Endocannabinoids vs Cannabinoids Unveiling the Internal & External Worlds

Endocannabinoids vs cannabinoids, a fascinating realm where the body’s own internal chemistry meets the power of the plant kingdom. Imagine a bustling city within you, constantly managing traffic, keeping things in balance, and ensuring everything runs smoothly. This internal city is powered by a network of messengers and receivers, a system so intricate it’s almost poetic. These messengers, the endocannabinoids, are the city’s own currency, crafted within to maintain order.

Then, along come the cannabinoids, the external players, like guests from a faraway land, carrying their own unique properties and impacting the city in ways both subtle and profound.

We’ll embark on an exploration that dives deep into the origins of these compounds, the intricate pathways they travel, and the remarkable ways they interact with the body’s master control system, the endocannabinoid system (ECS). We’ll journey through the biology of how these molecules are made and broken down, how they activate receptors, and the effects they produce, comparing the natural, homegrown versions with their plant-derived counterparts.

Prepare to uncover the secrets of how these two forces interact, and the potential they hold for well-being and understanding the complexities of the human experience. Let’s get started!

How do naturally produced endocannabinoids differ from externally derived cannabinoids in their origin and function?

The Cannabinoids Within – Boojum Group

It’s time to delve into the fascinating world of cannabinoids, but with a twist! We’re not just talking about the stuff you might have heard of; we’re also going to explore the body’s own, homegrown versions. Prepare to journey through the inner workings of our biology, comparing and contrasting the origins and effects of these amazing compounds. Buckle up, it’s going to be a fun ride!

Biological Origins of Endocannabinoids vs. Cannabis-Derived Cannabinoids

The story of cannabinoids begins within our own bodies, in a process as intricate as a finely tuned Swiss watch. Endocannabinoids, the body’s natural version, are synthesized on demand, unlike their plant-derived cousins.Endocannabinoids are synthesized from fatty acid precursors, primarily arachidonic acid (AA), a component of cell membranes. Two key enzymes play starring roles:

  • N-acyl phosphatidylethanolamine-phospholipase D (NAPE-PLD): This enzyme converts N-acyl phosphatidylethanolamine (NAPE) into anandamide (AEA), one of the most well-studied endocannabinoids. Think of it as the AEA factory.
  • Diacylglycerol lipase (DAGL): This enzyme converts diacylglycerol (DAG) into 2-arachidonoylglycerol (2-AG), another important endocannabinoid. DAGL is essentially the 2-AG production line.

These enzymes are activated by various stimuli, such as stress, injury, or even just the simple act of eating. The precursors themselves are already present within our cells, ready to be converted when needed. It’s a “just-in-time” production system.In stark contrast, cannabinoids derived from the cannabis plant, known as phytocannabinoids, originate in specialized structures called trichomes. These tiny, resin-producing glands are found on the flowers and leaves of the cannabis plant.

The most well-known phytocannabinoids are:

  • Tetrahydrocannabinol (THC): This is the psychoactive component, responsible for the “high” associated with cannabis use.
  • Cannabidiol (CBD): This is a non-psychoactive compound that has gained popularity for its potential therapeutic effects.

Phytocannabinoids are synthesized through a complex biochemical pathway within the plant. The precursor to THC and CBD is cannabigerolic acid (CBGA), often referred to as the “mother of all cannabinoids.” Through enzymatic reactions, CBGA is converted into other cannabinoids, depending on the specific enzymes present in the plant. The plant’s genetics and environmental factors influence the cannabinoid profile, determining the relative amounts of THC, CBD, and other compounds.

What specific metabolic pathways govern the breakdown of endocannabinoids versus the metabolism of externally introduced cannabinoids?: Endocannabinoids Vs Cannabinoids

Endocannabinoids vs cannabinoids

The body’s handling of cannabinoids, both those it produces internally (endocannabinoids) and those it encounters from external sources (like cannabis), is a fascinating dance of enzymes and pathways. Understanding these metabolic processes is crucial because they determine how long cannabinoids exert their effects and how potent they are. It’s a delicate balance that significantly influences the therapeutic potential and potential side effects of these compounds.

Enzymatic Degradation of Endocannabinoids

Our internal cannabinoid system is remarkably efficient at regulating itself. When endocannabinoids, like anandamide (AEA) and 2-arachidonoylglycerol (2-AG), are released, they don’t stick around forever. They’re quickly broken down by specific enzymes, ensuring a precise and controlled signaling process.The primary players in this degradation process are:* Fatty Acid Amide Hydrolase (FAAH): FAAH is like the cleanup crew for AEA. It’s the main enzyme responsible for breaking down AEA, effectively shutting down its signaling activity.

Think of it as a molecular Pac-Man, gobbling up AEA molecules.

Monoacylglycerol Lipase (MAGL)

MAGL takes care of 2-AG. It’s the key enzyme responsible for breaking down 2-AG, the other major endocannabinoid. Without MAGL, 2-AG levels would build up, potentially leading to overstimulation of cannabinoid receptors.These enzymes work tirelessly to maintain a balanced endocannabinoid system. The efficiency of FAAH and MAGL, along with their activity levels, directly influences how long an endocannabinoid signal lasts.

For instance, inhibiting FAAH can increase AEA levels and prolong its effects. This is a strategy that has been explored for potential therapeutic benefits.

Metabolism of Externally Derived Cannabinoids in the Liver

When you ingest or inhale cannabinoids from sources like cannabis, your body treats them differently than the endocannabinoids it produces. The liver, acting as a major detoxification center, plays a crucial role in processing these external cannabinoids. This process, known as first-pass metabolism, significantly impacts the bioavailability and duration of effects.The key enzymes involved in this process are the cytochrome P450 (CYP450) enzymes.

These are a large and diverse group of enzymes responsible for metabolizing a wide range of compounds, including drugs, toxins, and cannabinoids. The most important CYP450 enzymes involved in cannabinoid metabolism are:* CYP2C9: This enzyme is a major player in the metabolism of THC (tetrahydrocannabinol), the primary psychoactive component of cannabis.

CYP3A4

This enzyme also contributes to the metabolism of THC and other cannabinoids.These enzymes transform cannabinoids into various metabolites. For example, THC is converted into 11-hydroxy-THC, which is also psychoactive, and then further metabolized into 11-nor-9-carboxy-THC (THC-COOH), which is inactive. The metabolic products and their effects vary depending on the specific cannabinoid and the individual’s metabolism.The liver’s metabolism of cannabinoids can significantly reduce their bioavailability.

This means that a large portion of the ingested cannabinoids are broken down before they reach the bloodstream, reducing the intensity of the effects. The route of administration can also influence the first-pass effect. For example, when cannabinoids are smoked or vaporized, they bypass the liver to a certain extent, leading to faster and more potent effects compared to oral consumption.

Factors Influencing Cannabinoid Metabolism

The way our bodies process both endocannabinoids and externally derived cannabinoids is not a one-size-fits-all process. Several factors can influence the rate and efficiency of these metabolic pathways, leading to variations in the duration and intensity of cannabinoid effects.Here’s a breakdown of the key factors:* Individual Differences:

Genetics

Genetic variations in the genes that encode for FAAH, MAGL, and CYP450 enzymes can significantly impact metabolic rates. Some individuals may metabolize cannabinoids more quickly or slowly than others.

Age

Metabolic rates tend to slow down with age, potentially affecting how long cannabinoids remain active in the body.

Sex

Differences in hormone levels and body composition can influence cannabinoid metabolism between men and women.* Dosage:

Amount Consumed

Higher doses of cannabinoids generally lead to a greater burden on the metabolic pathways, potentially prolonging the duration of effects.

Frequency of Use

Regular cannabinoid use can sometimes lead to changes in enzyme activity, either increasing or decreasing the rate of metabolism.* Route of Administration:

Inhalation (Smoking/Vaporizing)

Bypasses the liver to a large extent, leading to faster absorption and a quicker onset of effects. The duration of effects tends to be shorter compared to oral consumption.

Oral Consumption (Edibles)

Undergoes significant first-pass metabolism in the liver, leading to lower bioavailability but potentially longer-lasting effects.

Sublingual (Under the Tongue)

Bypasses the liver to some extent, offering faster absorption than oral consumption.

Topical (Creams/Lotions)

Limited systemic absorption; effects are usually localized to the application area.* Other Factors:

Drug Interactions

Other drugs or substances that are also metabolized by CYP450 enzymes can potentially interact with cannabinoid metabolism, altering their effects.

Liver Health

Individuals with liver conditions may have impaired cannabinoid metabolism, potentially leading to increased or prolonged effects.

Diet and Lifestyle

Factors such as diet, exercise, and overall health can also play a role in cannabinoid metabolism.Understanding these factors is crucial for predicting how an individual will respond to cannabinoids and for optimizing their therapeutic use. For instance, knowing someone’s genetic predisposition or their medication regimen can help tailor the dosage and administration method to achieve the desired effects while minimizing potential side effects.

In what ways do endocannabinoids and cannabinoids interact with the endocannabinoid system, and what are the variations in their interactions?

Endocannabinoids vs cannabinoids

The endocannabinoid system (ECS) is a complex network of receptors, endocannabinoids, and enzymes that plays a crucial role in maintaining homeostasis within the body. Both naturally produced endocannabinoids and externally derived cannabinoids, like those found in the cannabis plant, interact with this system, but their mechanisms of action and resulting effects differ significantly. Understanding these variations is key to appreciating the ECS’s multifaceted role in health and disease.

Activation of Cannabinoid Receptors by Endocannabinoids

Endocannabinoids, such as anandamide (AEA) and 2-arachidonoylglycerol (2-AG), are the body’s natural ligands for cannabinoid receptors, primarily CB1 and CB2. Their interaction with these receptors initiates a cascade of intracellular signaling events that influence cellular function.The process of endocannabinoid activation can be summarized as follows:* Synthesis: Endocannabinoids are synthesized “on demand” from precursor molecules within cell membranes.

For example, AEA is derived from the phospholipid precursor N-arachidonoyl phosphatidylethanolamine (NAPE), while 2-AG is produced from diacylglycerol (DAG).

Release

Upon stimulation, these endocannabinoids are released from the cell and diffuse across the synapse.

Receptor Binding

Both AEA and 2-AG bind to CB1 and CB2 receptors. The affinity of each endocannabinoid for these receptors varies; for example, 2-AG generally has a higher concentration in the brain than AEA and may play a more prominent role in CB1 receptor activation.

Signal Transduction

Upon binding, these receptors, which are G protein-coupled receptors (GPCRs), initiate a signaling cascade. Activation of CB1 receptors, predominantly found in the central nervous system, often leads to the inhibition of neurotransmitter release (e.g., glutamate, GABA) by reducing calcium influx and increasing potassium efflux in presynaptic neurons. This can modulate processes such as pain perception, memory, and motor control.

CB2 receptors, more prevalent in immune cells, can trigger anti-inflammatory effects and modulate immune responses. Activation of CB2 receptors typically results in the suppression of pro-inflammatory cytokines.

Cellular Effects

The downstream effects of receptor activation are diverse, depending on the cell type and the specific signaling pathways involved. This may include changes in gene expression, modulation of ion channels, and alteration of cellular metabolism. For example, consider the scenario of chronic pain. When an injury occurs, the body releases endocannabinoids like AEA and 2-AG to help manage the pain.

These endocannabinoids bind to CB1 receptors in the brain, reducing the perception of pain. Simultaneously, they activate CB2 receptors on immune cells in the affected area, reducing inflammation and promoting healing.

The specific signaling pathways triggered by endocannabinoid-receptor interactions are complex and can vary depending on the specific receptor, the cell type, and the context.

Interactions of Phytocannabinoids with the Endocannabinoid System

Phytocannabinoids, such as THC and CBD, interact with the ECS in various ways, often differing significantly from the actions of endocannabinoids.Here’s a breakdown of how phytocannabinoids interact:* Direct Receptor Binding: THC primarily binds to CB1 and CB2 receptors, acting as a partial agonist. This means it activates the receptors, but not as strongly as the endogenous ligands like AEA and 2-AG.

This direct interaction is the primary mechanism behind THC’s psychoactive effects, as it mimics the action of the body’s own endocannabinoids, but to a greater degree, particularly in the brain. CBD, on the other hand, has a very low affinity for CB1 and CB2 receptors. Its effects are not primarily due to direct binding.

Modulation of Receptor Activity

CBD acts as an allosteric modulator. It can bind to other sites on the CB1 and CB2 receptors and can alter the shape of the receptors, which indirectly affects their interaction with other ligands, including THC and endocannabinoids. This can result in both increased or decreased activation. CBD is also known to influence other receptors, like serotonin receptors.

Indirect Effects on Endocannabinoid Levels

Both THC and CBD can influence the levels of endocannabinoids in the body, although through different mechanisms.

CBD inhibits the enzyme fatty acid amide hydrolase (FAAH), which breaks down AEA. By inhibiting FAAH, CBD can increase the levels of AEA in the brain, potentially contributing to its therapeutic effects, such as reducing anxiety and pain. THC does not directly affect FAAH activity, but it can influence the levels of endocannabinoids through its effects on the receptor signaling pathways.

For instance, the activation of CB1 receptors by THC can indirectly influence the synthesis and release of endocannabinoids. For instance, a person with anxiety might experience a reduction in symptoms when using CBD. This is likely due to CBD’s ability to enhance AEA levels in the brain, which then activates CB1 receptors, promoting a sense of calm.

Conversely, THC, by directly activating CB1 receptors, can cause anxiety in some individuals, while in others it can reduce anxiety.

Differences in the Effects of Various Cannabinoids

The diverse effects of cannabinoids, especially the contrasting experiences of THC and CBD, are a direct consequence of their varying interactions with the ECS.The differences in effects are rooted in:* Psychoactive Effects of THC: THC’s ability to bind directly to CB1 receptors in the brain is the primary driver of its psychoactive effects. This includes altered perception, mood changes, and cognitive impairments.

The degree of these effects varies depending on the dose, the individual’s sensitivity, and the presence of other cannabinoids.

Non-Psychoactive Effects of CBD

CBD does not produce the same psychoactive effects as THC. Its interaction with the ECS is more complex, primarily involving indirect modulation of the system. This difference in action is the key to understanding CBD’s popularity.

Relating Effects to ECS Interaction

THC‘s direct CB1 receptor activation can result in a range of effects, including pain relief, appetite stimulation, and anxiety.

CBD, on the other hand, exerts its effects through multiple pathways, including the indirect modulation of the ECS. Its potential benefits include anti-inflammatory properties, pain relief, and anti-anxiety effects. The entourage effect, the synergistic interactions between different cannabinoids and other compounds in the cannabis plant, further complicates the picture. For example, the presence of CBD can reduce some of the psychoactive effects of THC, making the overall experience more manageable for some individuals.

A patient experiencing chronic pain might find relief with a THC-dominant product. This is because THC directly activates the CB1 and CB2 receptors, reducing pain signals. Another patient might opt for a CBD-dominant product, especially if they are concerned about the psychoactive effects. CBD indirectly modulates the ECS, providing pain relief without the same level of psychoactive effects.

Can you describe the therapeutic potential of targeting the endocannabinoid system with externally derived cannabinoids and the use of endocannabinoid-based treatments?

The endocannabinoid system (ECS) presents a fascinating target for therapeutic interventions. By understanding how cannabinoids, both those produced naturally within the body and those derived from external sources, interact with the ECS, we can unlock potential treatments for a wide range of conditions. This involves exploring the therapeutic applications of cannabinoids, addressing the concept of endocannabinoid deficiency, and examining various strategies to modulate the ECS for clinical benefit.

Therapeutic Applications of Cannabinoids

Cannabinoids, particularly those derived from the cannabis plant, have demonstrated promising therapeutic potential in several areas. Research and clinical trials continue to explore and expand upon these applications, with the scientific evidence base steadily growing.

  • Chronic Pain Management: Cannabinoids have shown efficacy in alleviating chronic pain conditions. They interact with the ECS receptors, particularly CB1 and CB2, to reduce pain signaling. This is especially relevant for neuropathic pain, inflammatory pain, and pain associated with conditions like cancer.
  • Epilepsy Treatment: Certain cannabinoids, such as cannabidiol (CBD), have demonstrated efficacy in reducing seizure frequency in some forms of epilepsy, particularly in children with treatment-resistant conditions like Dravet syndrome and Lennox-Gastaut syndrome. CBD’s mechanism of action in epilepsy is multifaceted, involving interactions with the ECS and other neurological pathways.
  • Multiple Sclerosis (MS) Symptom Management: Cannabinoids have been shown to help manage symptoms associated with multiple sclerosis, such as spasticity, pain, and bladder dysfunction. By modulating the ECS, cannabinoids can alleviate these symptoms and improve the quality of life for individuals with MS.
  • Nausea and Vomiting: Cannabinoids, particularly those with antiemetic properties, have proven useful in reducing nausea and vomiting, especially in patients undergoing chemotherapy. These compounds can interact with the ECS to reduce the sensation of nausea and prevent vomiting.
  • Appetite Stimulation: Cannabinoids can stimulate appetite, making them beneficial for patients experiencing appetite loss due to conditions like HIV/AIDS or cancer. They can interact with the ECS to increase food intake.

Endocannabinoid Deficiency and Modulation of the Endocannabinoid System

The concept of endocannabinoid deficiency proposes that certain conditions may arise, or be exacerbated, due to an underactive ECS. This could be caused by reduced production of endocannabinoids, impaired receptor function, or accelerated breakdown of endocannabinoids. Modulating the ECS, either through external cannabinoids or other means, presents a potential therapeutic strategy.

  • External Cannabinoids: Introducing cannabinoids from external sources, such as cannabis-derived products, can supplement the ECS and provide therapeutic effects. The specific cannabinoid and dosage depend on the condition being treated and individual patient factors.
  • Inhibiting Endocannabinoid Breakdown: Inhibiting the enzymes that break down endocannabinoids, such as FAAH (fatty acid amide hydrolase) and MAGL (monoacylglycerol lipase), can increase the levels of endocannabinoids in the body. This approach could enhance ECS signaling and provide therapeutic benefits.
  • Other Modulation Methods: Beyond cannabinoid administration and enzyme inhibition, other methods to modulate the ECS are being explored, including the use of receptor agonists and antagonists, and substances that influence the production or release of endocannabinoids.

Clinical Trial and Study Examples

Numerous clinical trials and studies have investigated the therapeutic potential of cannabinoids and endocannabinoid-based treatments. Here are some examples:

Study Design: A randomized, double-blind, placebo-controlled trial. Patient Population: Patients with treatment-resistant epilepsy, specifically those with Dravet syndrome. Outcomes: The study found that treatment with CBD significantly reduced the frequency of seizures compared to the placebo group. This led to the FDA approval of CBD-based medications for this condition.

Study Design: A double-blind, randomized, placebo-controlled trial. Patient Population: Patients with chronic neuropathic pain. Outcomes: The study demonstrated that treatment with a cannabinoid medication significantly reduced pain scores compared to the placebo group, with improved sleep quality and functional abilities reported.

Study Design: A randomized, double-blind, placebo-controlled trial. Patient Population: Patients with multiple sclerosis experiencing spasticity. Outcomes: The study showed that an oral cannabinoid spray significantly reduced spasticity and improved mobility compared to the placebo group.

Study Design: A randomized, double-blind, placebo-controlled trial. Patient Population: Patients undergoing chemotherapy who experienced nausea and vomiting. Outcomes: The study found that a cannabinoid medication was effective in reducing nausea and vomiting compared to a placebo or standard antiemetic treatments, improving the quality of life during chemotherapy.

Study Design: A randomized, double-blind, placebo-controlled trial. Patient Population: Patients with HIV/AIDS experiencing appetite loss. Outcomes: The study showed that a cannabinoid medication increased appetite and promoted weight gain in patients compared to the placebo group, improving nutritional status and overall well-being.

What are the key differences in the pharmacological profiles of endocannabinoids and cannabinoids, focusing on their specific effects on the body?

Let’s delve into the fascinating world of how our bodies react differently to internally produced endocannabinoids and externally introduced cannabinoids. Understanding these distinctions is key to appreciating the complexities of the endocannabinoid system and its impact on our well-being. We’ll explore the nuances of their effects, duration, and intensity, providing insights into why a natural “high” differs from the one experienced with cannabis.

Duration of Action and Intensity of Effects

The duration and intensity of effects from endocannabinoids and cannabinoids differ significantly, largely due to variations in their metabolic pathways, receptor affinity, and distribution within the body. Endocannabinoids, produced on demand, are typically short-lived and exert localized effects. Cannabinoids, on the other hand, can have more prolonged and systemic effects.Here’s a breakdown of the factors influencing these differences:

  • Metabolism: Endocannabinoids are rapidly broken down by enzymes like fatty acid amide hydrolase (FAAH) and monoacylglycerol lipase (MAGL). This rapid degradation limits their duration of action. In contrast, exogenous cannabinoids, like THC, have varying metabolic rates, influenced by factors such as liver function and the presence of other substances. Some cannabinoids, particularly those consumed orally, may undergo first-pass metabolism in the liver, which can reduce their bioavailability and alter their effects.

  • Receptor Affinity: The affinity of a substance for cannabinoid receptors (CB1 and CB2) plays a crucial role. Endocannabinoids, such as anandamide and 2-AG, have varying affinities. Exogenous cannabinoids, like THC, often have a higher affinity for CB1 receptors, leading to more potent psychoactive effects.
  • Distribution: The distribution of a substance throughout the body influences its impact. Endocannabinoids are produced and act locally, limiting their systemic reach. Cannabinoids, particularly those administered through inhalation or ingestion, can be distributed more broadly via the bloodstream, affecting various tissues and organs.

Distinct Pharmacological Effects of THC and CBD, Endocannabinoids vs cannabinoids

Different cannabinoids produce unique pharmacological effects, impacting mood, cognition, and physical sensations in distinct ways. The primary psychoactive compound in cannabis, THC, is responsible for the “high” associated with the drug, while CBD, a non-psychoactive compound, offers a range of potential therapeutic benefits.Let’s look at their key differences:

  • THC (Tetrahydrocannabinol): THC primarily activates CB1 receptors in the brain, leading to psychoactive effects.
    • Mood: THC can induce euphoria, relaxation, and altered perception. However, it can also trigger anxiety, paranoia, and dysphoria in some individuals.
    • Cognition: THC can impair short-term memory, coordination, and cognitive functions. It can also enhance sensory experiences.
    • Physical Sensations: THC can cause increased heart rate, dry mouth, red eyes, and altered appetite.
  • CBD (Cannabidiol): CBD interacts with the endocannabinoid system indirectly and has minimal psychoactive effects.
    • Mood: CBD may reduce anxiety and improve mood by interacting with serotonin receptors.
    • Cognition: CBD may enhance cognitive function, including focus and memory, and can mitigate the cognitive impairments caused by THC.
    • Physical Sensations: CBD may have anti-inflammatory and analgesic effects, potentially reducing pain and inflammation. It can also help with nausea and promote relaxation without the intoxicating effects of THC.

For instance, consider two individuals: one taking a THC-dominant product and the other a CBD-dominant one. The first might experience a strong sense of euphoria, altered time perception, and increased appetite (the “munchies”). The second, however, might feel a sense of calm, a reduction in pain or anxiety, and possibly improved focus, without the intense psychoactive effects.

Impact of Cannabinoid Ratios and Dosages

The overall effects experienced are significantly influenced by cannabinoid ratios and dosages. These factors affect both the therapeutic potential and the likelihood of side effects.Here’s how these elements interplay:

  • Cannabinoid Ratios: The ratio of THC to CBD in a cannabis product greatly influences its effects.
    • High-THC, Low-CBD: Products with a high THC content are more likely to induce psychoactive effects and may be associated with increased anxiety or paranoia in some users.
    • Balanced THC/CBD: Products with a balanced ratio can provide a combination of benefits, such as pain relief and reduced anxiety, with a milder psychoactive experience. The CBD can help mitigate some of the adverse effects of THC.
    • High-CBD, Low-THC: Products with a high CBD content are less likely to produce psychoactive effects and are often used for their potential therapeutic benefits, such as reducing anxiety, inflammation, and seizures.
  • Dosage: The amount of cannabinoids consumed has a direct impact on the intensity and duration of effects.
    • Low Dose: Low doses may produce subtle effects, such as mild relaxation or pain relief, with fewer side effects.
    • Moderate Dose: Moderate doses can produce more noticeable effects, including altered perception, increased appetite, and potential therapeutic benefits.
    • High Dose: High doses can lead to more intense psychoactive effects, including anxiety, paranoia, and impaired cognitive function. They may also increase the risk of adverse side effects.

Consider a person with chronic pain. A low dose of a balanced THC/CBD product might provide mild pain relief and relaxation without significant cognitive impairment. A higher dose of the same product might offer more potent pain relief but could also cause some level of intoxication. In contrast, a person with anxiety might benefit from a high-CBD, low-THC product, which could reduce anxiety without the psychoactive effects that could worsen their condition.

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