Outpatient medication-assisted treatment for heroin use disorder — built for the reality that most of what’s sold as heroin today is fentanyl, and that the people using it often need integrated care for hepatitis C, skin-and-soft-tissue infections, and years of IV-use consequences. Four clinics across Southeast Tennessee and North Georgia, same-day appointments available.
CARF AccreditedLicensed in Tennessee & GeorgiaSame-day appointments availableConfidential from your first call
At a glance
How we treat heroin addiction
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Restoration Recovery treats heroin addiction with FDA-approved medication-assisted treatment at all four clinics. Daily Suboxone is prescribed everywhere; Sublocade and Brixadi injections are given at our Chattanooga, Cleveland, and Ringgold locations (Soddy-Daisy is oral-only). Today’s heroin supply is overwhelmingly adulterated with fentanyl in the Tennessee/Georgia market, which raises the same tolerance and overdose-risk profile as direct fentanyl use. Buprenorphine cuts overdose mortality by approximately 50% per Sordo 2017 BMJ and is the ASAM-recommended first-line treatment for opioid use disorder.
First visits include DSM-5 evaluation, COWS scoring, counseling intake, doctor evaluation, and medication ordering. Patients with severe OUD or fentanyl-adulterated heroin exposure often benefit from a long-acting injectable (Sublocade or Brixadi) early in stabilization. Same-week appointments available; TennCare, BlueCare, BCBS, UHC, and most commercial insurance accepted.
What Is Heroin?
Heroin is a semi-synthetic opioid derived from morphine. It has no accepted medical use in the United States, is Schedule I under the Controlled Substances Act, and has existed as a street drug in roughly the same chemical form since the late nineteenth century. It is typically sold as a white or brown powder, a black sticky substance (“black tar heroin,” more common west of the Mississippi), or a rock-like form, and is most often injected, smoked, or snorted. The subjective effects — a rapid euphoric rush followed by hours of sedation — are the result of a full opioid-receptor agonist acting on the same receptors that respond to prescribed opioids like hydrocodone, oxycodone, and fentanyl. Physical dependence develops fast. Regular daily use over even a few weeks can produce withdrawal symptoms that drive continued use.
The practical reality is that, for the last several years, “heroin” and “fentanyl” have become the same product in most U.S. markets. The heroin sold on the street east of the Mississippi in 2024 and 2025 is, in the majority of samples, adulterated with illicit fentanyl, mostly fentanyl, or entirely fentanyl. DEA NFLIS drug-chemistry data show the fentanyl co-occurrence rate in heroin samples went from near zero in 2013 to roughly half of heroin samples nationally by 2022–2023, with state-level rates as high as 95% in parts of the Northeast. West-coast markets dominated by black tar heroin have lagged this transition, but the direction of travel is clear. For treatment purposes, we assume any patient presenting with heroin use disorder has significant fentanyl exposure, because the alternative assumption is unsafe.
That shift matters for everything that comes next on this page. It changes what the overdose risk looks like, it changes the window before buprenorphine can safely start, and it changes the kind of medical workup a patient who has been injecting for months or years needs. What hasn’t changed is the treatment itself: buprenorphine-based MAT is still the most effective intervention we have, and it still works.
Fentanyl in “heroin” samples, U.S.
NFLIS drug chemistry, co-occurrence rate
~0%2013
~20%2018
~50%2022–202395% in parts of NE
DEA NFLIS drug-chemistry labs found fentanyl co-occurring with heroin in roughly half of seized “heroin” samples nationally by 2022–2023, up from near zero a decade earlier. In some Northeast states the rate exceeds 95%. In west-coast black-tar markets it remains under 5%.
IDU-associated endocarditis, SE U.S.
Heart-valve infection hospitalizations
1×2010 baseline
12×NC 2010–2015
+238%National 2000–2013IDU-IE admissions
Hospitalizations for drug-dependence-associated infective endocarditis rose roughly twelvefold in North Carolina alone over five years. Nationally, IDU-associated endocarditis admissions rose 238% between 2000 and 2013 while non-drug-use endocarditis rose only 38%. Appalachia has been hit hardest.
The Heroin-to-Fentanyl Picture
The numbers tell a specific story, and it isn’t a success story even where the headline looks like one. CDC WONDER data show heroin-involved overdose deaths in the United States peaked at roughly 15,500 in 2016 and fell to about 4,000 by 2023. That reads as progress. The reality is closer to the opposite: the drug we call heroin has been displaced in most illicit markets, not because users stopped, but because traffickers switched to a cheaper, more potent, easier-to-smuggle synthetic. An estimated 80% of those remaining heroin-involved deaths in 2022 also involved illicitly manufactured fentanyl, and total synthetic-opioid deaths rose into the 70,000-plus range over the same window.
The first panel shows the chemistry-lab evidence. DEA’s National Forensic Laboratory Information System (NFLIS) tracks what’s actually in the drug samples seized by U.S. law enforcement. In 2013, essentially no heroin samples contained fentanyl. By 2018, the co-occurrence rate was around 20%. By 2022–2023, it was around 50% nationally, with state-level rates as high as 95% in parts of New Jersey and the Northeast. West coast markets, still dominated by Mexican-produced black tar heroin, have been slower to transition, but the national picture is that if you bought what someone told you was heroin in the Southeast in the last three years, you almost certainly consumed fentanyl.
The second panel shows one of the downstream consequences. Injection drug use is the primary driver of a sharp rise in infective endocarditis — a serious infection of the heart valves — and in skin, soft-tissue, and bone infections. North Carolina alone saw a roughly twelvefold increase in drug-dependence-associated endocarditis hospitalizations between 2010 and 2015. Nationally, IDU-associated endocarditis admissions rose 238% between 2000 and 2013, while endocarditis admissions not tied to drug use rose only 38%. These hospitalizations are expensive ($50,000+ per admission on average), disproportionately uninsured or Medicaid-covered, and concentrated in Appalachia. About a third of these patients are also hepatitis C positive. For every endocarditis admission, there are many more patients walking around with abscesses, cellulitis, and undiagnosed HCV — which is why integrated infectious-disease care matters as much as the MAT itself for this population.
Sources: Brandeis / University of California study on fentanyl co-occurrence in the U.S. illicit drug supply 2013–2023 (PMC11470258); CDC NCHS Data Brief No. 522, Drug Overdose Deaths in the United States, 2003–2023; CDC NIDA overdose death trend data (heroin peak 15,469 in 2016; 3,984 in 2023); CDC MMWR Vol. 66 No. 22, Hospitalizations for Endocarditis and Associated Health Care Costs Among Persons with Diagnosed Drug Dependence — North Carolina, 2010–2015; Wurcel AG et al., endocarditis and drug use hospitalization trends, 2000–2013; CDC Viral Hepatitis Progress Report 2025 (HCV in PWID).
Recognizing it
Signs of Heroin Use Disorder
Heroin use disorder is a medical condition, not a moral failing. For patients who inject, the signs are often more visible than for pill-first or snorting-only patients, but that doesn’t make them more shameful — it makes them more medically urgent. Common signs include both universal opioid-use-disorder criteria and a specific cluster tied to intravenous use.
Universal opioid use disorder signs
Physical tolerance. Needing more of the drug to achieve the same effect, or finding that a dose that used to hold you through the night no longer prevents early morning withdrawal.
Withdrawal within hours of last use. Muscle aches, sweating, nausea, diarrhea, restlessness, insomnia, anxiety, runny nose, watery eyes.
Preoccupation. A large share of the day spent thinking about, obtaining, using, or recovering from use.
Loss of control. Using more than intended, or being unable to stop despite repeated attempts.
Continued use despite consequences. Maintaining use in the face of clear damage to health, relationships, work, housing, or legal standing.
Isolation. Withdrawing from family, friends, or activities that used to matter — often because use has become a secret to protect.
IV-use-specific signs
Track marks and chronic injection sites. Visible puncture scars, hyperpigmented linear marks over superficial veins, especially on forearms, hands, feet, and — when peripheral veins are exhausted — neck or groin.
Collapsed or sclerosed veins. Veins that no longer flow, feel hard or rope-like, or disappear entirely. Patients often report progressively longer “hit attempts” and switching to harder-to-access sites.
Skin abscesses and cellulitis. Recurrent red, warm, painful swellings at injection sites. These are bacterial infections, often Staphylococcus, and they don’t self-resolve.
Febrile episodes or new heart murmur. Fevers without an obvious source, night sweats, unexplained weight loss, or a new cardiac murmur can all indicate infective endocarditis. This is a medical emergency, not an outpatient problem — go to an ER.
Unexplained back or spine pain. In an IV user, new severe back pain can be spinal osteomyelitis or an epidural abscess. Get it worked up.
Hepatitis C exposure. A previous positive HCV test, a liver enzyme abnormality on an old lab, or any history of jaundice. CDC estimates HCV prevalence among people who inject drugs exceeds 40%. Many are undiagnosed.
HIV risk behavior. Shared needles, cookers, water, or cotton — any of these carries HIV transmission risk. Testing is part of standard intake.
Withdrawal fear shaping daily decisions. Life scheduled around dose timing — the morning hit before work, the extra injection before a family event because you know what 8 hours without one looks like.
You do not have to meet every item on this list. The formal DSM-5 threshold for opioid use disorder is 2 of 11 criteria in a 12-month period. Mild, moderate, and severe are all treatable — and treatment earlier is almost always easier than treatment later.
Heroin Withdrawal: Timeline & Symptoms
Heroin withdrawal is medically uncomfortable but not typically life-threatening in otherwise healthy adults. It is, however, severe enough that many people relapse simply to stop the symptoms, and that’s not weakness — it’s physiology. Medication-assisted treatment is designed specifically to prevent withdrawal rather than force you to endure it. Heroin is a relatively short-acting opioid: pure heroin withdrawal onset is typically 6 to 12 hours after last use, peaks on day 1 to 3, and the acute phase resolves over 5 to 7 days, with post-acute symptoms lingering longer.
The full clinical picture: nausea, vomiting, diarrhea, abdominal cramping, chills alternating with sweating, dilated pupils, goosebumps (“kicking”), muscle and bone pain, profound fatigue, insomnia, and intense cravings. Blood pressure and heart rate rise. This is when most unmedicated attempts to stop fail.
This is the stretch MAT is built for — buprenorphine prevents these symptoms, so most patients never go through the peak unmedicated.
Acute GI symptoms subside and appetite begins to return. Sleep remains fragmented and cravings stay strong. Low mood and anxiety may peak here as the body re-regulates.
Week 2 and beyond · Post-acute
Post-acute withdrawal
Low energy, difficulty concentrating, mood changes, anhedonia, and intermittent cravings that can persist weeks to several months if unmanaged. MAT dramatically shortens and softens this phase.
Fentanyl changes this timeline
Because most U.S. illicit “heroin” now contains fentanyl, real-world withdrawal often doesn’t follow the clean textbook timeline. Fentanyl stores in body fat and clears more slowly, so onset can be delayed (8–24+ hours instead of 6–12) and the safe window before starting buprenorphine is often extended — commonly 24 to 72 hours after last use instead of 12 to 24. Starting buprenorphine too early after fentanyl exposure triggers precipitated withdrawal, so your provider uses a COWS (Clinical Opiate Withdrawal Scale) score at intake to time induction correctly.
How We Treat Heroin Addiction
Every opioid patient is evaluated for medication-assisted treatment, because the evidence is overwhelming: more than a 50% reduction in fatal overdose risk, significantly longer retention in treatment, and sharply lower rates of illicit opioid use. We pair MAT with psychosocial support and — where clinically relevant — integrated care for the medical conditions that come with years of IV use.
Buprenorphine + naloxone taken under the tongue. Buprenorphine is a partial agonist: it stabilizes cravings and prevents withdrawal at the same receptors heroin and fentanyl act on, but with a ceiling on euphoria and respiratory depression. Same-day induction when the COWS score is in range; with heavy fentanyl exposure, induction may be delayed 24–72 hours.
A long-acting extended-release buprenorphine injection given once a month at our clinics — it removes the daily dosing decision and holds steady blood levels for the full month. Per FDA labeling, Sublocade requires at least 7 days of transmucosal buprenorphine (Suboxone) before the first injection.
Brixadi (weekly or monthly)
Another extended-release buprenorphine injection with flexible dosing intervals — helpful for patients still finding the right maintenance dose, who want more frequent clinic contact than Sublocade’s monthly cadence, or whose insurance coverage differs between the two. Ordered per-patient and administered at a follow-up visit once it arrives.
Individual counseling
Licensed therapists experienced in substance use disorder — including the trauma history common in long-term IV use, grief around lost relationships, and the work of rebuilding a life that no longer revolves around drug-seeking.
Certified peer support
Specialists with lived recovery experience — many have walked the heroin-to-recovery path themselves. That conversation often lands when a clinical one doesn’t.
Intensive outpatient (IOP)
Clinician-led sessions several times a week for patients who benefit from more structure — delivered in a group format by design. IOP is the only group-setting service we offer, and it’s a separate, structured program rather than an informal group activity.
Integrated behavioral health
Anxiety, depression, trauma/PTSD, and bipolar or psychotic-spectrum disorders are common in long-term heroin patients and directly affect retention — we address them rather than hand them off.
Integrated Hepatitis C Care
Because injection drug use is the dominant driver of hepatitis C transmission in the United States and prevalence among people who inject drugs exceeds 40%, we integrate HCV testing and treatment into our MAT program rather than running them as parallel referral tracks. Universal HCV screening is offered at intake for any patient with injection history, and for patients who test positive, we treat hepatitis C in-house. Modern treatment is an 8-to-12-week course of oral direct-acting antivirals with a cure rate above 95%, and there is no requirement to stop using before starting HCV therapy — starting HCV treatment while stabilizing on MAT is standard. Our hepatitis C care page covers the program in detail.
Most patients with heroin use disorder start medication-assisted treatment right in our outpatient clinics — buprenorphine can begin at the appropriate COWS-score window after last use, under clinical supervision. Some situations do need medical stabilization first: active endocarditis, osteomyelitis, or a severe untreated co-occurring psychiatric illness are emergencies that need hospital-level care before outpatient treatment. Get those evaluated urgently, and we’ll get you started on MAT as soon as you’re medically cleared.
Not sure where to start?
You don’t have to be in withdrawal, and you don’t have to have stopped. Call and we’ll walk you through the first visit and time your medication correctly.
Your first visit typically lasts 2 to 3 hours and follows a four-step clinical flow. For heroin in the fentanyl era, the COWS score is what times your first dose — you leave the same day with a Suboxone prescription.
01
Intake
Paperwork, a DSM-5 assessment to confirm diagnosis and severity, and a COWS score to measure your current withdrawal state — the score guides whether you can start buprenorphine the same day or need a longer interval.
02
Counseling
You meet a counselor to discuss your use history, prior treatment, co-occurring conditions, injection history, and recovery goals — and we document HCV, HIV, and infection risk factors so the medical evaluation can focus.
03
Doctor evaluation
A provider reviews your intake, COWS score, and notes, walks you through Suboxone, Sublocade, and Brixadi, and — for IV patients — discusses HCV screening, HIV testing, liver function, and any current infection concerns.
04
Prescription
You leave the same day with a Suboxone prescription. If you prefer the extended-release route, your provider orders Sublocade or Brixadi during this visit and you bridge on Suboxone until your injection appointment.
About 2–3 hours.You leave the same day with a Suboxone prescription.Bring a photo ID, insurance card, and a list of any medications.
What each step covers in detail+
Intake. A DSM-5 assessment to confirm opioid use disorder and its severity (mild, moderate, or severe, based on the 11 criteria met in a 12-month period), plus a COWS (Clinical Opiate Withdrawal Scale) score. The COWS score is especially important for heroin patients in the fentanyl era — it guides whether you’re clinically ready to start buprenorphine the same day, or whether we need a longer interval to avoid precipitated withdrawal.
Prescription and injection ordering. You leave the same day with a Suboxone prescription. If you prefer the extended-release route, your provider orders Sublocade or Brixadi during this visit — we don’t stock injections on-site — and you continue on Suboxone as a bridge. Your injection appointment is scheduled for a follow-up once the medication arrives, typically after a short stabilization period on Suboxone (Sublocade’s FDA label requires at least 7 days of transmucosal buprenorphine before the first injection).
What to bring. A valid photo ID, your insurance card if applicable, and a list of any medications you take. If you’ve had prior HCV or HIV testing, bring what you have. If you’ve had a recent ER visit for endocarditis, cellulitis, or abscess, bring the discharge summary. Our guide on what to expect at your first Suboxone appointment walks through the process in more detail.
Why Medication-Assisted Treatment Works for Heroin
For many patients, the fear of withdrawal is what keeps them stuck. MAT removes that barrier — the medication prevents withdrawal rather than forcing you to endure it — which is why it works when willpower alone doesn’t. In the fentanyl-contaminated-supply era, that same mechanism is also the single most powerful overdose-risk reduction available: if you’re not in withdrawal, you’re not chasing your next dose from a batch of unknown potency. MAT is endorsed as the standard of care for opioid use disorder by SAMHSA, NIDA, ASAM, and the World Health Organization, and the buprenorphine trials behind it have been running for over twenty years with consistent results. Large-scale evidence shows that patients on buprenorphine-based MAT:
Experience more than a 50 percent reduction in the risk of fatal opioid overdose
Stay in treatment significantly longer than those receiving counseling alone
Report fewer cravings and lower rates of illicit opioid use
Are more likely to maintain employment and stable housing during recovery
Have lower rates of infectious disease transmission associated with injection use, including hepatitis C and HIV
Because the illicit opioid supply has been functionally replaced by fentanyl, the overdose risk of a relapse is not what it was ten years ago — the gap between a patient’s tolerance and an unknown-potency batch of fentanyl is, in many cases, the difference between survivable and not. The case for starting treatment today instead of next month is simply stronger now. And MAT is not a replacement of one drug with another: buprenorphine’s partial-agonist pharmacology gives it a ceiling on euphoria and respiratory depression that full agonists like heroin and fentanyl don’t have, so blood levels stabilize, the daily peak-and-crash cycle disappears, and patients can engage in counseling, address long-ignored medical problems, rebuild relationships, and return to work.
Evidence base: Sordo et al., 2017 (BMJ) mortality meta-analysis; SAMHSA, NIDA, ASAM, and WHO treatment guidelines for opioid use disorder; and 20+ years of buprenorphine cohort and trial data.
Harm Reduction, Honestly
We aren’t going to pretend every heroin patient walks in on day one ready to stop, and we aren’t going to moralize about what a patient did between the decision to come in and the first appointment. Small choices make a measurable difference in survival: carry naloxone (Narcan is available over the counter at pharmacies nationwide), don’t use alone (or use the Never Use Alone hotline at 1-800-484-3731), use fentanyl test strips when they’re available, and avoid combining opioids with benzodiazepines or alcohol, which multiplies overdose risk. None of this replaces treatment, but all of it reduces the chance that today’s use becomes a fatal overdose before your appointment. The most powerful harm-reduction intervention available is starting MAT — a more-than-50% reduction in fatal-overdose risk that no other intervention comes close to matching.
Why Restoration Recovery
Chattanooga’s longest-running outpatient addiction treatment clinic. Decades of clinical experience treating opioid use disorders in Southeast Tennessee — through the prescription-opioid era, the heroin surge that followed, and now the fentanyl era.
Integrated hepatitis C care. HCV is the most common co-morbidity in long-term heroin patients. We test, treat, and cure in-house rather than handing you a referral and losing you between providers.
CARF accredited. The gold standard for outpatient addiction care — reviewed on an ongoing basis, not a one-time stamp.
One integrated team. Medical providers, counselors, certified peer support specialists, psychiatric care, and HCV treatment under one roof — not parallel referral tracks that leave you coordinating your own care.
Four clinic locations across Southeast Tennessee and North Georgia, with telehealth follow-up for established patients.
Most major insurance accepted — TennCare, Georgia Medicaid, commercial plans, Medicare, and supplemental Medicare. We verify your benefits before your first visit.
Same-day Suboxone appointments. You don’t have to wait weeks to start.
Licensed in both states. Tennessee and Georgia, HIPAA compliant, 42 CFR Part 2 compliant — confidential from the first phone call.
CARF-accredited outpatient addiction care
TennCare, BlueCare, BCBS, UHC, Medicare & most commercial insurance accepted. We verify your benefits before your first visit — no surprises. Licensed in TN & GA · HIPAA · 42 CFR Part 2.
Don’t have insurance? Contact us anyway. We can help you explore options, including TennCare eligibility screening for those who may qualify, and we’ll walk you through self-pay pricing. For a full list of accepted carriers and the verification process, visit our insurance page.
Four Clinic Locations
We operate four outpatient clinics across Southeast Tennessee and North Georgia. All locations offer heroin addiction treatment with same-day appointments available.
Telehealth follow-up visits are available for established patients who have completed their initial in-person evaluation. Phones are answered Monday through Friday, 9am to 4:30pm Eastern. After hours? The 988 Suicide & Crisis Lifeline and the free, confidential SAMHSA National Helpline (1-800-662-4357) are available 24/7.
Questions
Frequently Asked Questions
Is it still heroin if it’s really fentanyl?+
Clinically, it doesn’t matter. If you’ve been using what was sold to you as heroin over the last several years, your dependence is most likely driven by fentanyl, heroin, or a mixture of both. The treatment path is the same either way: buprenorphine-based MAT (Suboxone, Sublocade, or Brixadi), with induction timing guided by a COWS score. What does matter is that your provider knows to expect fentanyl exposure, because the pharmacology changes how long you need to wait before your first Suboxone dose. Tell us what you’ve been using, honestly — we’ve heard it.
How do I get tested for hepatitis C?+
HCV testing is part of standard intake for any patient with injection drug use history. CDC now recommends universal HCV screening for all adults at least once, plus periodic re-screening for anyone actively injecting. If your test is positive, we treat hepatitis C in-house rather than handing you a referral — see our hepatitis C care page for details. Modern HCV treatment is 8 to 12 weeks of oral medication with a cure rate above 95%. You do not need to stop using to be treated; we start treatment in patients stabilizing on MAT every week.
Can I start Suboxone if I’m still using?+
You don’t have to be in full withdrawal to call, and you shouldn’t stop cold turkey on your own. What determines timing is a COWS (Clinical Opiate Withdrawal Scale) score at your first visit. For short-acting opioids like heroin, the typical induction window is 6 to 12 hours after last use. For fentanyl — which is what most illicit “heroin” in the U.S. now contains — the window is often 24 to 72 hours, because fentanyl stores in body fat and clears more slowly. Your provider measures COWS at intake and times the first dose so you don’t risk precipitated withdrawal. “Still using” is not a disqualifier; it’s the starting point for most of the patients we see.
Is naloxone (Narcan) really going to help if it’s fentanyl?+
Yes. Naloxone (Narcan) reverses fentanyl overdose, and it works. The caveats are practical, not pharmacological: because fentanyl is more potent, more than one dose is sometimes needed, and because fentanyl is shorter-acting in the brain than some illicit drug users expect, a second overdose is possible after the naloxone wears off. That’s why any reversal should be followed by calling 911 and observation. Carry naloxone, keep it where others can access it, don’t use alone, and don’t wait to see if someone “sleeps it off.” And understand that the single most powerful overdose-risk reduction available is being on buprenorphine-based MAT — it cuts fatal overdose risk by more than 50%.
What about endocarditis or other infections from IV use?+
Injection drug use is a known cause of infective endocarditis (an infection of the heart valves), skin and soft-tissue abscesses, osteomyelitis, and blood-borne infections including hepatitis B, hepatitis C, and HIV. Hospitalizations for IDU-associated endocarditis rose roughly twelvefold in parts of the Southeast between 2010 and 2015, hitting Appalachia hardest. If you have current or recent IV use and new fevers, night sweats, unexplained back pain, or a new heart murmur, get evaluated urgently — not at our outpatient clinic, but at an ER or urgent-care. Once you’re stabilized, medication-assisted treatment is what prevents the next episode, and we’ll get you started as soon as you’re medically cleared.
Can I start treatment if I don’t have veins left for labs?+
Yes. Lab access is a real problem for long-term IV users, and it doesn’t stop you from starting treatment. Most first-visit decisions — DSM-5 diagnosis, COWS score, Suboxone induction — don’t require a blood draw that day. When labs are needed (liver function, HCV, HIV, pregnancy testing), our team works with phlebotomists experienced with difficult access, including hand, foot, and external jugular sites where appropriate. If that still doesn’t work, oral-fluid and point-of-care testing fill in a lot of the gap. The goal is to get you on medication on day one and sort out the peripheral workup around that — not the other way around.
4 clinics across Tennessee & North Georgia
Ready to start heroin addiction treatment?
Same-day appointments available, and most major insurance is accepted. Heroin addiction is treatable — including after years of daily use, and after attempts that didn’t last. You don’t need all the answers before you call, and you don’t need to be clean before your first appointment. Our team will walk you through every step, from your first call to your first visit and every follow-up after.
