIONS
The Canadian Paediatric Society is extremely concerned
with the practice of inhalant abuse among children and
adolescents, and believes that more needs to be done to
understand and combat this dangerous practice.
Health professionals must make themselves aware of key
points regarding inhalant abuse, including the following:
• epidemiologyandtrends;
• itssignsandsymptoms,effectsand dangers,andthe
treatment of acute cases;
• screeningtechniques;and
• theavailabilityoflocalresourcesforprevention,
intervention and treatment.
Health professionals must be ambassadors of education,
working with children and youth, parents, schools, teachers,
media and policy-makers, especially regarding the following:
• typesandexamplesofabusedchemicals;
• signsanddangersofinhalantabuse;
• interventionandtreatment:whattodoifsomeone
suspects another is abusing; and
• combatingmisconception:advisethatevencasual
substance abuse is dangerous.
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Health professionals should use their knowledge, experience and community connections to achieve the following:
• playaguidingroleincreatinganetworkofhealthand
community care for inhalant abusers;
• guidepolicyregardinginhalantabuseprevention
education and treatment;
• ensurethatthesocialdeterminantsofhealthaffecting
inhalant abuse are understood and considered in policy;
• advocateforthereplacementofdangerousand
psychoactive substances in common products with less
harmful alternatives; and
• advocateforandcontributetoresearchthatincreasesour
understanding of inhalant abuse – including
epidemiology, and effective prevention and treatment
strategies that address the social determinants of health –
particularly in Aboriginal peoples, with research that is
specific to First Nations, Métis and Inuit populations.
Health services and authorities should ensure access to
effective family-based treatment programs, including longterm residential treatment when required.
ACKNOWLEDGEMENTS: The author thanks Ellison Richmond,
research assistant, who made significant contributions to this
document. The Canadian Paediatric Society also thanks
Dr Michael Rieder, Chair of the Canadian Paediatric Society’s
Drug Therapy and Hazardous Substances Committee, who
reviewed this position statement on behalf of the committee.
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FIRST NATIONS, INUIT AND MÉTIS HEALTH COMMITTEE
Members: Drs William Abelson, Prince George, British Columbia (Board Representative); Anna Banerji, Toronto, Ontario; Lola
Baydala, Edmonton, Alberta; Heidemarie Schröter, Calgary, Alberta; Sam Wong, Edmonton, Alberta (Chair)
Liaisons: Ms Debbie Dedam-Montour (National Indian and Inuit Community Health Representative); Ms Carolyn Harrison (Health
Canada, First Nations and Inuit Health Branch); Ms Kathy Langlois (Health Canada, First Nations and Inuit Health Branch);
Ms Veronica Matthews (Aboriginal Nurses Association of Canada); Ms Heather McCormack (Health Canada, First Nations and
Inuit Health Branch); Dr Kelly Moore (American Academy of Pediatrics, Committee on Native American Child Health); Ms Rena
Morrison (Assembly of First Nations, Health and Social Sector); Ms Anna Claire Ryan (Inuit Tapiriit Kanatami); Ms Barbara van
Haute (Métis National Council)
Consultant: Dr Kent Saylor, Montreal, Quebec
Principal Author: Dr Lola Baydala, Edmonton, Alberta
The recommendations in this statement do not indicate an exclusive course of treatment or procedure to be followed. Variations, taking
into account individual circumstances, may be appropriate. All Canadian Paediatric Society position statements are reviewed, revised or
retired as needed on a regular basis. Please consult the “Position Statements” section of the CPS website (www.cps.ca/english/publications/
statementsindex.htm) for the most current version.
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