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Cultural Issues in Substance Abuse Treatment

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Title: Cultural Issues in Substance Abuse Treatment


1
Cultural Issues in Substance Abuse Treatment
  • Russell F. Lim, MD
  • Associate Clinical Professor
  • UC Davis School of Medicine
  • Department of Psychiatry
  • Behavioral Sciences
  • rflim_at_ucdavis.edu

38th Semi-Annual Substance Abuse Research
Consortium (SARC) Meeting, Sacramento, CA,
September 23, 2008
2
Agenda-1
  • APA Practice Guidelines for the
  • Treatment of Patients with Substance Use
    Disorders, 2nd ed., 2006
  • Psychiatric Evaluation of Adults, 2nd ed., 2006
  • Substance abuse in special populations
  • The DSM-IV-TR Outline for Cultural Formulation
  • Ethnocultural Factors in Substance Abuse
    Treatment, Straussner, 2001

3
Agenda-2
  • TIP 40- Clinical Guidelines for the Use of
    Buprenorphine in the Treatment of Opioid
    Addiction, 2004
  • TIP 42- Substance Abuse Treatment for Persons
    With Co-Occurring Disorders (COD), 2005
  • TIP 47- Substance Abuse Clinical Issues in
    Intensive Outpatient Treatment, 2006

4
General Assessment Principles Clinical Factors-1
  • The number and type of substances used
  • The individual's genetic vulnerability for
    developing a substance use disorder (s)
  • The severity of the disorder, the rapidity with
    which it develops, and the degree of associated
    functional impairment (s)
  • The individual's awareness of the disorder as a
    problem

5
General Assessment Principles Clinical Factors-2
  • The individual's readiness for change and
    motivation to enter into treatment for the
    purpose of change
  • The associated general medical and psychiatric
    conditions (either co-occurring or induced by
    substance use)
  • The individual's strengths (protective and
    resiliency factors) and vulnerabilities
  • The social, environmental, and cultural context
    in which the individual lives
  • and will be treated

6
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7
Characteristics of Substance Abuse Disorders in
Women-1
  • Information on the natural history, clinical
    presentation, physiology, and treatment of
    substance use disorders in women is limited.
  • 34 of all individuals with a substance use
    disorder other than nicotine dependence in the
    U.S.
  • Women's low utilization of substance use disorder
    treatment services may
  • be related to

8
Characteristics of Substance Abuse Disorders in
Women-2
  • Psychosocial and financial barriers (e.g., lack
    of child care, lack of health insurance) prevent
    many women from seeking treatment.
  • Women's perception of greater social stigma
    associated with their substance abuse.

9
Characteristics of Substance Abuse Disorders in
Women-3
  • Higher prevalence than men of primary
    co-occurring mood and anxiety disorders that
    require psychiatric care.
  • Many women with a substance use disorder have a
    history of physical and/or sexual abuse (both as
    children and as adults).
  • Poorer prognosis for medical sequelae of alcohol
    abuse and
  • dependence in women.

10
Characteristics of Substance Abuse Disorders in
Women-4
  • Alcohol-dependent women consume less alcohol than
    men yet progress to late stages of
    alcohol-related illness more rapidly.
  • Shorter time course to the initial development of
    alcohol-related medical morbidity than do men.
  • Prevalence rates of alcohol-related cirrhosis of
    the liver and cardiomyopathy in women are twice
    that in men.

11
Characteristics of Substance Abuse Disorders in
Women-5
  • Women frequently initiate cocaine and opioid use
    in the context of a substance-using partner and
    tend to initiate use at a younger age than men.
  • Tailoring the goals of treatment to meet the
    needs of women improves treatment outcomes for
    substance-using women.

12
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13
Characteristics of Substance Abuse Disorders in
Adolescents-1
  • Alcohol and other psychoactive substance use,
    abuse, and dependence in children and adolescents
    presents a serious public health problem in the
    US.
  • Substance abuse is among the leading causes of
    morbidity and mortality from motor vehicle
    accidents, suicidal behavior, violence, drowning,
    and unprotected sexual activity.

14
Characteristics of Substance Abuse Disorders in
Adolescents-2
  • Regional studies reveal that 7-10 of
    adolescents are in need of treatment for
    substance use disorders.
  • Dual diagnosis is common in most adolescents with
    substance use disorders, most often conduct
    disorder and/or major depression, although ADHD,
    anxiety disorders (social phobia and PTSD),
    bipolar disorder, eating disorders, learning
    disabilities, and axis II disorders.

15
Characteristics of Substance Abuse Disorders in
Adolescents-3
  • Outcomes for adolescents appear to be enhanced by
    the availability of treatment that is
    developmentally appropriate and peer oriented and
    includes educational, vocational, and
    recreational services.
  • Family therapy also appears to have benefit.

16
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17
Characteristics of Substance Abuse Disorders in
Elderly Individuals-1
  • Substance use disorders in elderly individuals
    are often undiagnosed and under-treated.
  • Abuse of and dependence on prescribed
    medications, particularly benzodiazepines,
    sedative-hypnotic medications, and opioids.

18
Characteristics of Substance Abuse Disorders in
Elderly Individuals-2
  • Alcohol use disorders, whether an extension of a
    long-standing disorder or of later onset, are a
    major problem among elderly individuals,
    particularly those living alone.
  • A large multi-site study (PRISM-E) has shown that
    elderly primary care patients screening positive
    for a substance use disorder prefer to be treated
    within the medical system, with integrated
  • treatment (Bartels SJ, 2004).

19
Characteristics of Substance Abuse Disorders in
Elderly Individuals-3
  • VA patients age 54 years or older who received
    specialized services for elderly patients as part
    of a treatment program were four times more
    likely to complete the program and remained in
    treatment longer than those who received
    conventional services. (Kofoed LL,1987)

20
Characteristics of Substance Abuse Disorders in
Cultural Groups
  • Treatment services that are culturally sensitive
    and address the special concerns of ethnic
    minority groups may improve acceptance of,
    adherence to, and, ultimately, the outcome of
    treatment.
  • Current research suggests poorer prognoses for
    ethnic and racial minorities in conventional
    treatment programs, although this may be
    accounted for by socioeconomic group differences.

21
Source Office of Applied Studies, SAMHSA, 1991-3
22
Source Office of Applied Studies, SAMHSA, 1991-3
23
Source Office of Applied Studies, SAMHSA, 1991-3
24
Source Office of Applied Studies, SAMHSA, 1991-3
25
Source Office of Applied Studies, SAMHSA, 1991-3
26
Substance Abuse Disorders Issues in Hispanic
Americans
27
Hispanic Americans-1
  • Second largest ethnic group in USA
  • Mexican-Americans, Puerto Ricans,
    Cuban-Americans, and immigrants from Central and
    South American countries
  • Heterogeneous

28
Hispanic Americans-2
  • Emphasis on family
  • Religious influences
  • Tradition of folk healers
  • Gender roles
  • Styles of communication

29
Barriers to treatment
  • Language
  • Inability of staff to earn confianza
  • Geographic
  • Criminal justice system
  • Lack of Hispanic physicians
  • Lack of insurance
  • Legal status

30
Treatment Issues
  • Hispanics drop out of some types of drug abuse
    treatment programs at higher rates than Anglos
    (DeLeon,et al, 1992)
  • Focus of treatment should emphasize family
    values, cultural background
  • Culturally appropriate assessment and engagement
    is critical
  • Therapeutic alliance is key

31
Effective substance abuse treatment for Hispanics
  • Involve extended family
  • Use of folk healers
  • Support of church
  • Support of merchants, civic organizations
  • Respeto, dignidad, personalismo

32
Substance Abuse Disorders Issues in African
Americans
33
African Americans
  • Importance of religion and spirituality
  • Extended family network
  • Disproportional high rate of poverty
  • Concerns about racial discrimination
  • Concerns about privacy

34
African Americans-Barriers to Help Seeking
  • Concerns about stigma
  • Mistrust of health professionals
  • Belief that prayer alone can heal
  • Belief that suffering is a part of life for Black
    people
  • Criminal justice system

35
African Americans-Adequacy of Treatment
Services-1
  • Trust issues in therapeutic relationships
  • Cultural sensitivity of care providers
  • Ethnically appropriate assessment of client
    behavior, symptoms and needs
  • Cultural Issues in Substance Abuse Treatment
    CSAT, 1999

36
African Americans-Adequacy of Treatment Services-2
  • Additional services to consider (cont.)
  • On site twelve-step programs attended by members
    from the ethnic groups in the area
  • Employment of appropriate ethnic staff at all
    levels
  • Involvement of professional and paraprofessional
    counselors from the recovering community
  • Cultural Issues in Substance Abuse Treatment
    CSAT, 1999

37
Substance Abuse Disorders in Asian Americans
38
Introduction to Asian Americans
  • Many groups (43) and languages with separate
    cultures- Heterogeneous
  • Asian/Pacific Americans are one of the fastest
    growing ethnic minority groups
  • Major groups
  • Chinese
  • Filipino
  • Japanese
  • Korean
  • Substance abuse is under-reported due to shame
    and stigma
  • Southeast Asian (Vietnamese, Cambodian,
    Laotian, Hmong, Mien)
  • South Asian

39
Epidemiology
  • Published data shows low incidence
  • Lack of comprehensive data on many groups-not
    included in many studies
  • Heterogeneity makes drawing conclusions difficult
  • Language is a barrier
  • Stigma and shame

40
Risk Factors
  • Acculturation stress
  • Increased freedom
  • Alienation from parent culture
  • Access to alcohol and drugs
  • Traumatic experiences
  • Personal losses loss of supports

41
Assessment Issues
  • Be familiar with the immigration history of the
    group
  • General knowledge-Cultural norms
  • Specific knowledge-Migration history
  • Cultural consultation
  • Delay screening of habits

42
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43
Treatment Issues
  • Know the cultural values
  • Bilingual and bicultural staff
  • Trauma issues in immigrants
  • Awareness of shame and stigma
  • Community based treatment
  • Using culturally acceptable treatment approaches

44
Substance Abuse Disorders Issues in American
Indians
Sarah Penman, Buck Bear Heart, Lakota Nation,
South Dakota, 1998
45
Historical and Sociocultural Factors
  • Impact of Colonization
  • Loss of knowledge and traditions
  • Impact of disease from colonial contact
  • Forced relocation from the land
  • Removal of children from the family

46
Demographics-1
  • Over 560 federally recognized tribes
  • Over 250 distinct languages among tribes
  • Most American Indians live in Western States
  • 44 live in rural areas

47
Demographics-2
  • (1997-99) 26 live in poverty
  • Life expectancy 63.5 years
  • Median age 27.8 years
  • (1990 01) population increased 22.4 to 2.5
    million

48
Epidemiology-1
  • 5th leading cause of death chronic liver disease
    and cirrhosis
  • ( MMWR,CDC, 1994-96 )
  • 20 12 17 yr olds illicit drug use
  • (SAMSHA Household Survey , 1999)
  • Death rates due to alcoholism 7 x greater then
    general population
  • Suicide 1.5 x national rate

49
Epidemiology-2
  • 70 with lifetime alcohol disorder and
    psychiatric disorder
  • (Robin et.al 1997)
  • Fetal Alcohol Syndrome rate 3x higher than for
    all other groups 2.97 per 1,000 births
  • (CDC , 1998)
  • PTSD prevalence rate 2.75 x higher than general
    population
  • (Kessler et al., 1995)

50
Surgeon Generals Recommendations
  • Improve Access to Treatment
  • VA/Tribal Outreach Projects-PTSD, Depression,
    Substance Abuse highly co-morbid. Natives teach
    Natives.
  • Reduce Barriers to Care
  • Tribal Health Programs
  • Chapter Houses, Lodges
  • Medicine Person/ Healers
  • Sweat Lodge, Ceremonies
  • Community Fairs, Pow Wows, Rodeo Circuit
  • Denver Pow Wow Eagle Lodge (Residential Drug
    and Alcohol) sponsors dancers
  • crafts booth

51
Characteristics of Substance Abuse Disorders in
GLBT
  • Multiple studies do indicate increased rates of
    drug use among gay and bisexual sexually active
    men and lesbian women compared with exclusively
    heterosexual men and women, with a prominence of
    cannabis and nicotine dependence for both
    homosexual men and lesbian women.
  • Special therapeutic strategies have been
    developed that target known regional associations
    between sexual
  • orientation and substance abuse.

52
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53
DSM-IV TR Outline for Cultural Formulation
  • Included in the text of the APA Practice
    Guideline for the Psychiatric Assessment of
    Adults, 2nd Edition, American Journal of
    Psychiatry, June 2006 supplement
  • Subject of the Clinical Manual of Cultural
    Psychiatry edited by Russell F. Lim, MD, APPI,
    2006

54
DSM-IV TR Outline for Cultural Formulation
  • A. Cultural identity of the individual
  • B. Cultural explanations of the
  • individuals illness
  • C. Cultural factors related to
  • psychosocial environment and
  • levels of functioning
  •  

55
DSM-IV TR Outline for Cultural Formulation
  • D. Cultural elements of the
  • relationship between the individual
  • and the clinician
  • E. Overall cultural assessment for
  • diagnosis and care

56
A. Cultural identity of the individual
  • Ethnicity
  • Race
  • National origin/Indigenous culture
  • Migration/acculturation/bi-culturality
  • Language (s)
  • Age
  • Gender
  • Sexual orientation

57
Cultural identityThink widely
  • Religious/spiritual beliefs practices
  • Socioeconomic status
  • Political orientation
  • Geographic location
  • Disabilities
  • Other aspects of identity, such as vocation

58
Can health disparities be caused by the
clinicians poor understanding of the patients
culture?
  • Clinicians can prematurely close on and make
    assumptions about the persons cultural identity,
    then make erroneous assessments, diagnosis and
    treatment plans.
  • VERSUS
  • Clinicians will enhance rapport and the
    therapeutic relationship by being respectful to
    the whole person including his/her cultural
    identity for improved adherence.

59
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60
B. Cultural expressions and explanations of
illness-1
  • Idioms of distress
  • Meaning and perceived severity of symptoms in
    relation to the norms of the cultural reference
    group

61
B. Cultural expressions and explanations of
illness-2
  • Culture-Bound Syndromes
  • Explanatory model (s)- cultural healing rituals
  • Treatment pathway(s)history and expectations
    (professional and popular sources of care)

62
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63
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64
C. Cultural factors related to psychosocial
environment and levels of functioning
  • Stressors and social supports
  • Religion and kin networks

65
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66
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67
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68
Culturally related strengths andsupports
Personal strengths (Pamela Hays, 2007)
  • Culturally-related knowledge and practical
    skills
  • Culture-specific beliefs that help one cope
  • Respectful attitude toward the natural
    environment
  • Commitment to helping ones own group
  • Wisdom from experience

69
Culturally related strengths andsupports
Environmental conditions
  • An altar in ones home or room to honor deceased
    family members and ancestors
  • A space for prayer and meditation
  • Foods related to cultural preferences (cooking
    and eating)
  • Pets
  • A gardening area
  • Access to outdoors for subsistence or recreation

70
Recommended References
  • Hays P. Addressing Cultural Complexities in
    Practice, 2nd ed. Washington, DC APA Press, 2007
  • Josephson A, Peteet J (eds.). Handbook of
    Spirituality and World Views in Clinical
    Practice. Washington, DC APPI, 2004
  • McGoldrick M, et al (eds.). Ethnicity and Family
    Therapy, 3rd ed. New York Guilford Press, 2005

71
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72
D. Cultural elements of the relationship between
the individual and the clinician
  • Intra-ethnic and inter-ethnic transference/counter
    -transference
  • Clinical methods
  • Mental status exam

73
1. Understand the cultural identity of the
clinician through self-reflection.
  • Be aware of and understand ones own personal and
    professional identity development.
  • Be aware of biases and limitations of knowledge
    and skills that might affect the clinical
    encounter.

74
2. Compare the cultural identity of the patient
to that of the clinician.
  • Compare the cultural identity variables for
    similarities and differences.
  • Go beyond a categorical approach to understanding
    of self-construal of identity.
  • Factor in the context of the clinical encounter.
  • Look for problems in the clinical encounter,
    assessment and treatment that might arise from
    similarities and differences.

75
3. Assess the cultural elements of the
relationship in an ongoing way.
  • Rapport and respect
  • Dealing with stigma and shame
  • Empathy
  • Communication, verbal and non-verbal
  • Transference and counter-transference
  • Involvement with significant others, community
    organizations

76
E. Overall cultural assessment for diagnosis and
care
  • Culturally congruent treatment plan
  • Cultural consultants
  • Diagnosis- Category fallacy vs. cultural
    relativism

77
Differential diagnosis The goal is a more
accurate diagnosis.
  • Axis I and II psychopathology
  • -Age, gender, cultural considerations
  • Cultural phenomena
  • Cultural idiom of distress
  • Culture-Bound Syndrome
  • Sign or symptom of psychopathology Sign or
    symptom of a V code diagnosis

78
Differential diagnosis Issues
  • Misdiagnosis due to
  • Cultural idioms of distress, explanatory models,
    treatment pathways
  • Inadequate relationship to gather history
  • Clinician bias,stereotyping, clinical uncertainty
  • Prevalence may vary by culture/gender.
  • Misdiagnosis can lead to mis-treatment.
  • Course and outcome may vary by culture/gender.

79
Treatment planning-1
  • Process
  • Negotiate and manage a treatment plan to maximize
    adherence/compliance
  • Content
  • Biological
  • Psychological
  • Sociocultural

80
Treatment planning-2
  • Biological
  • Medication pharmacodynamics and pharmacokinetics
    may vary due to
  • Genetics related to race/ethnicity
  • Diet
  • Environment
  • Interaction with herbal medications
  • Medication adherence/compliance strategies
  • Medication combined with other biological
    approaches such as acupuncture?

81
Treatment planning-3
  • Psychotherapy
  • Patient/family expectations and goals
  • Be the Tiger Balm oil at the first interview.
  • -Evelyn Lee, Ed D
  • Family vs. individual vs. group
  • Supportive vs. Cognitive-Behavioral vs.
    Insight-oriented
  • What cultural modifications in therapy would
    help?
  • What therapist characteristics would
    facilitate/hinder treatment?

82
Treatment planning-4
  • Sociocultural Approaches
  • Utilize cultural strengths when possible such as
  • Family
  • Spiritual/religious beliefs/practices
  • Work with other systems of care such as
  • Primary care
  • Faith organizations and leaders

83
Ethnocultural Factors in Substance Abuse
Treatment, Straussner, 2001
  • Six sections, twenty chapters
  • Assessment
  • Specific Populations
  • African
  • Native American Latino
  • European
  • Middle Eastern
  • Asian

84
TIP 40- Clinical Guidelines for the Use of
Buprenorphine in the Treatment of Opioid
Addiction, 2004
  • The presence of certain life circumstances or
    co-morbid medical or psychosocial conditions
    warrant special attention during the evaluation
    and treatment of opioid addiction with
    buprenorphine.
  • Pregnant women, adolescents, geriatric patients,
    patients under the jurisdiction of the criminal
    justice system, and healthcare professionals who
    are addicted

85
TIP 42- Substance Abuse Treatment for Persons
With Co-Occurring Disorders (COD), 2005- Homeless
  • Address the housing needs of clients.
  • Help clients obtain and maintain housing.
  • Address real-life issues in addition to housing,
    such as children, healthcare needs, legal and
    pending criminal justice issues, Supplemental
    Security Insurance/entitlement applications.
  • Work closely with shelter workers and other
    providers of services to the homeless.

86
TIP 42- Substance Abuse Treatment for Persons
With COD, 2005-Community Treatment
  • Recognize special service needs.
  • Give positive reinforcement for small successes
    and progress.
  • Clarify expectations regarding response to
    supervision.
  • Use flexible responses to infractions.
  • Provide ongoing monitoring of symptoms.
  • Design highly structured activities.
  • Give concrete directions.

87
TIP 42- Substance Abuse Treatment for Persons
With COD, 2005- Adaptations for Women-1
  • Identify and build on each woman's strengths.
  • Avoid confrontational approaches Instead, use
    supportive interventions in the early stages of
    treatment.
  • Teach coping strategies, based on a woman's
    experiences, with a willingness to explore the
    woman's individual appraisals of stressful
    situations.

88
TIP 42- Substance Abuse Treatment for Persons
With COD, 2005- Adaptations for Women-2
  • Arrange to meet the daily needs of women, such as
    childcare and transportation.
  • Have a strong female presence on staff.
  • Promote bonding among women.
  • Develop programs for both women children.

89
TIP 42- Substance Abuse Treatment for Persons
With COD, 2005 Adaptations for Women-3
  • Offer program components that help women reduce
    the stress associated with parenting, and teach
    parenting skills.
  • Provide interventions that focus on trauma and
    abuse.
  • Foster family reintegration and build positive
    ties with the extended/kinship family.

90
TIP 47- Substance Abuse Clinical Issues in
Intensive Outpatient Treatment, 2006
  • Many assumptions and approaches used in intensive
    outpatient treatment (IOT) programming were
    developed for and validated with middle-class,
    employed, adult men.
  • Chapter 9 the justice system population, women,
    people with co-occurring mental disorders, and
    adolescents and young adults.

91
TIP 47- Substance Abuse Clinical Issues in
Intensive Outpatient Treatment, 2006 Chapter 10
  • Review of current research that supports the need
    for individualized treatment that is sensitive to
    the client's culture
  • Principles in the delivery of culturally
    competent treatment services
  • Topics of special concern, including foreign-born
    clients, women from other cultures, and religious
    considerations
  • Clinical implications of culturally competent
    treatment

92
TIP 47- Substance Abuse Clinical Issues in
Intensive Outpatient Treatment, 2006 Chapter 10
  • Sketches of diverse client populations, including
  • Ethnic groups (Af AM, As AM, Hisp., NA)
  • Persons with HIV/AIDS
  • Lesbian, gay, and bisexual (LGB) populations
  • Older adults and Persons with physical and
    cognitive disabilities
  • Rural and Homeless populations
  • Resources on culturally competent treatment for
    various populations

93
Conclusions
  • Cultural competence is critical in assessment and
    treatment
  • DSM-IV-TR Outline for Cultural Formulation
  • Ethnic groups are heterogeneous
  • Cultural consultation-cultural norms
  • General and specific cultural knowledge
  • Engage the family and the community
  • Treatment must be in the cultural context of the
    patient and his or her values
  • and belief systems

94
Questions?
95
Internet Links
  • APA Practice Guideline for the Treatment of
    Patients with Substance Use Disorders, 2nd
    edition, 2006 (http//www.psychiatryonline.com/con
    tent.aspx?aID141079)
  • APA Practice Guideline for the Psychiatric
    Evaluation of Adults, 2nd edition, 2006
  • (http//www.psychiatryonline.com/pracGuide/pracGu
    ideTopic_1.aspx)
  • TIP 40- Clinical Guidelines for the Use of
    Buprenorphine in the Treatment of Opioid
    Addiction, 2004
  • (http//www.ncbi.nlm.nih.gov/books/bv.fcgi?ridhs
    tat5.chapter.72248)
  • TIP 42- Substance Abuse Treatment for Persons
    With Co-Occurring Disorders, 2005
  • (http//www.ncbi.nlm.nih.gov/books/bv.fcgi?ridhs
    tat5.chapter.74073)
  • TIP 47- Substance Abuse Clinical Issues in
    Intensive Outpatient Treatment, 2006
  • (http//www.ncbi.nlm.nih.gov/books/bv.fcgi?ridhs
    tat5.chapter.88658)

96
Clinical Manual
Contact Information Russell F. Lim,
MD Associate Clinical Professor 2230 Stockton
Blvd. Sacramento, CA 95817 rflim_at_ucdavis.edu 916-
734-5070 x 60190 Fax 916-875-1086
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