4/10/2014 Poorly Controlled Pain and Prescription Drug Abuse

Transcription

4/10/2014
Poorly Controlled Pain and
Prescription Drug Abuse
Mary Lynn McPherson, Pharm.D., BCPS, CPE
Nina Cimino, Pharm.D.
University of Maryland School of Pharmacy
[email protected]
Objectives
• Describe the public health challenges related
to the abuse and diversion of controlled
prescription drugs.
• Design tactics on how pharmacy practice
settings can identify controlled prescription
drug abuse and diversion.
• Explain how pharmacists and pharmacy
technicians can effectively work towards
reducing the abuse and diversion of controlled
prescription drugs.
What is pain?
• “It is so much more than just pain intensity. Over time,
many [patients] find the effects of living with chronic
pain impact their ability to work, engage in
recreational and social activities, and for some,
[perform] the most basic everyday activities that
people just take for granted. Not surprisingly, pain
begins to chip away at their mood, often leaving them
angry, frustrated, anxious, and/or depressed. Our
families suffer along with us, and many relationships
are forever altered.”
…An advocate for people with chronic pain
www.iom.edu; Relieving Pain in American
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IASP Definition of Pain
• “An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage…Pain is always subjective…It is
unquestionably a sensation in a part or parts
of the body, but it is also always unpleasant
and therefore also an emotional experience.”
Why Focus on Chronic Pain Issues?
Disease
Number of Sufferers
Diabetes
25.8 million people
Coronary Heart Disease and Stroke
23.3 million people
Cancer
11.9 million people
TOTAL
61 million people
Disease
Number of Sufferers
Chronic Pain
100 million people
Institute of Medicine Report. 2011; http://www.painmed.org/patient/facts.html#incidence.
The Prevalence of Pain is Staggering
Age Adjusted Rates of U.S. Adults
Reporting Pain in the Last 3 Months
30%
25%
20%
15%
10%
5%
0%
Low Back
Neck
Knee
Headache Shoulder
Finger
Hip
CDC and NCHS. Health. 2011.
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Extent of Pain-related Disability Among
Adults with Pain in the Last 3 Months, 2009
The Disability of Pain is Crippling
45%
40%
35%
Basic Actions
30%
Complex Activities
25%
20%
15%
10%
5%
0%
Low Back
Knee
Headache
Neck
Shoulder
Finger
Hip
CDC and NCHS. Health. 2011.
The Prevalence of Pain is Increasing
Trends in Pain Prevalence, 1999-2004
40%
35%
30%
25%
99-00
20%
01-02
15%
03-04
10%
5%
0%
All > 20 yrs 20-44 yrs 45-64 yrs > 65 yrs
Men
Women
Institute of Medicine Report. 2011.
Pain is a Chronic Problem
Trends in Pain Prevalence, 1999-2004
70%
60%
20
20years
yearsand
andover
over
50%
20-44
20-44years
years
40%
45-64
45-64years
years
30%
65
65years
yearsand
andover
over
20%
10%
0%
3 months to less than 1 year
1 year or more
Institute of Medicine Report. 2011.
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Just the Facts – on Pain
• > 50% hospitalized patients have pain in their last days;
50-75% patients die in moderate to severe pain
• ~ 20% of American adults report pain or physical
discomfort that disrupts their sleep a few nights a week or
more
• Chronic pain patients receiving opioids:
– > 50% state little or no control over pain
– 6/10 experience breakthrough pain
• Impact on quality of life
– Almost 2/3 report an impact on overall enjoyment of life
– Over 70% report depression, trouble concentrating, reduce
energy
– 86% report an inability to sleep well
American Academy of Pain Medicine - http://www.painmed.org/patient/facts.html
Just the Facts – on Pain
• Chronic pain sufferers make major adjustments
– 20% take disability from work
– 17% change jobs altogether
– 13% need help with ADLs
– 13% move to a home easier to manage
– 63% have seen their physician about their pain; 40%
have seen a specialist
– Almost 40% have seen more than one doctor about
pain
American Academy of Pain Medicine - http://www.painmed.org/patient/facts.html
Barriers to Improved Pain Care
• System-level barriers
– Failure to routinely implement strategies to
address the biological-cognitive-emotional aspects
of pain through a comprehensive and
interdisciplinary approach to pain management
• Institutional, educational, organizational,
reimbursement-related
– Clinical services and research endeavors are
performed in silo, disease-specific fashion
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• Clinician-level barriers
– Some pain conditions have no treatment guidelines
– HCP are not well educated in best practices in pain
management
– Difficult for PCPs to identify/engage other clinicians
– Lack of understanding of importance of pain management
– Regulatory/law enforcement policies constrain the
appropriate use of opioids
– Insurance coverage restrictions
– Additional basic and clinical research is needed
• Patient-level barriers
– Pain patients are closely scrutinized; questions and
reservations may cloud the perceptions of clinicians,
family, employers and others
– Some patients will try to scam the system <<<<< legitimate
pain patients
– Cultural beliefs (pain = weakness, “suck it up”)
– Doctor shopping (“didn’t take me seriously,” “didn’t listen,”
“still had too much pain”)
– Disproportionately undertreated pain in children, older
adults, women, rural residents, lower education/income,
certain racial and ethnic groups
Steps in Care
• Self-management
– Possibly in consultation with family/friends
• Primary care
– Rx drugs, exercise, PT, weight loss
• Specialist care
– Specialist in underlying disease, pain specialist
• Pain center
– Interdisciplinary approach may be offered
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Evaluating a Complaint
of Pain
•
•
•
•
•
•
•
•
P – precipitating
P – palliating
P – previous treatment or therapy
Q – quality
R – region and radiation
S – severity
T – temporal
U – you – how does the pain affect you
Management of Pain
• Non-pharmacologic
–
–
–
–
–
PT, OT
Acupuncture
Exercise, stretching
Energy therapy
Cognitive behavior
therapy
• Pharmacologic
– Non-opioids
– Opioids
– Adjuvant analgesics
Acetaminophen
• Acetaminophen – also known as:
– Paracetamol
– APAP (N-acetyl-para-aminophenol)
– Brand names (Tylenol)
• Indication
• Mild to moderate non-inflammatory nociceptive pain
• Role in therapy
• Self-limiting painful conditions such as tension headache,
mild to moderate musculoskeletal pain, dental pain
• Low back pain
• Osteoarthritis
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Acetaminophen
• Mechanism of action – acts centrally
– Analgesic and anti-pyretic
– Lacks anti-inflammatory activity (probably)
• Analgesic effects are in the central nervous
system
– Inhibits COX enzymes in the CNS
– Interactions with nitric oxide containing pathways
– Block substance P action
• Adverse effects
– Very well tolerated
– Hepatotoxicity seen with acute and chronic use
• Alcoholism, supratherapeutic dosing
Smith HS. Pain Physician 2009;12:269-280.
NSAIDs
Nonsteroidal Anti-inflammatory Drugs
•
•
•
•
•
•
•
•
•
•
Aspirin
Salsalate (Disalcid)
Diflunisal (Dolobid)
Choline magnesium
trisalicylate (Trilisate)
Ibuprofen (Motrin, Advil)
Naproxen (Naprosyn, Aleve)
Fenoprofen (Nalfon)
Ketoprofen (Orudis)
Flurbiprofen (Ansaid)
Oxaprozin (Daypro)
•
•
•
•
•
•
•
•
•
•
•
Indomethacin (Indocin)
Tolmetin (Tolectin)
Sulindac (Clinoril)
Diclofenac (Voltaren)
Etodolac (Lodine)
Meclofenamate (Meclomen)
Mefenamic acid (Ponstel)
Piroxicam (Feldene)
Nabumetone (Relafen)
Ketorolac (Toradol)
Celecoxib (Celebrex)
NSAIDs
• Indication:
– To lower a fever
– Treatment of mild to moderate pain that may be
inflammatory in nature
• Role in therapy:
– Acute and chronic pain
– Especially helpful in certain types of somatic pain such
as muscle and joint pain, bone/dental pain,
inflammatory pain, post-operative pain
– Opioid-sparing effect
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Selected NSAID Indications
•
•
•
•
•
•
•
•
Headache
Toothache
Sinus pain
Muscular pains
Bursitis
Tendonitis
Backache
Primary dysmenorrhea
• Pain due to fever, cold,
flu
• Rheumatoid arthritis
• Osteoarthritis
• Ankylosing spondylitis
• Gout
• Acute painful shoulder
• Sprains
Oral, rectal,
parenteral, topical
NSAID Mechanism of Action
• Primary mechanism is to inhibit the enzyme
cyclooxygenase (COX), resulting in blockage of
prostaglandin synthesis. There are two COX isoforms.
• COX-1
– Constitutively expressed in most normal tissues
– Plays a particularly important role in GI tract, kidneys and
platelets
– COX1 produces PG with beneficial effects such as
regulation of blood flow to gastric mucosa and kidneys
– COX-1 causes platelet aggregation via the thromboxane A2
(TXA2) pathway
NSAID Mechanism of Action
• COX-2
– Not usually present, but can be induced in response to
inflammatory stimuli
– Expressed constitutively in renal vasculature
– COX-2 produces prostaglandins that activate and
sensitize nociceptors
– Minimal antiplatelet effects because COX-2 selective
NSAIDs do not affect the TXA2 pathway
– The goal with COX-2 inhibitor therapy is preserving
prostaglandin-mediated gastroprotection (which
occurs through the COX-1 enzyme)
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NSAID Adverse Effects
•
•
•
•
•
•
•
•
Dyspepsia, abdominal pain
GI discomfort, GI bleeding
Clotting problems, bleeding
Cardiovascular complications
Hepatic complications
Impaired renal function
Prolonged pregnancy/labor
Aspirin-exacerbated respiratory disease
Opioids
Phenanthrenes
• Codeine
• Morphine
• Hydromorphone
• Levorphanol
• Hydrocodone
• Oxycodone
• Oxymorphone
• Buprenorphine
• Nalbuphine
• Butorphanol
Benzomorphans
• Pentazocine
Phenylpiperidines
• Fentanyl
• Alfentanil
• Sufenanil
• Meperidine
Diphenylheptanes
• Methadone
• (Propoxyphene)
Atypical Opioids
• Tapentadol, Tramadol
Opioids
• Indications:
– Treatment of moderate to severe pain that does not
respond to non-opioids alone
– Cough, diarrhea, dyspnea, opioid dependence
• Role in therapy:
Acute (trauma, postoperative pain)
Breakthrough pain
Cancer pain
Chronic noncancer pain
Effective in visceral and somatic pain; and (to a lesser
extent) neuropathic pain
– Frequently given with non-opioid therapy (opioid-sparing)
– Management of opioid addiction
–
–
–
–
–
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Opioid Adverse Effects
• Nausea and vomiting
• Constipation
• CNS adverse effects
– Sedation
– Decreased cognition/delirium
•
•
•
•
Respiratory depression
Pruritus
Pupillary constriction
Long-term effects
Opioids and Patient-Related Variables
• Age
• Opioid tolerant/naïve
– History of responsiveness, adverse effects
•
•
•
•
•
•
•
Renal impairment, hepatic impairment
Ethnicity
Body habitus
Ability to manipulate/use dosage formulation
History of substance abuse
Health beliefs
Fever, pregnancy, breast-feeding
P’col Management Neuropathic Pain
• First line recommendations
– Tricyclic antidepressants
– Dual reuptake inhibitors of serotonin and
norepinephrine
– Calcium channel α2-δ ligands
– Topical lidocaine
• Second line recommendations
– Opioid analgesics
– Tramadol
Dworkin RH et al. Mayo Clin Proc March 2010;85 (3) (suppl):S3-S14
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P’col Management Neuropathic Pain
• Third line recommendations
– Other antidepressants and anticonvulsants
– Topical low-concentration capsaicin
– Dextromethorphan, memantine, mexiletine
• Directions for the future
– Cannabinoids
– Botulinum toxin
– High-concentration capsaicin patch
– Lacosamide
– Selective serotonin reuptake inhibitors
– Combination therapies
Dworkin RH et al. Mayo Clin Proc March 2010;85 (3) (suppl):S3-S14
Who’s Still With Me?
• Which of the following is an adverse effect
associated with NSAID therapy?
– A. Increased cardiovascular events/death
– B. Gastrointestinal upset and bleeding
– C. Respiratory depression
– D. A and B are correct
– E. A, B and C are correct
So we’ve got the tools….
What’s the dealio?
http://www.cdc.gov/HomeandRecreationalSafety/pdf/PolicyImpact-PrescriptionPainkillerOD.pdf
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Poorly
controlled
pain
Drug abuse
and
diversion
http://www.cdc.gov/homeandrecreationalsafety/rxbrief/
Where are the prescription painkillers
coming from?
Got drug from dealer or
stranger
Took from friend or
relative without asking
Bought from friend or
relative
Prescribed by one doctor
Obtained free from friend
or relative
Other source
http://oas.samhsa.gov/NSDUH/2k10NSDUH/2k10Results.htm#2.16
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4/10/2014
Manchikanti et al. 2012
Scope of the Problem
• In 1997 opioid sales in the US were equivalent to
96mg morphine equivalents/person;
710mg/person in 2010
• This equates to hydrocodone 5mg Q6H x 45 days
for every adult in the US
• Hydrocodone/acetaminophen was the most
prescribed drug from 2006-2011
• The US has 4.6% of the world’s population but
consumes 83% and 99% of the world supply of
oxycodone and hydrocodone, respectively
Growth of Opioid Sales
Opioid
Growth in Sales 1997-2007
Hydrocodone
280%
Oxycodone
866%
Methadone
1,293%
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Global Use of Hydrocodone
• Britain + France + Germany + Italy
– 3.237 grams
• United Stated
– 27,400,000 grams
Extent of Misuse
• 20% of Americans use opioids for non-medical
purposes
– Non-medical costs $500 billion every year
• 7 million Americans over age 12 report using
prescription psychotherapeutic drugs for nonmedical purposes in the past month
– 5.1 million report using pain relievers nonmedically
Opioids in Chronic Pain Patients
• 5-41% of patients receiving opioids for chronic
non-cancer pain abuse them
• Among patients with chronic pain who are
treated with opioids
– 3.3% develop addiction
– 11.5% show aberrant drug-related behavior or use
of illicit drugs
– 20.4% divert opioids
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• We must provide adequate analgesics to those in pain
• This must be balanced against growing concerns about harm
due to analgesics
– Abuse and addiction
– Serious injury and death
– Due to both prescription and nonprescription medications
NEJM 2009;361:2105-2108
Voluntary Strategies to  Opioid Abuse
• Assessment (history, physical exam) includes
psychosocial factors, family history, risk of abuse
• Monitor aberrant behavior that may indicate abuse
• Random urine drug screening, pill counts, agreements
• State prescription drug monitoring programs
• New abuse-deterrent opioid formulations
• Remove unused drugs through a “drug take-back”
event
• Required strategies - REMS
REMS Components
• Medication Guide or PPI
• Communication Plan
– Communication plan to healthcare providers to
support implementation of this REMS
• Elements to Assure Safe Use
– Training of prescribers, certification of dispensers
– Patients in registry, monitoring parameters
• Implementation System
– To monitor and evaluate implementation of above
http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM188155.pdf
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Pharmacists and REMS
• Providing Medication Guide and reviewing
with patient/caregiver
• Informing prescribers of which opioids have a
REMS in place and what the requirement
elements are
– Elements to assure safe use
– Implementation system
Poll Question
• Which of the following statements is CORRECT
regarding REMS?
– A. Every opioid on the market has a mandatory REMS
strategy
– B. REMS strategies may include a medication guide,
elements to assure safe use, implementation system and
communication plan
– C. Patients must take a knowledge test before receiving a
prescribed opioid
– D. Answers A, B and C are correct
Education Challenges
• Improving care for people with acute or chronic pain
requires broad improvements in education
regarding:
– The multiple causes and effects of pain
– The range of treatments available to help people obtain
relief, and
– The need to consider chronic pain as a biopsychosocial
disorder
• Educational efforts should be directed to:
– People with pain
– General public
– Health professionals
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Patient Education
•
•
•
•
•
•
•
•
•
•
•
•
Steps people can take on their to prevent or obtain relief
Differences between pain that is protective and not protective
Reasons why the need for pain relief is important
When and how emergency or urgent care should be sought
Treatment-related pains, major categories of pain therapies, and
advantages and disadvantages of each
Different types of HCP who may be able to help and how
Treatments health insurers may or may not reimburse
Ways in which others can help prevent pain from progressing
How pain is measured including different assessment scales
Pain is a complex mind-body interaction
The right to pain care, including access to medications
Self-management techniques
Educating Patients
•
•
•
•
American Chronic Pain Association
American Pain Foundation
American Pain Society
PainKnowledge.org
• American Society of Pain Educators
• Become a Certified Pain Educator (CPE)!
– www.paineducators.org
8 Prescribing Guidelines
• Assess patients at risk of abuse before
opioid therapy and manage accordingly.
– Opioid Risk Tool (ORT) – Dr. Lynn Webster
•
•
•
•
•
Family history of substance abuse
Personal history of substance abuse
Age
History of preadolescent sexual abuse
Psychological disease
– Screener and Opioid Assessment for Patients
with Pain (SOAPP)
http://www.zerodeaths.org/
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Patterns Suggestive of Habituation
• Adverse consequences/harm due to use
– Intoxicated/somnolent/sedated; declining activity
– Irritable/anxious/labile mood
– Increasing sleep disturbance, pain complaints, relationship dysfunction
• Impaired control over use / compulsive use
–
–
–
–
Reports lost or stolen prescriptions or medications
Frequent early renewal requests; urgent calls or unscheduled visits
Abusing other drugs or alcohol; cannot produce medications on request
Withdrawal noted at clinic visits; observers report over- or sporadic use
• Preoccupation with use due to craving
– Frequently misses appointment unless opioid renewal expected
– Does not try nonopioid treatments; cannot tolerate most medications
– Requests medications with high reward; only opioids relieve pain
Clin J Pain 2002;18:S28-S38
• Watch for and treat co-morbid mental
disease when it occurs
• Use conventional conversion tables
cautiously when rotating (switching) from
one opioid to another
• Avoid combining benzodiazepines with
opioids, especially during sleep hours
• Methadone should be started at a very
low dose and titrated slowly regardless of
whether the patient is opioid tolerant or
not
• Assess for sleep apnea in patients on high
daily doses of methadone or other opioids
and in patients with a predisposition
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• Tell patients on long-term opioid therapy
to reduce opioid dose during upper
respiratory infections or asthmatic
episodes
• Avoid using long-acting opioid
formulations for acute post-operative or
trauma-related pain
http://www.azcjc.gov/ACJC.Web/Rx/AZ%20Dispensing%20Guidelines%20(Printable).pdf
Arizona Guidelines
1. Use prescription drug monitoring program
before dispensing
2. Use clinical judgment regarding contacting
prescriber
3. Use clinical judgment regarding contacting other
pharmacies
4. Require government-issued ID for all new or
unknown patients
5. Do not fill suspect prescriptions
6. Educate patients about proper storage and
disposal of controlled substances
http://www.azcjc.gov/ACJC.Web/Rx/AZ%20Dispensing%20Guidelines%20(Printable).pdf
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Symptom Analysis
•
•
•
•
•
•
•
•
Precipitating
Palliating
Previous treatment
Quality
Region/radiation
Severity
Temporal
Associated Symptoms
Is an opioid even REALLY the right
analgesic for this pain?
• Probably
– Chronic somatic or neuropathic pain
• Musculoskeletal pain
• Peripheral neuropathy
• Postherpetic neuralgia
• Probably not
– Chronic visceral or central pain syndromes
• Abdominal or pelvic pain
• Fibromyalgia
• Headache
Pharmacist – Last Line of Defense
• Monitor prescriptions for falsification or
alteration
– Legitimate prescription pads could be stolen from
physician’s office and Rx’s written for fictitious
patients
– Patient may alter physician’s prescription
– Patient may “call in” their own prescription
– Watch “doctor-shoppers”
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Pharmacist – Last Line of Defense
• Monitor prescriptions for falsification or
alteration (be suspicious of…)
– More prescriptions or larger quantities than
normal
– Patient returns to pharmacy too frequently
– Prescriptions for antagonistic drugs (depressants
and stimulants)
– New customers show up with series of
prescriptions from same physician
Monitoring Patient Response – 4A’s
• Analgesic
– What was your pain level on average during the past
week?
– What was your pain level at its worst during the past
week?
– What percentage of your pain has been relieved
during the past week?
– Is the amount of pain relief you are now obtaining
from your current pain reliever(s) enough to make a
real difference in your life?
• Query to clinician: is the patient’s pain relief
clinically significant?
Pain Assessment and Documentation Tool (PADT), as described in: Chou R, et al. Opioid Treatment
Guidelines: Clinical guidelines for the Use of chronic opioid therapy in chronic noncancer pain. The
Journal of Pain, Vol 10, No 2 (February), 2009: pp 113-130
• Activities of Daily Living (better, same, worse)
– Physical functioning
– Family relationships
– Social relationships
– Mood
– Sleep patterns
– Overall functioning
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• Adverse Effects (none, mild, moderate, severe)
– Nausea, vomiting, constipation
– Itching, mental cloudiness, sweating
– Fatigue, drowsiness, other
• Patient’s overall severity of side effects (none,
mild, moderate, severe)?
• (Potential) Aberrant Drug-Related Behavior
– Purposeful oversedation
– Negative mood changes
– Appears intoxicated
– Increasingly unkempt or impaired
– Involvement in car or other accident
– Requests frequent early renewals
– Increased dose without authorization
– Reports lost or stolen prescriptions
• (Potential) Aberrant Drug-Related Behavior
– Attempts to get prescriptions from other doctors
– Changes route of administration
– Uses pain medication in response to situational
stressor
– Insists on certain medications by name
– Contact with street drug culture
– Abusing alcohol or illicit drugs
– Hoard (i.e., stockpiling) of medications
– Arrested by police
– Victim of abuse, other
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Other Strategies
Urine Drug Testing and Opioid Agreements
• Analysis of a urine specimen to detect the
presence of, or absence of a drug and/or the
metabolites of a drug
• Consider metabolic pathway
– Oxycodone → oxymorphone
– Codeine and heroin → morphine
– Hydrocodone → dihydrocodeine
• Opioid Treatment Agreements
Magnani B, Kwong T. Clin Lab Med 32(2012):379-390.
Reality Check! 
• Which of the following statements is CORRECT
regarding opioid prescribing guidelines?
– A. There are validated instruments available to
screen patients for potential abuse
– B. Most prescription analgesics used in an
unintended fashion were obtained freely from a
friend or relative
– C. Benzodiazepines plus opioid therapy increases
the risk of adverse events
– D. A and B are correct
– E. A, B and C are correct
Six Steps to Zero – Patient Counseling
• Never take a prescription painkiller unless it is
prescribed to you
• Do not take pain medicine with alcohol
• Do not take more doses then prescribed
• Use of other sedatives or anti-anxiety medications
can be dangerous
• Avoid using prescription painkillers to facilitate sleep
• Lock up prescription painkillers
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Public Education – Why?
• Educated people can take steps to avoid pain
• Educated people can give appropriate advice and assistance
to friends, family, colleagues
• Advocate for and accept appropriate treatment of acute and
chronic pain personally or for family or friends
• An educated public can act at the community level to
minimize hazards that contribute to pain-producing injuries
among students and in the general community
• Educated citizens can advocate for improved pain prevention
and control policy measures
Pharmacist Pain Educators
• Public education is a normal public health activity
• “Inform, educate and empower people about public
health issues” is one of the Ten Essential Public Health
Services that every public health agency is expected to
provide
• Public education enhances the effects of all major
influences on disease control:
– Policy, community-wide environmental control
measures, community awareness support and action,
work and school support, clinical expertise, family
involvement and patient self-management
Health Care Provider Education
•
•
•
•
•
•
•
•
Physicians
Nurses
Psychology
Pharmacy
Dentistry
Physical Therapy
Occupational Therapy
Others
http://extracredit1020.wordpress.com/authors/rezwana-2/becoming-a-pharmacist/
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4/10/2014
Pharmacists
• Assessment of pain
complaint
• Over-the counter analgesic
selection and counseling
• REMS and other abuse
reduction strategies
• Educating
– Patients
– The public
– Healthcare providers
• CERTIFIED PAIN EDUCATOR!
Maryland Board of Pharmacy
Annual Continuing Education Breakfast
“Prescription Drug Monitoring In Maryland”
The Role of Opioid therapy in the Management of
Chronic Non-Cancer Pain
Mary Lynn McPherson, Pharm.D., BCPS, CPE
Nina Cimino, Pharm.D.
University of Maryland School of Pharmacy
[email protected]
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4/10/2014 Poorly Controlled Pain and Prescription Drug Abuse

Transcription

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