Cummins dpf cleaning interval

Xbox Controller Randomly Disconnecting From Xbox Wireless Adapter

2023.06.05 03:28 Smithy000 Xbox Controller Randomly Disconnecting From Xbox Wireless Adapter

I'm having a persistent issue with my Xbox Wireless Controllers and I was hoping that some of you might have experienced the same problem and could help me out. The problem lies in the connection between my controllers and my PC through the Xbox Wireless Adapter.
Here's the situation: I use an Xbox Wireless Controller connected to my PC via the Xbox Wireless Adapter. At random intervals, the controller loses connection, the controller's light starts flashing, and any audio coming through headphones attached to the controller cuts out. I've done a bit of troubleshooting myself (ensuring the USB driver for the Wireless Adapter is updated via Device Manager, and that the controller's firmware is updated through the Xbox Accessories app) but I still run into the issue on a daily basis.
In an attempt to resolve the issue, I even bought another Xbox Wireless Controller but, unfortunately, the problem persists. It's been two years since I first started experiencing this and, despite upgrades during this time (upgrading my CPU from a 3500X to a 5600X, and performing a clean install of Windows 11 on a new SSD), the problem remains unsolved.
An interesting observation is that when two controllers are connected, they both lose their connection simultaneously, which leads me to suspect the issue isn't with the controllers themselves but is likely linked to the USB/PC side of things.
My current theories for the root cause include: a faulty Xbox Wireless Adapter or a design flaw within it, a power delivery issue with the USB port (which is located at the front of the device, coming off the motherboard USB header), or a potential bug in the driver or how it's implemented in Windows.
I doubt it's a wireless interference issue as I reside in a remote area with few wireless devices. Almost everything on my LAN is wired.
If anyone has dealt with a similar issue or has any new troubleshooting suggestions that I haven't yet tried, I'd be more than grateful for your advice.
Additionally, if there's any pertinent system information you need to help diagnose this issue, please do let me know. Thanks in advance for your assistance! 😊
submitted by Smithy000 to techsupport [link] [comments]


2023.06.05 03:04 GuvnorJack How to clear acne starter pack

I see a lot of people still insecure about their acne from all ages and after going through it for almost half my life so far I wanna share some things that have helped me get it under control.
  1. WASH ALL THE TIME. Shower daily if possible, especially when you know you’re dirty. In addition, make sure to keep your complexion clean, not too oily and not too dry, wash your face and moisturise and your skin requires. Keeping your pores clean and correctly oiled enough is key to keeping them clear.
  2. Additionally people underestimate the effect of things other than their face. If you touch your face often, keep them soapy clean, and your hair is a bigger factor than you think. Especially people with longer hair I know aren’t the biggest fans of regular thorough washing but trust me it’s worth it, because if it’s even framing your face let alone on your forehead etc, it will cause breakouts if it’s dirty.
  3. Hydrate. You can never drink enough water as it is but keeping well hydrated helps your skin heal and reduce blemishes and pimples really well. I suggest drinking at regular intervals, especially when you wake up or go to bed to keep it flowing regularly to clear yourself up.
  4. Pop Pimples well. A lot of people are against it despite finding it entertaining. I’ve always found more success popping whiteheads with clean hands and then washing the area after.
  5. Eat healthier. I’ve noticed times when I’ve been eating more things like chocolate and sugared drinks my complexion takes a turn for the worse, so cut them down if you don’t mind going without.
  6. Get in the sun. It can be difficult, but even on cloudy days it’s worth getting some decent sunlight time. If you get the chance to relax in the sun on a very bright and hot day especially though, take it. You’ll feel better after having your face in natural light and a tan helps even your complexion and make blemishes and redheads less prominent.
This is not fits all advice, some people simply don’t suffer and others have particularly bad cases, but for me these have helped go from a very bumpy, red and uneven face to a smoother, evenly coloured one. Acne is extremely common in the west and it is a lot to do with the lifestyle but some simple changes can definitely defeat those angry breakouts that can reduce your confidence time to time. Hope you get something good out of this and remember we are all beautiful human beans, stay happy :D
submitted by GuvnorJack to teenagers [link] [comments]


2023.06.04 23:44 satans_toast Timing of Debt Limit Expiration

The Fiscal Responsibility Act of 2023 suspends the public debt limit until January 1, 2025. That's during the lame-duck interval between the 2024 election and inauguration day.
My suspicious nature has a real problem with this. Lame duck sessions feel like a bad time to have serious discussions on anything.
It feels like losing Congresspeople could decide on a scorched-earth policy and play hardball, leaving the resulting mess to the new Congress, or they could do the right thing out of conscience, letting the new Congress off the hook.
If the Presidency changes, Congress could conceivably serve the new president's wishes regardless of outcome, even if he's not yet in power, or (again) make a mess for the new president to clean up.
I'm a big fan of a two-year budget (including debt ceiling) process that starts right after everyone is sworn in. This way, all the new people can set their direction as soon as they are sworn in, instead of a prior Congress or president sandbagging them.
Or am I making too much of this?
[editted for typos]
submitted by satans_toast to centrist [link] [comments]


2023.06.04 21:06 Thehomescents Essential Oils vs Candles: What is Best You Can Pick in the End?

Many of us strive to create comfortable homes, but the way to achieve the desired setting depends on the personal tastes of each. A pleasant scent can help you get in the mood for rest, or on the contrary. Be that as it may, both scented candles and modern analogs in the form of essential oil diffusers will be appropriate in both cases. Each option has individual advantages and disadvantages, so choosing the ideal solution should handle it carefully.
Essential oils vs candles

Essential Oils vs. Fragrance Oils in Candles

Humanity has used candles since time immemorial. Burning candles with fragrance oils is the realization of several purposes at once: lighting the room, warmth, and scenting the space around the candle.
essential oils vs candles
It’s unlikely to achieve a subtle yet continuous aroma for a long time from such items, so it is worth considering the use of essential oils in diffusers. If you are not familiar with both options, we will fix that. What’s the difference between the scented candle and the essential oil diffuser? It’s worth finding out.

Essential Oils

Some of us have probably heard about the power of ester oils, as such substances increase physical and emotional health.
It’s hard to find a candle consisting of pure essential oils, but infusing pure oils into a device is possible.
essential oils
Be that as it may, the vaporization of even an all-natural product from herbal ingredients (usually extracted directly) does not guarantee a positive influence on the human organism and the surrounding environment in general. It is for this reason that essential oils require special attention.

Fragrance Oils

Unlike essential oils added to candles, scented oils are synthetically produced and designed specifically for cosmetics and candles.
fragrance oils
Each ingredient is tested and validated only after approval by RIFM and IFRA.
Sometimes fragrance oil is used to fill an essential oil diffuser, making it versatile. That is, you can buy any product, which means there are more scent options.

Great Scent Debate: Compare Products by Main Categories

To determine which product is the best for you, it’s always worth evaluating it with several criteria. These are primarily health benefits and sleep quality when using scented items. Whether looking to purchase a diffuser and its oil bottles or confidence that scented candles provide the right level of comfort and benefit, it’s important to consider applying essential oils with the following characteristics in mind.

Toxins

Some people are sure that a candle with oils spreads toxins when the waxing melts. Usually, this is more true of paraffin waxes, where a few drops of aroma oils.
Hot wax (soy or bee type) will be much safer for your health, but they still cause some damage to the environment.
Also, don’t exclude the fact that in many the glass jar with a candle is filled with wax with fake fragrances, and even scented lavender oil can be a cheap knockoff of a natural product.
Ultrasonic diffusers are filled only with an all-natural lineup. Fragrance oil emits negative ions, which clean the air of allergens and cause the production of the happiness hormone in the human body. Diffusers are hardly prone to spread toxins.
Note: When aromatic oils burn at high temperatures, their molecular structure changes, reducing the healing effect.

Scent

Whether you like essential oils derived right from herbs or prefer to buy items with a lighter flavor, it’s a good decision. Scent options abound. Which one is the most persistent and can expand your possibilities?
Fragrance options are available. Which one is most persistent and can expand your abilities?
The scent released from candles is often quite strong, but if you choose a cheaper option product, it isn’t a guarantee that you will be able to reap the health benefits.
When the wax melts, its scent is by the pleasant aroma of the candle’s essential oils. In addition, after extinguishing, you can feel the unpleasant smell of the smoldering wick. It’s not the best home fragrance.
Most diffusers successfully solve the problems of candles so the environment doesn’t suffer from harmful substances emitted during combustion (an advantage over burning candles).
You can create a suitable blend of natural essential oils. It will help relieve stress after a hard day’s work. The main thing is that your personal choice has a positive effect.

Odor persistence

A single burning candle can have a distinct aroma. However, unadulterated essential oils poured into candles are not retaining their original scent characteristics for long periods.
A standard waxing candle (8 oz.) typically extinguishes within approximately 40-50 hours of burning, while the lighter scent emanating from the diffuser will keep you happy for 80 hours (if you use 5 ml of essential oil).
Note: To save your favorite fragrance in the air as long as possible, it’s worth activating the interval mode on the diffuser. That can be a new window of opportunity for you because you won’t have to add oil for 10-14 hours.

Aromatherapy Effectiveness of Diffusing Essential Oils and Aroma Candles

While pure essential oils are safer and cleaner options, different scents of burning candles help create a cozy atmosphere. Their internal heat and the light emanating from the open flame are even more conducive to relaxation, not to mention the pleasant aroma.
The essential oil diffuser also has its benefits in the aromatherapy process. Some models have lighting. It will bring style to your surroundings.
As we said before, the pleasant aroma of fragrance oils that emanates from it doesn’t change its intensity over time.

Safety

For many people, a diffuser is the safest idea when choosing an odor dispenser for the home. It makes sense because even the glass of the cup isn’t always able to protect against open flame unattended. In addition, the cup can break, and broken glass is an additional source of injury.
If you can not constantly monitor the burning of the candle during aromatherapy, buy a diffuser. It is always a safer and cleaner option.

Cost

One candle isn’t the same as the other candles, but so are different models of diffusers. Determine which one will be cost effective and review the full page of available products.
If you plan to have aromatherapy sessions only on rare occasions, you can buy a candle with one scent or even a few with different fragrances. They cost between $1 and $100. Light and warmth from them will be a nice bonus to the fragrance.
If you need to change candle scents to improve your mood, it is better to buy a diffuser. The natural oil scents that emanate from it will constantly delight you, but the cost of the device and oils will be higher.
On average, a diffuser will cost between $15 and $75.
essential oils vs candles

Are Essential Oils Better for You than Candles?

Pure essential oil without burning particles is better for the organism, but only if you follow the dosage and have no health problems. A candle is suitable for occasional use, and not all essential oils give the desired scent (aroma oil is a good pick).

Why Choose Essential Oils Over Candles?

The use of scented candles is simple. At first, the smell from the candle can be strong, but the scent is lost. They are commonplace. The essential oils from the device remain stable with their naturalness and toxic safety. They smell longer than a candle.

Are Oil Diffusers Less Toxic than Candles?

The answer is yes. The scents emanating from them are clean, and the operation of the device doesn’t cause the emission of harmful chemical compounds into the air.

Can Essential Oils Replace Candles?

If you are used to the regime, whether you visit the gym regularly or prefer to enjoy burning a scented candle after work, this is unlikely to change soon. In addition to a pleasant fragrance, a wax product creates an atmosphere, so it’s too early to give it up in favor of modern devices.

Scented Candlesor Essential Oil: What to Pick in the End?

Both products are popular today. If you enjoy aromatherapy, using a diffuser is more cost-effective than a scented candle. Create a romantic setting and watch the open flame. You can always buy wax candles with lavender or other herbal oil. Candle burning can make all your dreams come true.
from The Home Scents https://www.thehomescents.com/essential-oils-vs-candle-what-is-best-you-can-pick-in-the-end/
via IFTTT
submitted by Thehomescents to Fragrances [link] [comments]


2023.06.04 21:03 diegorbb93 [Preservation Report] Redump “Shippūden”, a powerful return to take over Sony Playstation 3

[Preservation Report] Redump “Shippūden”, a powerful return to take over Sony Playstation 3
\"これだよ...This is It, folks! \"
One of the most interesting phenomena I’ve witnessed these years on the gaming preservation scene came from the “inertia”. Like a domino falling down one piece to another, I can’t count how many times I’ve seen one user pushing something whose effort would be followed by another one… And another one… And another one… Like the butterfly effect.
What became a simple project to dump some Wii discs, would start a revolution that would leadl VGPC to have the set fully dumped across all regions. Same with Playstation Portable, leading to dozens of UMDs getting dumped in Europe, not to count when the best dumpers in Redump started to punch the hell out the Japanese set and made a significant impact.
In this case, I must remind you about what happened in the last months:
https://www.reddit.com/emulation/comments/zsyc73/fundraiser_campaign_report_11k_dumps_11k_thank/
After our successful fundraiser campaign, the whole “search and buy” operation to buy every single undumped disc from our Missing lists was accelerated to the point where December and January became a wild hunting season to document and dump the remaining set and put a wonderful end to the Sony Playstation 2 Missing List in Redump. Up to this day, that means that 99% of the existing retail titles developed for the console have been dumped, with only 2-3 retail titles from Korea having exclusive software remaining to be dumped.
However, the massive energy we put on this project generated a powerful “inertia”… Do you think that the guys in charge of this project would stop there? You were wrong.
As we promised last time, no more fundraising campaigns would be pushed as we felt that the community had been generous enough with us. My partners and I felt that asking again for money wasn’t something in our cards, so this time, they took the following path by themselves.

https://preview.redd.it/wd1668w6o14b1.png?width=1244&format=png&auto=webp&v=enabled&s=5ddafef7d0d418ef8562c6cc44745367b407b791
When Redump started to push PS3 dumping, the rules were clear: While we needed to provide a clean ISO dump for the Blu-ray as it was (that means, encrypted), a tool was developed to extract the Disc Key that would allow us to decrypt the data. In the end, while we push proper preservation, having encrypted dumps with no functionality at all isn’t cool or productive.
However, providing the Disc Key wasn’t something we forced users to do. To dump them, a hacked PS3 or specific dumping hardware from the PS3 Scene was needed, so as long as one user delivered a clean dump with a BD writer, it could be added to Redump.
This generated a couple of problematic scenarios:
  1. A lot of MIAs. We had a lot of users who submitted dumps to Redump but never shared the main data.
  2. A lot of missing Disc Keys, so even if we had the data, it would not be useful as it was encrypted.
Now combine both cases and check the following lists:
- Up to this day
o http://wiki.redump.org/index.php?title=Sony_PlayStation_3_Japan_Missing_Dumps
o http://wiki.redump.org/index.php?title=Sony_PlayStation_3_MIA
- August/September 2022
o http://wiki.redump.org/index.php?title=Sony_PlayStation_3_Japan_Missing_Dumps&oldid=51055
o http://wiki.redump.org/index.php?title=Sony_-_PlayStation_3_MIA&oldid=50964
- December 2021
o http://wiki.redump.org/index.php?title=Sony_PlayStation_3_Japan_Missing_Dumps&oldid=47181
o http://wiki.redump.org/index.php?title=Sony_-_PlayStation_3_MIA&oldid=47129

In the interval of one year...

  • We rebuilt our whole Missing List and improved the existing Serial ID documentation
  • Took down more than 200 MIA titles leaving the actual number to 35
  • Made sure most of the Japan missing data was redumped, retrieved the necessary Disc Keys for all of them.
  • All while buying and dumping the remaining missing games.
In the last five months, after the successful PS2 campaign, our dear partners behind this established a similar vision to approach Sony Playstation 3. While the amount of discs pending to be bought wasn’t as big as PS2, dumping BDs can take longer and of course, it also takes time to write all the documentation needed to submit them to Redump.
But they didn’t hesitate. And again, they delivered. By the time I’m posting this, at least one version of all retail games ever produced for Sony Playstation 3 in Japan will be dumped and submitted. Similar to one of the massive Rasengans by Naruto’s most powerful form, my friends made sure we could strike this massive boss to the ground and beat it forever.
As always, this doesn’t mean the job is done… While we dumped the America full-set and have all the European set covered, there’s a big amount of stuff from Europe like Scandinavia regions, Netherlands, Poland, Austria, etc… We think that a lot of undocumented regional releases for the United Arab Emirates exist, not to mention South Africa or India. And finally, Korea and Asia regions have a massive amount of titles remaining undumped:
- http://wiki.redump.org/index.php?title=Sony_PlayStation_3_PAL_Missing_Dumps
- http://wiki.redump.org/index.php?title=Sony_PlayStation_3_Korea_Missing_Dumps
- http://wiki.redump.org/index.php?title=Sony_PlayStation_3_Asia_Missing_Dumps
I still need to confirm if any of these regions have any exclusive retail games we aren’t aware of (Korea usually provides some specific releases you won’t find in other region).

So… Where are we now?

Well, I’ve expressed my opinion several times before and there’s nothing I can add at this point. While our illusion has always been to see these Missing lists as empty as possible, the chance of improving and continue dumping for those regions in the same way we did is not just possible. These countries have a bad second hand market, overpriced games, more difficulties to buy online and lack of users helping with it.
When we reach this breaking point, the amount of energy, money and time pushed through slows down as priorities changes. In this case, we will have to put our focus on Sony Playstation Portable, where the situation is rather bad.
While the Scene dumped the whole full-set in Japan, Redump has been trying to make a better research for preservation as well as dumping verifications, because we continue to find badly dumped titles that need to be fixed. And sadly, the amount of Japanese games that we lack is…, quite big. PSP produced a massive amount of software for the country, not to count alternative releases/reprints.
Meanwhile, we are still lacking stuff from America and Europe, which is frustrating as we should have already managed to end those sets by now (of course, the problem comes from countries like Canada or European regions like France or Germany or Scandinavian countries).
This challenge marks our last big task for Sony Playstation preservation when it comes to the Redump.org database (PS4 & PS5 aside, which honestly, are a whole different conversation I’m not bringing here).

Anything else to add? Yeah, we present you Nkit v2!

Yes! The users have been waiting an answer when it comes to data handling. Users from Wii will probably remember “NKit” tool! This software created by Nanook brought us the NKit format for GC & Wii data in order to be useful and compressed. In time, while Dolphin Team created the format “RVZ”, Nanook was already working on NKit v2, since then RVZ support has been added and NKit format writing deprecated…
… He decided to establish Nkit v2 as a “multiplatform disc image processor (written in C#/DotNet6.0) primarily aimed at game preservation; capable of reading multiple formats, containers and archives for various systems. Tools that convert, scan, extract, fix, edit etc. and provide a nice and useful way to convert your data into different formats!”

A little picture from the app
https://github.com/Nanook/NKit/wiki
And yeah! That includes decrypting/encrypting PS3 images in batch mode, providing at the same time a simple analysis to confirm the conversion was correct! Testers have recently gave a pass over the whole PS3 library, which confirmed all the existing decryption keys in Redump were good.
Cheers to some of the folks from RPCS3 who helped Nanook confirming some of the theories he had in order to establish an easy method to make sure everything worked cool and simple!
NKit is still in active development, read the wiki for more information. I have no words to express my gratitude to Nanook, this tool has been essential to help us validate keys added to Redump and promises to keep us alert into any problem we can face with the existing set and the dumps to come.
Oh… And, in case you wonder… If you finally needed a deep & friendly tool to work with CHD… You better follow closer in the weeks to come, NKit has a strong answer for you all.
Some final words:
Again, the folks around VGPC keep doing their magic making sure no disc is left behind. As always I encourage the community to support us in any way you feel comfortable and keep pushing us for the best.
In case you wonder about the next rival, Xbox 360, we are reaching a breaking point into the USA region, where less than 50 discs remain undumped and less than 50 discs need a verification from the country. Our active dumpers are helping with new documentation that is improving ABGX as well as our database.
Finally, I want to encourage the community to keep helping with PS3 Sony Playstation Network contents on the NoPayStation project. The amount of content (DLC!) remaining undumped or not verified is still massive and by the time we least expect it, we’ll probably see Sony finally shutting down the whole place. Please, once those servers are gone, only what we saved will remain.
submitted by diegorbb93 to emulation [link] [comments]


2023.06.04 17:42 lamemane Self-service

I’ve been putting about 1k miles a month on my N, and the first service interval for my 2023 DCT just came up.
I’m planning on doing these myself until something serious needs to be replaced. So far I’ve inspected all of the fluids and replaced the oil/filter (the old oil still looked pretty clean). I’m also planning to take the car to have tires rotated in another 1k miles. Gonna take it to the shop for this since I don’t have a balancer.
Anything else yall have done for your first service?
submitted by lamemane to ElantraN [link] [comments]


2023.06.04 14:34 Dirtclodkoolaid AMA RESOLUTION 235

AMA RESOLUTION 235
AMA RESOLUTION 235 November 2018 INAPPROPRIATE USE OF CDC Guidelines FOR PRESCRIBING OPIOIDS (Entire Document)
“Resolution 235 asks that our AMA applaud the CDC for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths; and be it further, that no entity should use MME thresholds as anything more than guidance and that MME thresholds should not be used to completely prohibit the prescribing of, or the filling of prescriptions for, medications used in oncology care, palliative medicine care, and addiction medicine care: and be it further, that our AMA communicate with the nation’s largest pharmacy chains and pharmacy benefit managers to recommend that they cease and desist with writing threatening letters to physicians and cease and desist with presenting policies, procedures and directives to retail pharmacists that include a blanket proscription against filling prescriptions for opioids that exceed certain numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care; and be it further, that AMA Policy opposing the legislating of numerical limits on medication dosage, duration of therapy, numbers of pills/tablets, etc., be reaffirmed; and be it further, that physicians should not be subject to professional discipline or loss of board certification or loss of clinical privileges simply for prescribing opioids at a quantitative level that exceeds the MME thresholds found in the CDC Guidelines; and be it further, that our AMA encourage the Federation of State Medical Boards and its member boards, medical specialty societies, and other entities to develop improved guidance on management of pain and management of potential withdrawal syndromes and other aspects of patient care for “legacy patients” who may have been treated for extended periods of time with high-dose opioid therapy for chronic non-malignant pain.
RESOLVED, that our American Medical Association (AMA) applaud the Centers for Disease Control and Prevention (CDC) for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths
RESOLVED, that our AMA actively continue to communicate and engage with the nation’s largest pharmacy chains, pharmacy benefit managers, National Association of Insurance Commissioners, Federation of State Medical Boards, and National Association of Boards of Pharmacy in opposition to communications being sent to physicians that include a blanket proscription against filing prescriptions for opioids that exceed numerical thresholds without taking into account the diagnosis and previous response to treatment for a patient and any clinical nuances that would support such prescribing as falling within standards of good quality patient care.
RESOLVED, that our AMA affirms that some patients with acute or chronic pain can benefit from taking opioid pain medications at doses greater than generally recommended in the CDC Guideline for Prescribing Opioids for Chronic Pain and that such care may be medically necessary and appropriate, and be it further
RESOLVED, that our AMA advocate against misapplication of the CDC Guideline for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit patients’ medical access to opioid analgesia, and be it further
RESOLVED, that our AMA advocate that no entity should use MME (morphine milligram equivalents) thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guideline for Prescribing Opioids.””
Pain Management Best Practices Inter-Agency Task Force - Draft Report on Pain Management Best Practices: Updates, Gaps, Inconsistencies, and Recommendations Official Health and Human Services Department Released December 2018
“The Comprehensive Addiction and Recovery Act (CARA) of 2016 led to the creation of the Pain Management Best Practices Inter-Agency Task Force (Task Force), whose mission is to determine whether gaps in or inconsistencies between best practices for acute and chronic pain management exist and to propose updates and recommendations to those best practices. The Task Force consists of 29 experts who have significant experience across the disciplines of pain management, patient advocacy, substance use disorders, mental health, and minority health.”
In addition to identifying approximately 60 gaps in clinical best practices and the current treatment of pain in the United States, HHS PMTF provided recommendations for each of these major areas of concern. In alignment with their original charter, the PMTF will submit these recommendations to Congress to become our ‘National Pain Policy’. The 60+ gaps and inconsistencies with their recommendations will serve to fill gaps in pain treatment at both the state and federal level; and the overwhelming consensus was that the treatment of pain should be multimodal and completely individualized based on the individual patient. The heart of each recommendation in each section was a resounding call for individualization for each patient, in regards to both non-pharmacological and pharmacological modalities; including individualizations in both opioid and non-opioid pharmacological treatments.
While each of the gap+recommendation sections of what is poised to become our national pain policy is extremely important, one that stands out the most (in regards to opioid prescribing) is the Stigma section. Contained in this section is one of the core statements that shows our Health and Human Services agency - the one that should have always been looked to and followed - knew the true depth of the relationship (or lack of) between the overdose crisis and compassionate prescribing to patients with painful conditions:
“The national crisis of illicit drug use, with overdose deaths, is confused with appropriate therapy for patients who are being treated for pain. This confusion has created a stigma that contributes to raise barriers to proper access to care.”
The recommendation that follows - “Identify strategies to reduce stigma in opioid use so that it is never a barrier to patients receiving appropriate treatment, with all cautions and considerations for the management of their chronic pain conditions” - illustrates an acknowledgment by the top health agency of the federal government that the current national narrative conflating and confusing compassionate treatment of pain with illicit drug use, addiction, and overdose death is incorrect and only serving to harm patients.
Since March of 2016 when the CDC Guidelines were released, advocates, patients, clinicians, stakeholders, and others, have began pointing out limitations and unintended consequences as they emerged. In order to address the unintended consequences emerging from the CDC Guidelines, this task force was also charged with review of these guidelines; from expert selection, evidence selection, creation, and continuing to current misapplication in order to provide recommendations to begin to remedy these issues.
“A commentary by Busse et al. identified several limitations to the CDC guideline related to expert selection, evidence inclusion criteria, method of evidence quality grading, support of recommendations with low-quality evidence, and instances of vague recommendations. In addition, the CDC used the criterion of a lack of clinical trials with a duration of one year or longer as lack of evidence for the clinical effectiveness of opioids, whereas Tayeb et al. found that that was true for all common medication and behavioral therapy studies.
Interpretation of the guideline, in addition to some gaps in the guideline, have led to unintended consequences, some of which are the result of misapplication or misinterpretation of the CDC guideline.
However, at least 28 states have enacted legislation related to opioid prescription limits, and many states and organizations have implemented the guideline without recognizing that the intended audience was PCPs; have used legislation for what should be medical decision making by healthcare professionals; and have applied them to all physicians, dentists, NPs, and PAs, including pain specialists.441–444 Some stakeholders have interpreted the guideline as intended to broadly reduce the amount of opioids prescribed for treating pain; some experts have noted that the guideline emphasizes the risk of opioids while minimizing the benefit of this medication class when properly managed.”
“The CDC guideline was not intended to be model legislation for state legislators to enact”
“In essence, clinicians should be able to use their clinical judgment to determine opioid duration for their patients”
https://www.hhs.gov/ash/advisory-committees/pain/reports/2018-12-draft-report-on-updates-gaps-inconsistencies-recommendations/index.html
HHS Review of 2016 CDC Guidelines for responsible opioid prescribing
The Pain Management Task Force addressed 8 areas that are in need of update or expansion with recommendations to begin remediation for each problem area:
Lack of high-quality data exists for duration of effectiveness of opioids for chronic pain; this has been interpreted as a lack of benefit Conduct studies Focus on patient variability and response for effectiveness of opioids; use real-world applicable trials
Absence of criteria for identifying patients for whom opioids make up significant part of their pain treatment Conduct clinical trials and/or reviews to identify sub-populations of patients where long-term opioid treatment is appropriate
Wide variation in factors that affect optimal dose of opioids Consider patient variables for opioid therapy: Respiratory compromise Patient metabolic variables Differences in opioid medications/plasma concentrations Preform comprehensive initial assessment it’s understanding of need for comprehensive reevaluations to adjust dose Give careful considerations to patients on opioid pain regimen with additional risk factors for OUD
Specific guidelines for opioid tapering and escalation need to be further clarified A thorough assessment of risk-benefit ratio should occur whenever tapering or escalation of dose This should include collaboration with patient whenever possible Develop taper or dose escalation guidelines for sub-populations that include consideration of their comorbidities When benefit outweighs the risk, consider maintaining therapy for stable patients on long term opioid therapy
Causes of worsening pain are not often recognized or considered. Non-tolerance related factors: surgery, flares, increased physical demands, or emotional distress Avoid increase in dose for stable patient (2+ month stable dose) until patient is re-evaluated for underlying cause of elevated pain or possible OUD risk Considerations to avoid dose escalation include: Opioid rotation Non-opioid medication Interventional strategies Cognitive behavior strategies Complementary and integrative health approaches Physical therapy
In patients with chronic pain AND anxiety or spasticity, benzodiazepine co-prescribed with opioids still have clinical value; although the risk of overdose is well established When clinically indicated, co-prescription should be managed by specialist who have knowledge, training, and experience with co-prescribing. When co-prescribed for anxiety or SUD collaboration with mental health should be considered Develop clinical practice guidelines focused on tapering for co-prescription of benzodiazepines and opioids
The risk-benefit balance varies for individual patients. Doses >90MME may be favorable for some where doses <90MME may be for other patients due to individual patient factors. Variability in effectiveness and safety between high and low doses of opioids are not clearly defined. Clinicians should use caution with higher doses in general Using carefully monitored trial with frequent monitoring with each dose adjustment and regular risk reassessment, physicians should individualize doses, using lowest effective opioid dose that balances benefit, risk, and adverse reactions Many factors influence benefits and risk, therefore, guidance of dose should not be applied as strict limits. Use established and measurable goals: Functionality ADL Quality of Life
Duration of pain following acute and severely painful event is widely variable Appropriate duration is best considered within guidelines, but is ultimately determined by treating clinician. CDC recommendation for duration should be emphasized as guidance only with individualized patient care as the goal Develop acute pain management guidelines for common surgical procedures and traumas To address variability and provide easy solution, consideration should be given to partial refill system
Human Rights Watch December 2018 (Excerpt from 109 page report)
“If harms to chronic pain patients are an unintended consequence of policies to reduce inappropriate prescribing, the government should seek to immediately minimize and measure the negative impacts of these policies. Any response should avoid further stigmatizing chronic pain patients, who are increasingly associated with — and sometimes blamed for — the overdose crisis and characterized as “drug seekers,” rather than people with serious health problems that require treatment.
Top government officials, including the President, have said the country should aim for drastic cutbacks in prescribing. State legislatures encourage restrictions on prescribing through new legislation or regulations. The Drug Enforcement Administration (DEA) has investigated medical practitioners accused of overprescribing or fraudulent practice. State health agencies and insurance companies routinely warn physicians who prescribe more opioids than their peers and encourage them to reduce prescribing. Private insurance companies have imposed additional requirements for covering opioids, some state Medicaid programs have mandated tapering to lower doses for patients, and pharmacy chains are actively trying to reduce the volumes of opioids they dispense.
The medical community at large recognized that certain key steps were necessary to tackle the overdose crisis: identifying and cracking down on “pill mills” and reducing the use of opioids for less severe pain, particularly for children and adolescents. However, the urgency to tackle the overdose crisis has put pressure on physicians in other potentially negative ways: our interviews with dozens of physicians found that the atmosphere around prescribing for chronic pain had become so fraught that physicians felt they must avoid opioid analgesics even in cases when it contradicted their view of what would provide the best care for their patients. In some cases, this desire to cut back on opioid prescribing translated to doctors tapering patients off their medications without patient consent, while in others it meant that physicians would no longer accept patients who had a history of needing high-dose opioids.
The consequences to patients, according to Human Rights Watch research, have been catastrophic.”
[https://www.hrw.org/report/2018/12/18/not-allowed-be-compassionate/chronic-pain-overdose-crisis-and-unintended-harms-us](
Opioid Prescribing Workgroup December 2018
This is material from the Board of Scientific Counselors in regards to their December 12, 2018 meeting that culminated the works of a project titled the “Opioid Prescribing Estimates Project.” This project is a descriptive study that is examining opioid prescribing patterns at a population level. Pain management is a very individualized process that belongs with the patient and provider. The Workgroup reviewed work done by CDC and provided additional recommendations.
SUMMARY There were several recurrent themes throughout the sessions.
Repeated concern was voiced from many Workgroup members that the CDC may not be able to prevent conclusions from this research (i.e. the benchmarks, developed from limited data) from being used by states or payors or clinical care systems to constrain clinical care or as pay-for- performance standards – i.e. interpreted as “guidelines”. This issue was raised by several members on each of the four calls, raising the possibility that providers or clinical systems could thus be incentivized against caring for patients requiring above average amounts of opioid medication.
Risk for misuse of the analysis. Several members expressed concerns that this analysis could be interpreted as guidance by regulators, health plans, or clinical care systems. Even though the CDC does not plan to issue this as a guideline, but instead as research, payors and clinical care systems searching for ways to reign in opioid prescribing may utilize CDC “benchmarks” to establish pay-for-performance or other means to limit opioid prescribing. Such uses of this work could have the unintended effect of incentivizing providers against caring for patients reliant upon opioids.
…It was also noted that, in order to obtain sufficient granularity to establish the need for, dosage, and duration of opioid therapy, it would be necessary to have much more extensive electronic medical record data. In addition, pain and functional outcomes are absent from the dataset, but were felt to be important when considering risk and benefit of opioids.
...Tapering: Concerns about benchmarks and the implications for tapering were voiced. If tapering occurs, guidance was felt to be needed regarding how, when, in whom tapering should occur. This issue was felt to be particularly challenging for patients on chronic opioids (i.e. “legacy” patients). In addition, the importance of measuring risk and benefit of tapering was noted. Not all high-dose patient populations benefit from tapering.
Post-Surgical Pain
General comments. Workgroup members noted that most patients prescribed opioids do not experience adverse events, including use disorder. Many suggested that further discussion of opioids with patients prior to surgery was important, with an emphasis on expectations and duration of treatment. A member suggested that take-back programs would be more effective than prescribing restrictions.
Procedure-related care. Members noted that patient factors may drive opioid need more than characteristics of a procedure.
Patient-level factors. Members noted that opioid-experienced patients should be considered differently from opioid-inexperienced patients, due to tolerance.
Chronic Pain
It was noted that anything coming out of the CDC might be considered as guidelines and that this misinterpretation can be difficult to counter. There was extensive discussion of the 50 and 90 MME levels included in the CDC Guidelines. It was recommended that the CDC look into the adverse effects of opioid tapering and discontinuation, such as illicit opioid use, acute care utilization, dropping out of care, and suicide. It was also noted that there are major gaps in guidelines for legacy patients, patients with multiple diagnoses, pediatric and geriatric patients, and patients transitioning to lower doses.
There were concerns that insufficient clinical data will be available from the dataset to appropriately consider the individual-level factors that weigh into determination of opioid therapy. The data would also fail to account for the shared decision-making process involved in opioid prescribing for chronic pain conditions, which may be dependent on primary care providers as well as ancillary care providers (e.g. physical therapists, psychologists, etc).
Patient-level factors. Members repeatedly noted that opioid-experienced patients should be considered differently from opioid-experienced patients, due to tolerance.
Members noted that the current CDC guidelines have been used by states, insurance companies, and some clinical care systems in ways that were not intended by the CDC, resulting in cases of and the perception of patient abandonment. One option raised in this context was to exclude patients on high doses of opioids, as those individuals would be qualitatively different from others. A variant of this concern was about management of “legacy” patients who are inherited on high doses of opioids. Members voiced concerns that results of this work has caused harm to patients currently reliant upon opioids prescribed by their providers.
Acute Non-Surgical Pain
Patient-level factors. Members felt that opioid naïve versus experienced patients might again be considered separately, as opioid requirements among those experienced could vary widely.
...Guidelines were also noted to be often based on consensus, which may be incorrect.
Cancer-Related and Palliative Care Pain
It was noted that the CDC guidelines have been misinterpreted to create a limit to the dose of opioids that can be provided to people at all stages of cancer and its treatment. It was also noted that the cancer field is rapidly evolving, with immunotherapy, CAR-T, and other novel treatments that affect response rates and limit our ability to rely upon historical data in establishing opioid prescribing benchmarks.
Concern that data would not be able to identify all of the conditions responsible for pain in a patient with a history of cancer (e.g. people who survive cancer but with severe residual pain). Further, it was noted that certain complications of cancer and cancer treatment may require the least restrictive long-term therapy with opioids.
The definition of palliative care was also complicated and it was suggested that this include patients with life-limiting conditions.
Overall, it was felt that in patients who may not have long to live, and/or for whom returning to work is not a possibility, higher doses of opioids may be warranted.
https://www.cdc.gov/injury/pdfs/bsc/NCIPC_BSC_OpioidPrescribingEstimatesWorkgroupReport_December-12_2018-508.pdf
CDC Scientists Anonymous ‘Spider Letter’ to CDC
Carmen S. Villar, MSW Chief of Staff Office of the Director MS D­14 Centers for Disease Control and Prevention (CDC) 1600 Clifton Road Atlanta, Georgia 30329­-4027
August 29, 2016
Dear Ms. Villar:
We are a group of scientists at CDC that are very concerned about the current state of ethics at our agency. It appears that our mission is being influenced and shaped by outside parties and rogue interests. It seems that our mission and Congressional intent for our agency is being circumvented by some of our leaders. What concerns us most, is that it is becoming the norm and not the rare exception. Some senior management officials at CDC are clearly aware and even condone these behaviors. Others see it and turn the other way. Some staff are intimidated and pressed to do things they know are not right. We have representatives from across the agency that witness this unacceptable behavior. It occurs at all levels and in all of our respective units. These questionable and unethical practices threaten to undermine our credibility and reputation as a trusted leader in public health. We would like to see high ethical standards and thoughtful, responsible management restored at CDC. We are asking that you do your part to help clean up this house!
It is puzzling to read about transgressions in national media outlets like USA Today, The Huffington Post and The Hill. It is equally puzzling that nothing has changed here at CDC as a result. It’s business as usual. The litany of issues detailed over the summer are of particular concern:
Recently, the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) has been implicated in a “cover up” of inaccurate screening data for the Wise Woman (WW) Program. There was a coordinated effort by that Center to “bury” the fact that screening numbers for the WW program were misrepresented in documents sent to Congress; screening numbers for 2014 and 2015 did not meet expectations despite a multi­million dollar investment; and definitions were changed and data “cooked” to make the results look better than they were. Data were clearly manipulated in irregular ways. An “internal review” that involved staff across CDC occurred and its findings were essentially suppressed so media and/or Congressional staff would not become aware of the problems. Now that both the media and Congresswoman DeLauro are aware of these issues, CDC staff have gone out of their way to delay FOIAs and obstruct any inquiry. Shouldn’t NCCDPHP come clean and stop playing games? Would the ethical thing be to answer the questions fully and honestly. The public should know the true results of what they paid for, shouldn’t they?
Another troubling issue at the NCCDPHP are the adventures of Drs. Barbara Bowman and Michael Pratt (also detailed in national media outlets). Both seemed to have irregular (if not questionable) relationships with Coca­Cola and ILSI representatives. Neither of these relationships were necessary (or appropriate) to uphold our mission. Neither organization added any value to the good work and science already underway at CDC. In fact, these ties have now called into question and undermined CDC’s work. A cloud has been cast over the ethical and excellent work of scientists due to this wanton behavior. Was cultivating these relationships worth dragging CDC through the mud? Did Drs. Bowman and Pratt have permission to pursue these relationships from their supervisor Dr. Ursula Bauer? Did they seek and receive approval of these outside activities? CDC has a process by which such things should be vetted and reported in an ethics review, tracking and approval system (EPATS). Furthermore, did they disclose these conflicts of interest on their yearly OGE 450 filing. Is there an approved HHS 520, HHS 521 or “Request for Official Duty Activities Involving an Outside Organization” approved by Dr. Bauer or her Deputy Director Ms. Dana Shelton? An August 28, 2016 item in The Hill details these issues and others related to Dr. Pratt.
It appears to us that something very strange is going on with Dr. Pratt. He is an active duty Commissioned Corps Officer in the USPHS, yet he was “assigned to” Emory University for a quite some time. How and under what authority was this done? Did Emory University pay his salary under the terms of an IPA? Did he seek and receive an outside activity approval through EPATS and work at Emory on Annual Leave? Formal supervisor endorsement and approval (from Dr. Bauer or Ms. Shelton) is required whether done as an official duty or outside activity.
If deemed official, did he file a “Request for Official Duty Activities Involving an Outside Organization” in EPATS? Apparently Dr. Pratt’s position at Emory University has ended and he has accepted another position at the University of California ­ San Diego? Again, how is this possible while he is still an active duty USPHS Officer. Did he retire and leave government service? Is UCSD paying for his time via an IPA? Does he have an outside activity approval to do this? Will this be done during duty hours? It is rumored that Dr. Pratt will occupy this position while on Annual Leave? Really? Will Dr. Pratt be spending time in Atlanta when not on Annual Leave? Will he make an appearance at NCCDPHP (where he hasn’t been seen for months). Most staff do not enjoy such unique positions supported and approved by a Center Director (Dr. Bauer). Dr. Pratt has scored a sweet deal (not available to most other scientists at CDC). Concerns about these two positions and others were recently described in The Huffington Post and The Hill. His behavior and that of management surrounding this is very troubling.
Finally, most of the scientists at CDC operate with the utmost integrity and ethics. However, this “climate of disregard” puts many of us in difficult positions. We are often directed to do things we know are not right. For example, Congress has made it very clear that domestic funding for NCCDPHP (and other CIOs) should be used for domestic work and that the bulk of NCCDPHP funding should be allocated to program (not research). If this is the case, why then is NCCDPHP taking domestic staff resources away from domestic priorities to work on global health issues? Why in FY17 is NCCDPHP diverting money away from program priorities that directly benefit the public to support an expensive research FOA that may not yield anything that benefits the public? These actions do not serve the public well. Why is nothing being done to address these problems? Why has the CDC OD turned a blind eye to these things. The lack of respect for science and scientists that support CDC’s legacy is astonishing.
Please do the right thing. Please be an agent of change.
Respectfully,
CDC Spider (CDC Scientists Preserving Integrity, Diligence and Ethics in Research)
https://usrtk.org/wp-content/uploads/2016/10/CDC_SPIDER_Letter-1.pdf
January 13, 2016
Thomas Frieden, MD, MPH Director Centers for Disease Control and Prevention 1600 Clifton Road Atlanta, GA 30329-4027
Re: Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain
Dear Dr. Frieden:
There is no question that there is an opioid misuse epidemic and that efforts need to be made to control it. The Centers for Disease Control and Prevention (CDC) is applauded for its steps to undertake this lofty effort. However, based on the American Academy of Family Physicians’ (AAFP’s) review of the guideline, it is apparent that the presented recommendations are not graded at a level consistent with currently available evidence. The AAFP certainly wants to promote safe and appropriate prescribing of opioids; however, we recommend that the CDC still adhere to the rigorous standards for reliable and trustworthy guidelines set forth by the Institute of Medicine (IOM). The AAFP believes that giving a strong recommendation derived from generalizations based on consensus expert opinion does not adhere to evidence-based standards for developing clinical guideline recommendations.
The AAFP’s specific concerns with the CDC’s methodology, evidence base, and recommendations are outlined below.
Methodology and Evidence Base
All of the recommendations are based on low or very low quality evidence, yet all but one are Category A (or strong) recommendations. The guideline states that in the GRADE methodology "a particular quality of evidence does not necessarily imply a particular strength of recommendation." While this is true, it applies when benefits significantly outweigh harms (or vice versa). When there is insufficient evidence to determine the benefits and harms of a recommendation, that determination should not be made.
When evaluating the benefits of opioids, the evidence review only included studies with outcomes of at least one year. However, studies with shorter intervals were allowed for analysis of the benefits of nonopioid treatments. The guideline states that no evidence shows long-term benefit of opioid use (because there are few studies), yet the guideline reports "extensive evidence" of potential harms, even though these studies were of low quality. The accompanying text also states "extensive evidence" of the benefits of non-opioid treatments, yet this evidence was from shorter term studies, was part of the contextual review rather than the clinical systematic review, and did not compare non- opioid treatments to opioids.
The patient voice and preferences were not explicitly included in the guideline. This raises concerns about the patient-centeredness of the guideline.
https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/risk/LT-CDC-OpioidGuideline011516.pdf The Myth of Morphine Equivalent Daily Dosage Medscape Neuro Perspective
For far too many years, pain researchers and clinicians have relied on the concept of the morphine equivalent daily dosage (MEDD), or some variant of it, as a means of comparing the "relative corresponding quantity" of the numerous opioid molecules that are important tools in the treatment of chronic pain.
...And, most unfortunately, opioid prescribing guideline committees have relied on this concept as a means of placing (usually arbitrary) limits on the levels of opioids that a physician or other clinician should be allowed to prescribe. Although these guidelines typically bill themselves as "voluntary," their chilling effect on prescribers and adaptation into state laws[2] makes calling them "voluntary" disingenuous.
Although some scientists and clinicians have been questioning the conceptual validity of MEDD for several years, a recent study[3] has indicated that the concept is unequivocally flawed—thereby invalidating its use empirically and as a tool in prescribing guideline development.
The authors used survey data from pharmacists, physicians, nurse practitioners, and physician assistants to estimate daily morphine equivalents and found great inconsistency in their conversions of hydrocodone, fentanyl transdermal patches, methadone, oxycodone, and hydromorphone—illustrating the potential for dramatic underdosing or, in other cases, fatal overdosing.
Patients with chronic pain (particularly that of noncancer origin) who are reliant on opioid analgesia are already sufficiently stigmatized and marginalized[7] to allow this type of practice to continue to be the norm.
Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (eg, the Washington State Opioid Guideline Committee[8] and the Centers for Disease Control and Prevention Guideline Committee[9]) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance. Furthermore, their misconduct in doing so has been more pernicious than the use of MEDD by researchers and individual clinicians, because these guidelines widely affect society as a whole as well as individual patients with persistent pain syndromes. We opine that these committees are strongly dominated by the antiopioid community, whose agenda is to essentially restrict opioid access—irrespective of the lack of data indicating that opioids cannot be a useful tool in the comprehensive treatment of carefully selected and closely monitored patients with chronic pain.
Above 100% extracted from: Medscape Journal Brief https://www.medscape.com/viewarticle/863477_2
Actual Study https://www.dovepress.com/the-medd-myth-the-impact-of-pseudoscience-on-pain-research-and-prescri-peer-reviewed-article-JPR
Are Non-Opioid Medications Superior in Treatment of Pain than Opioid Pain Medicine? Ice Cream Flavor Analogy...
In the Oxford University Press, a November 2018 scientific white paper[5] was released that examined the quality of one of the primary studies that have been used to justify the urgent call to drastically reduce opioid pain medication prescribing while claiming that patients are not being harmed in the process.
The study is commonly referred to as ‘the Krebs study’. “The authors concluded that treatment with opioids was not superior to treatment with non opioid medications for improving pain-related function over 12 months.”
Here is an excerpt from the first paragraph of the design section (usually behind a paywall) from the Krebs study that gives the first hint of the bias that led to them to ‘prove’ that opioids were not effective for chronic pain:
“The study was intended to assess long-term outcomes of opioids compared with non opioid medications for chronic pain. The patient selection, though, specifically excluded patients on long-term opioid therapy.” 
Here is an analogy given in the Oxford Journal white paper to illustrate how the study design was compromised:
If I want to do a randomized control study about ice cream flavor preferences (choices being: vanilla, chocolate, or no preference), the results could be manipulated as follows based on these scenarios:
Scenario A: If a study was done that included only current ice-cream consumers, the outcome would certainly be vanilla or chocolate, because of course they have tried it and know which they like.
Scenario B: If a study was done that included all consumers of all food, then it can change the outcome. If the majority of study participants do not even eat ice-cream, than the result would certainly be ‘no preference’. If the majority do eat ice-cream it would likely be ‘chocolate’. Although this study is wider based, it still does not reflect real world findings.
Scenario C: In an even more extreme example, if this same study is conducted excluding anyone who has ever ate ice-cream at all, then the conclusion will again be ‘no preference’ and the entire study/original question becomes so ludicrous that there is no useful information to be extracted from this study and one would logically question why this type of study would even be conducted (although we know the answer to that)
Scenario C above is how the study that has been used to shift the attitudes towards the treatment of pain in our nation's medical community was designed. “One has to look deep into the study to find that they began with 9403 possible patients and excluded 3836 of them just because they had opioids in their EMR. In the JAMA article, they do not state these obvious biases and instead begin the explanation of participants stating they started with 4485 patients and excluded 224 who were opioid or benzo users.” That is the tip of the iceberg to how it is extremely misleading. The Oxford white paper goes into further detail of the studies “many flaws and biases (including the narrow focus on conditions that are historically known to respond poorly to opioid medication management of pain)”, but the study design and participant selection criteria is enough to discredit this entire body of work. Based on study design alone, regardless of what happened next, the result would be that opioids are no more effective than NSAIDs and other non-opioid alternatives.
The DEA Is Fostering a Bounty Hunter Culture in its Drug Diversion Investigators[8]
A Good Man Speaks Truth to Power January 2019
Because I write and speak widely on public health issues and the so-called “opioid crisis”, people frequently send me references to others’ work. One of the more startling articles I’ve seen lately was published November 20, 2018 in Pharmacy Times. It is titled “Should We Believe Patients With Pain?”[9]. The unlikely author is Commander John Burke, “a 40-year veteran of law enforcement, the past president of the National Association of Drug Diversion Investigators, and the president and cofounder of the International Health Facility Diversion Association.”
The last paragraph of Commander Burke’s article is worth repeating here.
“Let’s get back to dealing with each person claiming to be in legitimate pain and believe them until we have solid evidence that they are scamming the system. If they are, then let’s pursue them through vigorous prosecution, but let’s not punish the majority of people receiving opioids who are legitimate patients with pain.”
This seems a remarkable insight from anyone in law enforcement — especially from one who has expressed this view in both Pain News Network, and Dr Lynn Webster’s video “The Painful Truth”. Recognizing Commander Burke’s unique perspective, I followed up by phone to ask several related questions. He has granted permission to publish my paraphrases of his answers here.
“Are there any available source documents which establish widely accepted standards for what comprises “over-prescription?” as viewed by diversion investigators?” Burke’s answer was a resounding “NO”. Each State and Federal Agency that investigates doctors for potentially illegal or inappropriate opioid prescribing is pretty much making up their own standards as they go. Some make reference to the 2016 CDC Guidelines, but others do not.
  1. “Thousands of individual doctors have left pain management practice in recent years due to fears they may be investigated, sanctioned, and lose their licenses if they continue to treat patients with opioid pain relievers.. Are DEA and State authorities really pursuing the worst “bad actors”, or is something else going on?
Burke’s answer: “Regulatory policy varies greatly between jurisdictions. But a hidden factor may be contributing significantly to the aggressiveness of Federal investigators. Federal Agencies may grant financial bonuses to their in-house diversion investigators, based on the volume of fines collected from doctors, nurse practitioners, PAs and others whom they investigate.

"No law enforcement agency at any level should be rewarded with monetary gain and/or promotion due to their work efforts or successes. This practice has always worried me with Federal investigators and is unheard of at the local or state levels of enforcement.”

Commander Burke’s revelation hit me like a thunder-clap. It would explain many of the complaints I have heard from doctors who have been “investigated” or prosecuted. It’s a well known principle that when we subsidize a behavior, we get more of it. Financial rewards to investigators must inevitably foster a “bounty hunter” mentality in some. It seems at least plausible that such bonuses might lead DEA regulators to focus on “low hanging fruit” among doctors who may not be able to defend themselves without being ruined financially. The practice is at the very least unethical. Arguably it can be corrupting.
I also inquired concerning a third issue:
  1. I read complaints from doctors that they have been pursued on trumped-up grounds, coerced and denied appropriate legal defense by confiscation of their assets – which are then added to Agency funds for further actions against other doctors. Investigations are also commonly announced prominently, even before indictments are obtained – a step that seems calculated to destroy the doctor’s practice, regardless of legal outcomes. Some reports indicate that DEA or State authorities have threatened employees with prosecution if they do not confirm improper practices by the doctor. Do you believe such practices are common?”

Burke’s answer: “I hear the same reports you do – and the irony is that such tactics are unnecessary. Lacking an accepted standard for over-prescribing, the gross volume of a doctor’s prescriptions or the dose levels prescribed to their patients can be poor indicators of professional misbehavior. Investigators should instead be looking into the totality of the case, which can include patient reports of poor doctor oversight, overdose-related hospital admissions, and patterns of overdose related deaths that may be linked to a “cocktail” of illicit prescribing. Especially important can be information gleaned from confidential informants – with independent verification – prior patients, and pharmacy information.”

No formal legal prosecution should ever proceed from the testimony of only one witness — even one as well informed as Commander John Burke. But it seems to me that it is high time for the US Senate Judiciary Committee to invite the testimony of others in open public hearings, concerning the practice of possible bounty hunting among Federal investigators.
C50 Patient, Civil Rights Attorney, Maine Department of Health, and Maine Legislature Collaborative Enacted Definition of Palliative Care
One suggestion that our organization would like to make is altering the definition of “palliative care” in such a manner that it can include high-impact or intractable patients; those who are not dying this year, but our lives have been shattered and/or shortened by our diseases and for whom Quality of Life should be the focus. Many of our conditions may not SIGNIFICANTLY shorten my life, therefore I could legitimately be facing 30-40 years of severe pain with little relief; that is no way to live and therefore the concern is a rapidly increasing suicide rate.
This is a definition that one of our coalition members with a civil rights attorney and the Maine Department of Health agreed upon and legislators enacted into statues in Maine. This was in response to a 100mme restriction. This attorney had prepared a lawsuit based on the Americans with Disability Act that the Department of Health in Maine agreed was valid; litigation was never the goal, it was always patient-centered care.
A. "Palliative care" means patient-centered and family-focused medical care that optimizes quality of life by anticipating, preventing and treating suffering caused by a medical illness or a physical injury or condition that substantially affects a patient's quality of life, including, but not limited to, addressing physical, emotional, social and spiritual needs; facilitating patient autonomy and choice of care; providing access to information; discussing the patient's goals for treatment and treatment options, including, when appropriate, hospice care; and managing pain and symptoms comprehensively. Palliative care does not always include a requirement for hospice care or attention to spiritual needs. B. "Serious illness" means a medical illness or physical injury or condition that substantially affects quality of life for more than a short period of time. "Serious illness" includes, but is not limited to, Alzheimer's disease and related dementias, lung disease, cancer, heart, renal or liver failure and chronic, unremitting or intractable pain such as neuropathic pain.
Here is the link to the most recent update, including these definitions within the entire statute: https://legislature.maine.gov/statutes/22/title22sec1726.html?fbclid=IwAR0dhlwEh56VgZI9HYczdjdyYoJGpMdA9TuuJLlQrO3AsSljIZZG0RICFZc
January 23, 2019
Dear Pharmacists,
The Board of Pharmacy has had an influx of communication concerning patients not able to get controlled substance prescriptions filled for various reasons, even when signs of forgery or fraudulence were not presented. As a result of the increased “refusals to fill,” the board is issuing the following guidance and reminders regarding the practice of pharmacy and dispensing of controlled substances:
  1. Pharmacists must use reasonable knowledge, skill, and professional judgment when evaluating whether to fill a prescription. Extreme caution should be used when deciding not to fill a prescription. A patient who suddenly discontinues a chronic medication may experience negative health consequences;
  2. Part of being a licensed healthcare professional is that you put the patient first. This means that if a pharmacist has any concern regarding a prescription, they should attempt to have a professional conversation with the practitioner to resolve those concerns and not simply refuse the prescription. Being a healthcare professional also means that you use your medication expertise during that dialogue in offering advice on potential alternatives, changes in the prescription strength, directions etc. Simply refusing to fill a prescription without trying to resolve the concern may call into question the knowledge, skill or judgment of the pharmacist and may be deemed unprofessional conduct;
  3. Controlled substance prescriptions are not a “bartering” mechanism. In other words, a pharmacist should not tell a patient that they have refused to fill a prescription and then explain that if they go to a pain specialist to get the same prescription then they will reconsider filling it. Again, this may call into question the knowledge, skill or judgment of the pharmacist;
  4. Yes, there is an opioid crisis. However, this should in no way alter our professional approach to treatment of patients in end-of-life or palliative care situations. Again, the fundamentals of using our professional judgment, skill and knowledge of treatments plays an integral role in who we are as professionals. Refusing to fill prescriptions for these patients without a solid medical reason may call into question whether the pharmacist is informed of current professional practice in the treatment of these medical cases.
  5. If a prescription is refused, there should be sound professional reasons for doing so. Each patient is a unique medical case and should be treated independently as such. Making blanket decisions regarding dispensing of controlled substances may call into question the motivation of the pharmacist and how they are using their knowledge, skill or judgment to best serve the public.
As a professional reminder, failing to practice pharmacy using reasonable knowledge, skill, competence, and safety for the public may result in disciplinary actions under Alaska statute and regulation. These laws are:
AS 08.80.261 DISCIPLINARY ACTIONS
(a)The board may deny a license to an applicant or, after a hearing, impose a disciplinary sanction authorized under AS 08.01.075 on a person licensed under this chapter when the board finds that the applicant or licensee, as applicable, …
(7) is incapable of engaging in the practice of pharmacy with reasonable skill, competence, and safety for the public because of
(A) professional incompetence; (B) failure to keep informed of or use current professional theories or practices; or (E) other factors determined by the board;
(14) engaged in unprofessional conduct, as defined in regulations of the board.
12 AAC 52.920 DISCIPLINARY GUIDELINES
(a) In addition to acts specified in AS 08.80 or elsewhere in this chapter, each of the following constitutes engaging in unprofessional conduct and is a basis for the imposition of disciplinary sanctions under AS 08.01.075; …
(15) failing to use reasonable knowledge, skills, or judgment in the practice of pharmacy;
(b) The board will, in its discretion, revoke a license if the licensee …
(4) intentionally or negligently engages in conduct that results in a significant risk to the health or safety of a patient or injury to a patient; (5) is professionally incompetent if the incompetence results in a significant risk of injury to a patient.
(c) The board will, in its discretion, suspend a license for up to two years followed by probation of not less than two years if the licensee ...
(2) is professionally incompetent if the incompetence results in the public health, safety, or welfare being placed at risk.
We all acknowledge that Alaska is in the midst of an opioid crisis. While there are published guidelines and literature to assist all healthcare professionals in up to date approaches and recommendations for medical treatments per diagnosis, do not confuse guidelines with law; they are not the same thing.
Pharmacists have an obligation and responsibility under Title 21 Code of Federal Regulations 1306.04(a), and a pharmacist may use professional judgment to refuse filling a prescription. However, how an individual pharmacist approaches that particular situation is unique and can be complex. The Board of Pharmacy does not recommend refusing prescriptions without first trying to resolve your concerns with the prescribing practitioner as the primary member of the healthcare team. Patients may also serve as a basic source of information to understand some aspects of their treatment; do not rule them out in your dialogue.
If in doubt, we always recommend partnering with the prescribing practitioner. We are all licensed healthcare professionals and have a duty to use our knowledge, skill, and judgment to improve patient outcomes and keep them safe.
Professionally,
Richard Holt, BS Pharm, PharmD, MBA Chair, Alaska Board of Pharmacy
https://www.commerce.alaska.gov/web/portals/5/pub/pha_ControlledSubstanceDispensing_2019.01.pdf
FDA in Brief: FDA finalizes new policy to encourage widespread innovation and development of new buprenorphine treatments for opioid use disorder
February 6, 2018
Media Inquiries Michael Felberbaum 240-402-9548
“The opioid crisis has had a tragic impact on individuals, families, and communities throughout the country. We’re in urgent need of new and better treatment options for opioid use disorder. The guidance we’re finalizing today is one of the many steps we’re taking to help advance the development of new treatments for opioid use disorder, and promote novel formulations or delivery mechanisms of existing drugs to better tailor available medicines to individuals’ needs,” said FDA Commissioner Scott Gottlieb, M.D. “Our goal is to advance the development of new and better ways of treating opioid use disorder to help more Americans access successful treatments. Unfortunately, far too few people who are addicted to opioids are offered an adequate chance for treatment that uses medications. In part, this is because private insurance coverage for treatment with medications is often inadequate. Even among those who can access some sort of treatment, it’s often prohibitively difficult to access FDA-approved addiction medications. While states are adopting better coverage owing to new legislation and resources, among public insurance plans there are still a number of states that are not covering all three FDA-approved addiction medications. To support more widespread adoption of medication-assisted treatment, the FDA will also continue to take steps to address the unfortunate stigma that’s sometimes associated with use of these products. It’s part of the FDA’s public health mandate to promote appropriate use of therapies.
Misunderstanding around these products, even among some in the medical and addiction fields, enables stigma to attach to their use. These views can serve to keep patients who are seeking treatment from reaching their goal. That stigma reflects a perspective some have that a patient is still suffering from addiction even when they’re in full recovery, just because they require medication to treat their illness. This owes to a key misunderstanding of the difference between a physical dependence and an addiction. Because of the biology of the human body, everyone who uses a meaningful dose of opioids for a modest length of time develops a physical dependence. This means that there are withdrawal symptoms after the use stops.
A physical dependence to an opioid drug is very different than being addicted to such a medication. Addiction requires the continued use of opioids despite harmful consequences on someone’s life. Addiction involves a psychological preoccupation to obtain and use opioids above and beyond a physical dependence.
But someone who is physically dependent on opioids as a result of the treatment of pain but who is not craving the drugs is not addicted.
The same principle applies to replacement therapy used to treat opioid addiction. Someone who requires long-term treatment for opioid addiction with medications, including those that are partial or complete opioid agonists and can create a physical dependence, isn’t addicted to those medications. With the right treatments coupled to psychosocial support, recovery from opioid addiction is possible. The FDA remains committed to using all of our tools and authorities to help those currently addicted to opioids, while taking steps to prevent new cases of addiction.”
Above is the full statement, find full statement with options for study requests: https://www.fda.gov/NewsEvents/Newsroom/FDAInBrief/ucm630847.htm
Maryland’s co-prescribing new laws/ amendments regarding benzos and opioids
Chapter 215 AN ACT concerning Health Care Providers – Opioid and Benzodiazepine Prescriptions – Discussion of Information Benefits and Risks
FOR the purpose of requiring that certain patients be advised of the benefits and risks associated with the prescription of certain opioids, and benzodiazepines under certain circumstances, providing that a violation of this Act is grounds for disciplinary action by a certain health occupations board; and generally relating to advice regarding benefits and risks associated with opioids and benzodiazepines that are controlled dangerous substances.
Section 1–223 Article – Health Occupations Section 4–315(a)(35), 8–316(a)(36), 14–404(a)(43), and 16–311(a)(8) SECTION 1. BE IT ENACTED BY THE GENERAL ASSEMBLY OF MARYLAND, That the Laws of Maryland read as follows: Article – Health Occupations (a) In this section, “controlled dangerous substance” has the meaning stated in § 5–101 of the Criminal Law Article.
Ch. 215 2018 LAWS OF MARYLAND (B) On treatment for pain, a health care provider, based on the clinical judgment of the health care provider, shall prescribe: (1) The lowest effective dose of an opioid; and (2)A quantity that is no greater than the quantity needed for the expected duration of pain severe enough to require an opioid that is a controlled dangerous substance unless the opioid is prescribed to treat: (a.) A substance–related disorder; (b.) Pain associated with a cancer diagnosis; (c.) Pain experienced while the patient is receiving end–of–life, hospice, or palliative care services; or (d.) Chronic pain
(C.) The dosage, quantity, and duration of an opioid prescribed under [subsection (b)] of this [section] shall be based on an evidence–based clinical guideline for prescribing controlled dangerous substances that is appropriate for: (1.) The health care service delivery setting for the patient; (2.) The type of health care services required by the patient; (3.) and The age and health status of the patient.
(D) (1) WHEN A PATIENT IS PRESCRIBED AN OPIOID UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE OPIOID.
 (2) WHEN A PATIENT IS CO–PRESCRIBED A BENZODIAZEPINE WITH AN OPIOID THAT IS PRESCRIBED UNDER SUBSECTION (B) OF THIS SECTION, THE PATIENT SHALL BE ADVISED OF THE BENEFITS AND RISKS ASSOCIATED WITH THE BENZODIAZEPINE AND THE CO–PRESCRIPTION OF THE BENZODIAZEPINE. 
(E) A violation of [subsection (b) OR (D) of] this section is grounds for disciplinary action by the health occupations board that regulates the health care provider who commits the violation.
4-315 (a) Subject to the hearing provisions of § 4–318 of this subtitle, the Board may deny a general license to practice dentistry, a limited license to practice dentistry, or a teacher’s license to practice dentistry to any applicant, reprimand any licensed dentist, place any licensed dentist on probation, or suspend or revoke the license of any licensed dentist, if the applicant or licensee: (35) Fails to comply with § 1–223 of this article.
8–316. (a) Subject to the hearing provisions of § 8–317 of this subtitle, the Board may deny a license or grant a license, including a license subject to a reprimand, probation, or suspension, to any applicant, reprimand any licensee, place any licensee on probation, or suspend or revoke the license of a licensee if the applicant or licensee: (36) Fails to comply with § 1–223 of this article.
14–404. (a) Subject to the hearing provisions of § 14–405 of this subtitle, a disciplinary panel, on the affirmative vote of a majority of the quorum of the disciplinary panel, may reprimand any licensee, place any licensee on probation, or suspend or revoke a license if the licensee: (43) Fails to comply with § 1–223 of this article.
16–311. (a) Subject to the hearing provisions of § 16–313 of this subtitle, the Board, on the affirmative vote of a majority of its members then serving, may deny a license or a limited license to any applicant, reprimand any licensee or holder of a limited license, impose an administrative monetary penalty not exceeding $50,000 on any licensee or holder of a limited license, place any licensee or holder of a limited license on probation, or suspend or revoke a license or a limited license if the applicant, licensee, or holder:
(8) Prescribes or distributes a controlled dangerous substance to any other person in violation of the law, including in violation of § 1–223 of this article;
SECTION 2. AND BE IT FURTHER ENACTED, That this Act shall take effect October 1, 2018.
Approved by the Governor, April 24, 2018.
https://legiscan.com/MD/text/HB653/id/1788719/Maryland-2018-HB653-Chaptered.pdf
submitted by Dirtclodkoolaid to ChronicPain [link] [comments]


2023.06.04 10:25 ResponseTemporary573 How to better support a CEO with ADHD

Good morning everyone,
I hope you have had a great weekend so far. As you might see, I am new to this subreddit. I took on my role as an executive assistant to the CEO of an IT company around a month ago. A problem that has been emerging slowly but surely is my CEO's ADHD. The usual ways I try to keep him on track only works to a degree and I am a little stumped on how to proceed.
To give you a better idea of the situation in general: I work for a very small but successfully IT-company. Currently, all staff work together in an open-plan office, though we are looking to move into a different building within the next six months. Before I got hired, they only had an accountant to stay on top of the bookkeeping, no other full-time administrative staff. So, I walked into quite the chaotic situation. There was no filing plan, so everyone did the filing however worked best for them personally. Digital documents were often not named/renamed properly and the paths were pretty much randomized. Staff often had no idea when CEO would be in, as he often forgot to update his calendar. The communal mailboxes (for tickets, purchasing, accounting) were a complete mess: e-mails weren't marked as read, nothing was archived or deleted and the filing-structure within the mailboxes was as confusing as it was everywhere else. Electrical parts were strewn all over the office and the CEO had piles of documents (paper) and letters in his drawers, storage compartments, all over his desk and in various laptop bags. No cleaning company had been hired for nearly six months.
I remedied quite a few of these things: I hired a cleaning company, went through all the paper on and around the CEO's desk with him, created a filing plan and filed any loose paper accordingly and migrated the contents of any old file folders into the new system, gave a new structure to the mailboxes and went through them, regularly check in with CEO to keep his calendar as accurate as possible and created a space for all incoming deliveries and strewn about electrical parts. So far, so good.
Here are a few examples of behavior I struggle with:
- CEO gets excited about gadgets that get delivered, will start to rig them up half-way, get a phone call, get distracted and proceed to leave the half-rigged-up gadget sitting where he started to build it. I made an agreement with him, which room I will put any half-built gadget in. Until I did that, he left those things wherever the idea struck him. Still, those half-built gadgets will sit there for days or weeks, until he needs them. The other employees are extremely annoyed by this behavior, as those things and/or empty packages usually end up next to or on their desks, until I take them away to the designated room. At this point, they will ask me if they may put them there themselves and proceed to do so. No matter where they are, we still have half-built things piling up. Out of sight, yes, but still not ideal.
- He has a bad habit of doing other work during team-meetings. He'll ask a team-member about something, and will look up parts he plans to order while the person replies. If he'd look up, he'd see how unhappy the people he's replying to are about this. I am unsure how diplomatic I need to be, when I address this with him.
- Not delivering on deadlines. He tends to schedule appointments or deadlines for certain jobs via WhatsApp or in person, while he is out on business. Once he returns to the office, he already forgot about them and doesn't mention them. Sometimes, I find out through one of our technicians, if they happened to hear about it. Sometimes, though, I find out when a disgruntled customebusiness partner calls to ask about his whereabouts or the fast approaching/past deadline. I have taken to ask him if any updates to his calendar are necessary in regular intervals and asking him about his appointments after he returns to the office, to catch as much of it as I can, but there are still things that fall through the cracks. As a consequence, he will call one of his technicians or the account after hours and ask them to go on emergency errands or take emergency appointments the following morning, because he forgot about something and remembered in a panic. I tend to find out about these occasions from the disgruntled employees.
- In the same vein, the accountant is terribly unhappy and not far off from leaving, as he finds himself taking the brunt of those "emergency" tasks. As he has been the only person constantly in the office for quite some time before I joined, he ends up driving company vehicles to the car wash, to inspection or unloading them before he can take them there, as CEO remembered the night before the inspection appointment that the car is still full of computer parts. So far, I don't get any of those emergency messages, as he is pretty afraid that I'll walk out on him, if I see the full scope of the disorganization.
If you have any suggestions on how to address these problems, I would really appreciate them. As I am still new in my role, I am quite hesitant to approach him with a laundry list of problems, most of which he causes himself. While I know it isn't a conscious decision on his part, it still affects the other employees, morale and the processes of the business to his and everyone else's detriment.
Thank you in advance for reading.
submitted by ResponseTemporary573 to ExecutiveAssistants [link] [comments]


2023.06.04 03:58 icepack12345 New grill and first experience recipe

Picked up a Weber 22 Premium today for about 200 with a bag of kingsford.
My wife and had had the most amazing chicken ever.
Recipe: Boneless skinless thighs Cleaned up trimmings and cover generously with BBQ dry rub, paprika, onion powder
Then into a large ziplock bag with a half bottle of zesty Italian dressing and a bit of lime and franks red hot for color. Marinate in your refrigerator for minimum 4 hours and no more than 24 (we just did the minimum)
Onto the Webber 22 preheated 300-350 degrees. Sprinkle a bit more dry rub on top.
Flip every couple minutes until interval temp 160 degrees. Baste with BBQ (liquid not dry this time)
Then keep cooking until sauce is charred and blistering, almost looks like burnt ends. About 175-180 internal temp.
Cool for 5 minutes then plate up.
What should we do next?
submitted by icepack12345 to webergrills [link] [comments]


2023.06.03 21:53 Worth_Magazine5256 LOTRO triggering changes in device manager

Hi all,
so weirdly enough, around two days ago, I started experiencing the good old stutter and hitch, when the game freezes for a second and music resets. At first I thought this was just the good old Angmar doing its thing, but after experiencing the same thing in Forochel, I immediately found that this is in connection to the device manager.
Firstly, I spent the whole day pinpointing on what exactly is causing the device manager to freak out. I even wiped and reinstalled my whole PC, which did not help. I found out, that it is the internal camera and a port, which I assume is the port that the internal camera uses to connect to the pc, which start unplugging and re-plugging randomly. See screenshot: https://imgur.com/a/1VsDRan
Now, I did have problems with my camera before, but I really could not give an f., until it started affecting my game. Usually, I would just have the camera replaced or removed, but here is the twist.
-This for some reason only happens during the game of LOTRO. I still have to test if this happens in other games too (even though if it does, none have been affected by it apart from lotro). I am unable to reproduce the unplug/plug with the game turned off, everything works as normal while not playing the game. When i launch the game however, circa 5 minutes in it does it again. It seems to happen randomly without any specific interval, sometimes happening 2 times in a couple seconds or not happening at all for some time.
Does anyone know which setting in the game could trigger this, or if there is any reason the game itself could trigger such a thing? I have read that the game constantly reads the devices connected to the game, which is why the device manager refresh affects the game, but I have no clue how it would actually trigger the changes.

I will test out other games in the meanwhile, as I have to download them first (did the clean wipe of the PC). Any other suggestions or sharing your own experiences would be highly appreciated.

EDIT 1: So I tried playing TW WH3, the unplugging/re-plugging of the aforementioned happens too (also still only while playing). It naturally however, does not affect the game in the same way as LOTRO, as not many other games require to constantly read the devices connected. Does anyone have any ideas on what to do besides replacing the faulty PC parts? It really is not a problem for me outside of playing LOTRO, but if I have no choice I will sacrifice my time and money for it.

EDIT 2: I submitted a ticket to standingstone, will see if they can help in any way in the meanwhile.

EDIT 3: Finally managed to fix everything by finding the port which the camera was connected to (In device manager via view->connections). Disabled that port and turns out it is the camera which is faulty, so disabling the port actually worked.
submitted by Worth_Magazine5256 to lotro [link] [comments]


2023.06.03 19:48 ManintheArena8990 Anybody know trustworthy mechanic?, repeat problem with car.

Spend just over £900 in 2 months on this:
So basically my cars engine light kept coming on and it was losing power…
First mechanic, done a DPF regen, didn’t fix it.
Second mechanic cleaned the air-con and put in a new filter, didn’t fix it.
Bought a diagnostic machine, found the issue, think I need a new MAF sensor.
Dunno why I included all those details, but yeah, I need a trust worthy mechanic because I really don’t want to spend anymore on it.
submitted by ManintheArena8990 to glasgow [link] [comments]


2023.06.03 16:42 lemonheadedloser Random Quiet Bumping Noises That Won't Stop

So I am trying to record vocals for a song. I am using the PreSonus AudioBox iTwo, ATH M40x headphones, macbook pro, an AKG dynamic mic, the cables that come along with using all of that, and Logic Pro for recording.
There always seems to be tiny bumping noises in my audio, as if I am moving my mic around or as if there are people doing things downstairs even when in many cases, this is just not true. I don't know how to stop it (for context I am not in a sound proof room when recording currently, but I record upstairs with all windows and doors shut and no one but my grandma who is silent downstairs- although I had this issue when I recorded in soundproof rooms at college too) (I am also holding my mic because I don't have a mic stand, but even then I feel like these sounds shouldn't be this constant, since I make sure to hold my mic as still as physically possible and record in short intervals). Anyone have an advice/knowledge for why this is happening and how to stop it?
It's like, not loud enough to where when I pair it with the instruments that I could hear it, but I would like to have clean vocal audio before putting it with everything, you know what I mean?
submitted by lemonheadedloser to audio [link] [comments]


2023.06.03 16:32 Physical-Archer2322 Cleanjal Water Purifier: How Undersink Water Filters Work

Cleanjal Water Purifier: How Undersink Water Filters Work
Cleanjal Water Purifier is an under-sink water filtration system designed to give clean and purified water for domestic and marketable use. Understanding how under-sink water pollutants work can help druggies make informed opinions about their water sanctification needs. In this composition, we will explore the Cleanjal Water Purifier: How Undersink Water Filters Work. So to known more, keep on reading.
Clean Jal Water Purifier: How Undersink Water Filters Work
Filtration Process
Undersink water pollutants use multiple stages of filtration to remove contaminations and pollutants from the water force. These pollutants generally correspond to colorful sludge media and membranes, each designed to target specific pollutants. The filtration process generally involves the ensuing stages
Installation
Undersink water pollutants are installed beneath the kitchen Gomorrah, exercising the living water force line. They're generally connected to the cold water line, icing a constant force of filtered water for drinking, cuisine, and other purposes. The installation process may vary depending on the specific model, but it generally involves attaching the sludge system to the water line and connecting it to a devoted gate.
Conservation Regular conservation is essential to ensure the optimal performance and life of under-sink water pollutants. conservation conditions may include replacing sludge charges at recommended intervals, sanitizing the system, and periodically checking for leaks or other issues. Manufacturers generally give guidelines and instructions for proper conservation, which should be followed for effective filtration.
Conclusion Undersink water pollutants, similar to the Clean Jal Water Purifier, offer an accessible and effective result for carrying clean and purified drinking water at home or in marketable settings. By employing multiple filtration stages, including deposition filtration, actuated carbon filtration, and rear osmosis, these pollutants effectively remove contaminations and pollutants from the water force. The installation of an under-sink water sludge ensures a devoted source of purified water for diurnal use, furnishing peace of mind and promoting healthy life. Regular conservation and sludge reserves are necessary to ensure the continued effectiveness of the system.
submitted by Physical-Archer2322 to u/Physical-Archer2322 [link] [comments]


2023.06.03 14:47 ThrowRA_CalmDays Cheap EGR delete or expensive EGR replacement?

I have a 2014 Audi A4 B8.5 CJCB 2.0 TDI engine, and recently the engine management light has been going off and after scanning it with an OBDEleven reader it's showing an intermittent EGR flow error. Unfortunately, one of the bolts which attach the EGR to the engine block (the one most difficult to access) has been stripped which is going to make it much more expensive and time consuming to fix.
So I've been researching EGR delete options are there seem to be mixed opinions online about whether EGR deletes are good or bad for the vehicle. For example I've heard they have lead to accelerated turbo degradation, and DPF clean is not possible without the EGR. Is there any truth to any of this?
Does anyone have any experience with EGR deletes and how they have affect a turbocharged diesel engine? Also can anyone think of any other options for me?
Any help appreciated,
Thank you.
submitted by ThrowRA_CalmDays to MechanicAdvice [link] [comments]


2023.06.03 13:12 DaithiSan Is mapping and removing a DPF better than to remove and cleaning it? (Car in desc)

So going off my last post it turns out my car needs the DPF to be taken out and cleaned becuase the regeneration didnt complete or something, which is why the glow plug light is flashing and engine light is on presumably. One mechanic suggested taking it out completely but can run the risk of not passing my NCT if the check for nox gas? (Can't remember exactly what he said) another said it might just be a sensors fault? So with varying prices and I'm just trying to think on what to do next. I drive a 1.6 Seat leon 171 (Diesel)
submitted by DaithiSan to MechanicAdvice [link] [comments]


2023.06.03 10:52 midwestchauffeur The Importance of Car Service: Ensuring Optimal Performance and Safety

Introduction: Regular car service plays a vital role in maintaining the optimal performance and safety of our vehicles. It involves a comprehensive inspection, maintenance, and repair of various components, ensuring that our cars operate efficiently and reliably. In this article, we will explore the significance of car service and discuss the key benefits it offers to vehicle owners.
  1. Enhancing Safety on the Road: Heading: Prioritizing Your Safety
A well-maintained vehicle significantly reduces the risk of accidents and ensures the safety of both the driver and passengers. Car service includes checking critical safety features such as brakes, tires, suspension, lights, and steering systems. Timely identification and rectification of any issues in these components can prevent potential hazards on the road, providing peace of mind to drivers.
  1. Extending Lifespan and Reliability: Heading: Prolonging Your Vehicle's Lifespan
Regular car service helps in extending the lifespan of your vehicle. By adhering to manufacturer-recommended maintenance schedules, you can identify and address minor issues before they escalate into major problems. Routine oil changes, filter replacements, and inspections of belts, hoses, and fluid levels can prevent premature wear and tear, ensuring that your car remains reliable for years to come.
  1. Improving Fuel Efficiency: Heading: Maximizing Your Fuel Economy
Efficient fuel consumption is not only economical but also environmentally friendly. During car service, technicians analyze fuel delivery systems, engine performance, and other crucial factors that affect fuel efficiency. By maintaining optimal tire pressure, ensuring clean air filters, and keeping the engine properly tuned, you can significantly improve your car's fuel economy, saving you money at the pump.
  1. Avoiding Costly Repairs: Heading: Saving Your Wallet from Major Expenses
Neglecting regular car service may lead to more significant and costly repairs down the line. Regular inspections can identify potential issues early on, allowing for timely repairs or replacements of faulty components. By addressing minor problems promptly, you can prevent them from escalating into more severe damage, ultimately saving you from expensive repairs and breakdowns.
  1. Preserving Resale Value: Heading: Protecting Your Investment
If you plan to sell or trade in your vehicle in the future, regular car service is essential for maintaining its resale value. Potential buyers are more likely to be attracted to a well-maintained vehicle with a documented service history. Regular maintenance not only keeps your car in excellent condition but also demonstrates your commitment to its care, enhancing its market appeal.
  1. Accessing Expert Advice: Heading: Leveraging Professional Expertise
Car service provides an opportunity to consult with trained professionals who specialize in automotive maintenance. Technicians can offer valuable advice on how to best care for your specific make and model, including recommendations for optimal driving practices, maintenance intervals, and any potential recalls or updates from the manufacturer. This expertise ensures that you receive the best possible care for your vehicle.
Conclusion: Regular car service is a crucial aspect of responsible vehicle ownership. By prioritizing safety, extending your car's lifespan, improving fuel efficiency, avoiding costly repairs, preserving resale value, and leveraging professional expertise, you can enjoy a reliable and efficient driving experience. Remember to follow your manufacturer's recommended maintenance schedule and consult with trusted professionals to keep your car in top shape for years to come.
View Poll
submitted by midwestchauffeur to u/midwestchauffeur [link] [comments]


2023.06.03 00:25 JoshAsdvgi THE HERMIT, OR THE GIFT OF CORN

THE HERMIT, OR THE GIFT OF CORN

THE HERMIT, OR THE GIFT OF CORN
In a deep forest, far from the villages of his people, lived a hermit.
His tent was made of buffalo skins, and his dress was made of deer skin.
Far from the haunts of any human being this old hermit was content to spend his days.
All day long he would wander through the forest studying the different plants of nature and collecting precious roots, which he used as medicine.
At long intervals some warrior would arrive at the tent of the old hermit and get medicine roots from him for the tribe, the old hermit's medicine being considered far superior to all others.
After a long day's ramble in the woods, the hermit came home late, and being very tired, at once lay down on his bed and was just dozing off to sleep, when he felt something rub against his foot.
Awakening with a start, he noticed a dark object and an arm was extended to him, holding in its hand a flint pointed arrow.
The hermit thought, "This must be a spirit, as there is no human being around here but myself!"
A voice then said: "Hermit, I have come to invite you to my home."
"How (yes), I will come," said the old hermit.
Wherewith he arose, wrapped his robe about him and followed.
Outside the door he stopped and looked around, but could see no signs of the dark object.
"Whoever you are, or whatever you be, wait for me, as I don't know where to go to find your house," said the hermit.
Not an answer did he receive, nor could he hear any noises as though anyone was walking through the brush.
Re-entering his tent he retired and was soon fast asleep.
The next night the same thing occurred again, and the hermit followed the object out, only to be left as before.
He was very angry to think that anyone should be trying to make sport of him, and he determined to find out who this could be who was disturbing his night's rest.
The next evening he cut a hole in the tent large enough to stick an arrow through, and stood by the door watching.
Soon the dark object came and stopped outside of the door, and said: "Grandfather, I came to -- ," but he never finished the sentence, for the old man let go his arrow, and he heard the arrow strike something which produced a sound as though he had shot into a sack of pebbles.
He did not go out that night to see what his arrow had struck, but early next morning he went out and looked at the spot about where he thought the object had stood.
There on the ground lay a little heap of corn, and from this little heap a small line of corn lay scattered along a path.
This he followed far into the woods.
When he came to a very small knoll the trail ended.
At the end of the trail was a large circle, from which the grass had been scraped off clean.
"The corn trail stops at the edge of this circle,"said the old man, "so this must be the home of whoever it was that invited me."
He took his bone knife and hatchet and proceeded to dig down into the center of the circle. When he had got down to the length of his arm, he came to a sack of dried meat.
Next he found a sack of Indian turnips, then a sack of dried cherries; then a sack of corn, and last of all another sack, empty except that there was about a cupful of corn in one corner of it, and that the sack had a hole in the other corner where his arrow had pierced it.
From this hole in the sack the corn was scattered along the trail, which guided the old man to the cache.
From this the hermit taught the tribes how to keep their provisions when traveling and were overloaded.
He explained to them how they should dig a pit and put their provisions into it and cover them with earth.
By this method the Indians used to keep provisions all summer, and when fall came they would return to their cache, and on opening it would find everything as fresh as the day they were placed there.
The old hermit was also thanked as the discoverer of corn,
which had never been known to the Indians until discovered by the old hermit.
submitted by JoshAsdvgi to Native_Stories [link] [comments]


2023.06.03 00:20 reallyscaredtoask Why are my brakes squeaking when they're less than a month old?

I have a 2007 Toyota Camry LE, 2.4L engine and I changed the brakes and rotors on May 12, about 600 miles ago.
I changed my brakes myself using these front and rear rotors and pads from rock auto. I used this Brakleen Brake Parts Cleaner to clean all surfaces and the piston slide pins, as well as a wire brush to clean any rust or old brake dust and gunk on the metal parts. I used this Permatex Ultra Brake Parts Lubricant on the back of the pads (that touch the piston and the caliper, not the side that touches the rotor), both sides of the metal hardware, and in the piston slide pins.
The squeaking started very gradually. I heard absolutely no squeaking for the first two weeks, but then noticed very faint squeaking in short intervals. It didn't happen every time I braked, maybe ever 1 in 5 times I applied the brakes it would faintly squeak. Over the passed week or so I've heard it more and more, and its getting louder and louder.
Could it be the lubricant I used wasn't good enough? Or are my brake pads not good enough? Or is it more likely that I did something wrong?
submitted by reallyscaredtoask to MechanicAdvice [link] [comments]


2023.06.02 23:25 LoggedOffinFL Motor Power DPF Cleaner - Who's used it? Have seen great reviews on YT & Amazon.

Motor Power DPF Cleaner - Who's used it? Have seen great reviews on YT & Amazon. submitted by LoggedOffinFL to tdi [link] [comments]


2023.06.02 22:59 Pinball_Lizard Necromancy looks great, but... spare a thought for Arposandra?

Basically everything about Necromancy seems hauntingly beautiful, especially the city, but I can't help but feel a touch melancholy over the fact that this will push cleaning up Fifth Age "unfinished business" further into the future. And the one bit of it that I've wanted to see most of all is the Gnome finale and Arposandra.
Granted, the desert quests are also still missing a final installment, but we still get big lore from there fairly regularly, and it's pretty obvious what the final installment will have to include - open Menaphos, cure Sophanem, restore Tumeken, fight Amascut - the only big mystery there is if she's redeemable or not, and what's up with that weird machine.
The Gnomes by contrast have been waiting for TWELVE YEARS for an update to their storyline, and in the interval since then the vast majority of the other Fifth Age quest lines have concluded. We don't know what Arposandra is like. We don't know where Glouphrie is. We don't know why Arposandra is now seemingly ruled by another guy who claims to hate Glouphrie but looks exactly like him. We don't know how or if Glough and the monkeys are involved (and even 2007scape wrapped that one up!). And so on. The most the Gnomes have done in the Sixth Age era was send a delegation to Serten's Council and then do basically nothing.
I'd really love to talk to a mod about Arposandra and where the plans for it currently stand; even if the answer is "no plans at present," that's at least something. I hope that's not presumptuous of me. I was just once a kid who loved grinding Cooking in the Gnomes' restaurant, and my short green guys deserve the due the Goblins, Vampyres, Dwarves, and so many others have already gotten.
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2023.06.02 17:33 GeoTech84 I am officially done with developing and scanning my own color film

A bit of a long rant on all the reasons why I am officially done with C41 home developing and scanning. I will be using labs again from now on and I'm not looking back.
I've been shooting film since 2019, and in that time I've been developing and scanning all my own film for the last two years (C41 and black and white). Initially I did it to save money on dev and scan from the labs, and then came to really enjoy it as part of the whole process of creating the image from start to finish. As much as I enjoyed it, I've come to realize that all of the extra time and effort that goes with it isn't really worth it in the end due how much time I was putting in dealing with all the extra steps and work on my end.
I'll start by saying the first headache comes with scanning. I use a flatbed scanner since I don't have a DSLR setup, which is painfully slow, and usually incorporates a lot of dust no matter how clean you keep everything (especially for 35mm). It also was a roll of the dice on if the negatives were going to dry nice and straight, or curl up and make it virtually impossible to fit into the film holders. Even with the lomography film holders which were a big help, it could still be a huge pain to get negatives in place that would for some reason dry extremely curly as opposed to others. Once the negs were in, the scanning process starts and no matter what the first thing is always DUST. It's not hard to remove in lightroom or in Silverfast, but it becomes quite tedious, especially if you're scanning multiple rolls in one sitting. After you get rid of the dust, then comes color grading and editing. Again, it's not hard to color grade or correct the colors for a single image, but I it seems that no matter what steps I take to keep the process consistent, I would always have wildly varying color results on the same roll that I would need to correct in silverfast during scanning or after the fact in light room just to keep one roll of shots consistent.
Next is the chemicals themselves. Like most people, I used the cinesitll C41 chemicals. I've tried both powder and liquid which were both fine, but I could never really get consistent results on anything past the first 4 rolls or so. I tired all manner of internet advice of different time intervals to extend developing time, and I never used any chemicals older than 6 weeks. I always was able to have the best and most consistent results with the C41kit from Rollei which is more expensive, but definitely better in terms of consistency, and they give you a reliable time table on how to extend your developer. But still, after about 8 rolls, I would always notice some color shifting or grain I wasn't expecting and would have to correct it during the scanning process.
On top of that, C41 chemicals are a race against time. Once you mix them, you want to develop as many rolls as possible before they start to go bad, no matter how well you seal them away in the special air tight accordion containers that you store them in. I always felt like I was racing against the clock and putting so much pressure on myself to get all my rolls developed and scanned within a months time, which really adds a lot of stress and pressure on the entire process, and takes away a lot of time from other things.
I think the reason I put up with all of these things and did this for over two years was because I really started to think of it as much more of an important part of the photographic process, and that somehow it made me more of an "artist" or a better photographer since I was handling it all myself from start to finish. Don't get me wrong, you do have a lot more creative control when you do everything yourself for every step of the process, but getting lab scans and editing the files in lightroom makes you just as much of a photographer as the person who does home developing and scanning. It took me a while to realize that and accept that I shouldn't force myself to do all this because it will somehow make me a better artist.
All of this being said, I know there's lots of other things I could try, like other brands of chemicals, I could Invest in a DSLR setup, I could buy negative Lab pro, but after two plus years of dealing with all these minute headaches it feels so good to just get scans back from the lab that are clean and consistent every time (shoutout to Memphis film lab for their amazing service).
It's also worth mentioning that almost none of the above issues apply to black and white film (except dust and slow scanners). Black and white is cheap, easy, consistent, the chemicals last almost forever, you never have to worry about temperature, and pushing/ pulling is much easier and more forgiving. I could go on about how much simpler black and white developing is, but the point is I'll still be doing all black and white myself.

TL;DR : Developing and scanning color film takes a lot of work, I'll stick to film labs and black and white dev only from now on.
submitted by GeoTech84 to AnalogCommunity [link] [comments]


2023.06.02 17:26 TarkanV Evernote/Notion alternatives with those features?

Hi, everyone! So I was searching for a way to replace Evernote for some time now and it is quite complicated to get an accurate overview of the actual features that each apps is supposed to have... So I'm here to ask for help to find any solid alternatives (the pinned post is useful but not comprehensive enough for some features I think). I found Notion which is really feature packed but the fact that it's only web-based and doesn't seem to save anything locally is totally a deal breaker.I found Joplin but it's pretty bland, the reordering of notes is limited and the tag organization is pretty basic and there's no "search by tags" options.
So here are all features that I'd really like for the app to have :

I don't care about team tools, table or graph stuff but linking notes, search in pdfs and images and flashcards would be a good addition but totally optional!
Thanks in advance!
submitted by TarkanV to PKMS [link] [comments]