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14 Biggest Travel Mistakes To NOT Make
When travelling, it’s not unusual to find yourself making a careless mistake now and then. You are after all, exploring an environment that you are unfamiliar with. Whether you are a seasoned traveler or this is your first big trip, you will probably benefit from the following list. With just a little bit of planning, you can cut down your chances of making mistakes and have the best vacation possible.
Number 1 - Booking Without Comparing Rates If you’re one of those people who just books on impulse, basically just the first good deal you see, you are likely paying more than you could be. There are so many different travel sites on the internet, and by spending just a little bit of time researching and comparing, you will quickly learn just how much prices can vary - and you’ll be able to find the best deals - which are probably better than that first one you saw. To keep it simple, compare at least 3 sites like Travelocity, Expedia or Priceline.
Number 2 - Booking Your Trip Way Too Early So you and your friends decided to finally take that trip to Paris next summer. But wait! Don’t rush to book your trip just yet. Of course you want to make it real by booking everything right away but this can be a mistake and you could end up paying more. It’s best if you book your flight 3-4 months before you plan to travel. That’s around the time when airlines begin to increase and lower their rates based on demand. When it comes to cruises and tours, this is where you will want to wait until last minute - that is if you want to pay less. Since boats and tours have to fill up their spaces, they offer amazing last-minute deals, because it’s still better for them to make less profit than no profit at all on those empty seats.
Number 3 - Not Reading Reviews Yes, I know that these days most people do read reviews online, but you would be surprised to learn that there are still many who don’t - they just head over to the closest travel agency and book everything there, based on the advice of a travel agent. Don’t make this mistake - do your own research! Read reviews online. See what former guests have to say; check out photos of the rooms. Because by not doing this, you could find yourself arriving at a place that is far from what was promised - and you probably don’t want to stay in a bad neighborhood or sleep in a bed with bedbugs, right? You don’t have to stay at the best hotel in town, but where you stay is kind of important, and at least checking it out online can save you one big headache.
Number 4 - Traveling In Peak Season By definition, this is the period of highest demand, and it varies by destination. Travelling during the peak season means larger crowds just about anywhere you go. And even worse, you will be paying about double what it would cost you in the low season. Unless you enjoy crowded beaches and waiting in huge lineups to see attractions, you may want to consider travelling during the low season, or even better, the shoulder season - directly before or after high season, when the weather is still good, but there are much fewer people. It will not only be cheaper, but you will also have a more enjoyable time.
Number 5 - Thinking The Only Thing You Need Is A Valid Passport There are many locations you can travel to with a simple passport, but then there are those where you will need a Visa - places like China, Nigeria, or Russia to name a few. Of course this depends not only on the destination, but also where you are travelling from. While you can get a Visa in many countries upon arrival, there are often documents you need to fill out before you arrive - and without these, you can’t get a Visa. Then, another important thing to note is that many countries require a passport that will remain valid for at least six months after your departure date from the country. Make sure you don’t let this one slide. Check to see if you need a Visa or a new passport well in advance.
Number 6 - Skipping Travel Insurance This is one of those things that many people tend to overlook - because well, most of the time you won’t make use of it. But, you really never know when you may need it. It could be a small slip and you break your arm or some other unforeseen circumstance. Travel insurance will have your back and protect you while abroad. It usually doesn’t cost much and it will protect you should there be any medical or non-medical emergencies. Not having insurance could end up costing you thousands, so don’t skimp on this. Seriously!
Number 7 - Forgetting To Contact Your Bank Before The Trip It only takes a few minutes but could save you from being stuck in a foreign land without access to money. Some banks will completely block your account if an overseas charge is made. It is flagged as suspicious. And of course this is usually a good thing, but not when it is you trying to access your funds, thousands of miles away from home. When you call your bank to let them know that you will be travelling, you should also ask about their foreign transaction fees to avoid any bad surprises.
Number 8 - Not Having Copies Of Your Documents You don’t think it will happen to you - losing your wallet, fanny pack or whatever you carry. And getting robbed? Nah, that won’t happen to you, right? Well, the thing is that either of these can (and do) happen to people all the time. No matter how careful you think you are, you should carry copies of your important documents. These include copies of your ID, passport, travel insurance, and credit cards. Of course you’ll want to pack them separate from the originals.
Number 9 - Failing To Find Out Roaming Charges These charges can rack up very quickly, unbeknownst to you. You arrive at your destination and you excitedly call your friend or spouse to let them know you arrived - and before you know it, you’ve been on the phone for half an hour. That single call could cost you a hundred dollars or more. By simply finding out what’s covered by your phone plan, you can avoid any additional charges. If you find out that you aren’t covered, then it’s best if you switch your phone settings to airplane mode before you board the plane. This way, you can still use a Wi-Fi connection wherever available without accidentally using your data. Now, if you do think that you will need to use data on your trip, consider purchasing an international plan - or you can even buy a SIM card once you arrive.
Number 10 - Exchanging Currency At The Airport Sure it’s fast and easy to exchange currency at the airport. However, it’s also worth noting that you will get the worst possible conversion rate for your money. Now, it’s ok to exchange a few dollars to use for a taxi if you must, but the best thing to do is to actually take care of this before you leave. You can check rates of various banks in your area to find the best, and then head over to get the currency you need.
Number 11 - Eating Near Major Tourist Attractions On your trip, you are more than likely planning to visit at least a few of those amazing spots you’ve been hearing about and dreaming about seeing in real life. But any food place, be it a restaurant or food stand, is going to cost double the price (and sometimes more) near any major attraction. And since these places know that people aren’t coming back, they usually don’t worry too much about the quality or consistency of the food they serve. Besides, most visitors just arrived and don’t know much about the local foods so it doesn’t matter anyway. They’re just excited to be there and see the attractions. To most, it’s far more amazing to eat a ‘sub-par’ burger in front of a famous landmark than eating a delicious one at their favorite burger joint back home. Try eating in a ‘non-touristy’ area where the food will actually be amazing. It has to be, otherwise nobody would go back. Yes, you will have to walk a few blocks, but the food will be much tastier and cost a lot less. You can also ask locals about good places to eat. By the way, the same is true when it comes to shopping for just about anything near a major attraction. Stores will always have higher prices. Don’t be lazy. Take the effort and stroll off the beaten path. You’ll surely find the same T-shirt for a third of the price.
Number 12 - Not Packing A Travel Adapter There are 15 types of electrical outlet plugs used around the world, and if your choice of destination uses outlets different than the ones your country does, you won’t be able to plug in anything in without an adapter. You can use USB ports for many things, but we all know how slow those charges can be. In some cases you may not be able to charge at all depending on the power needs of the device. Amazon offers decent universal travel adapters for around 15 to 20 dollars.
Number 13 - Not Taking A Power Bank With You Most places you go will have somewhere to charge your devices - except when your battery is at 10 percent…. that’s when you won’t find anywhere to plug in and charge! You probably already know how that goes… But imagine you are hiking in the wilderness somewhere and you get lost - and then realize that your phone is almost completely drained. It sounds like a horror movie, but it can happen. You can easily avoid a scenario like this by taking a power bank (A.K.A. battery charger) with you. It won’t take up much space in your backpack and can come in very handy.
Number 14 - Planning Too Much For A Single Trip Assuming you aren’t just heading to a resort with a bunch of friends for a week of intoxication and partying, you will likely plan a lot and will want to see and do as much as possible on your trip. This sounds great, but if you plan too many things and fill up each day from morning to night, you could end up finding yourself stressed out and exhausted. Not to mention, when you pack too many things into one day, you can’t even really fully explore and enjoy anything. It’s ok if you don’t visit every single place on your list in one trip. You can save some for next time. Travelling is not only a lot of fun, but a great way to learn about different cultures and gain new insights of the world. With a little bit of preparation, you can ensure that you don’t make any of the mistakes on this list. And sure, while some things are beyond your control - such as flight delays or bad weather - the more prepared you are, the less can go wrong! And that’s a good thing. Do you have any crazy travel stories where things went wrong but perhaps could have been avoided? Or do you know any other mistakes people make while traveling? Share your story in the comments below, so we can learn from each other. If you found this video useful, give it a thumbs up, and share it with your friends, so they too can avoid these travel mistakes.

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12 Survival Tips That Could Save Your Life!
Life is unpredictable! You never know what could happen at any time. There are times when you find yourself in situations that are confusing and you just don’t know what to do. So it’s wise to be at least somewhat aware! Here are some survival tips that could save your life one day!
Number 1 - The Bystander Effect There’s a strange psychological phenomenon that happens when an accident occurs in a public place with many people around. People tend to stand-by and watch rather than help out as they don't want to become involved when they think someone else might help out, and so everyone holds back. This is called the 'bystander effect'. Should you find yourself in a situation like this, don't cry out for help to the greater masses but point at one person and plea to them. This increases your chances of getting help and people are far more likely to acknowledge you.
Number 2 - Parked Car At Night If you’re heading towards a vacant parking lot especially at night or when the area is not particularly safe, walk with the car keys in your hand. This will reduce the amount of time it takes you to get into your car and start it, thereby reducing your exposure to any sudden attack. In fact, a key held in your fist and protruding between your knuckles can also act as a makeshift weapon in case of any emergency.
Number 3 - Swarm of Bees If you ever find yourself being chased by a swarm of bees, don’t jump in a lake. Even though you’ve seen it in cartoons, don’t do it. The bees will wait above the water, ready to attack you. What’s worse, if you do jump into a body of water, you slow down your movement and you can’t breathe as well. You may even swallow a bunch of bees gasping for air. If you are being pursued by a swarm of bees, just keep running. They tend to defend their hives to a large proximity, so just keep running until they feel they’ve won and they stop chasing you.
Number 4 - Stranger in Your Car If a stranger gets in your car and orders you to take them somewhere, crash your car. Yeah, this sounds a bit crazy, but it’s far better than the alternative. You will no longer be useful to them because the car is damaged and you’ve drawn attention to them by crashing the car. So the only thing they can do at this point is run.
Number 5 - Being Roofied This usually happens to women. Some asshole will try to roofie you so he can do things with you that you probably wouldn’t want to, or who knows what else. There is a way to know if you’ve been roofied. Well kind of… When dissolved in alcohol, roofies give off a salty / bitter taste. So if your drink suddenly tastes strange, bitter, or different, then stop drinking it immediately. Be sure to pour it out so that nobody else grabs it and drinks it either.
Number 6 – Escape a Sinking Car In this situation, you've got to be quick! Start by rolling down the windows instead of opening the door. Opening the door is very difficult against the water pressure and it also allows far too much water into the vehicle which will only speed up the sinking process. You'll have about 30 seconds to a minute until the water rises to the bottom of the passenger windows. After that, the water pressure will force the window against the doorframe, making it just about impossible to roll down. Since most vehicles these days have electronically controlled windows, the circuits probably will short before you have a chance to roll them down. If this happens, you'll need a tool to break the window open. Two of the most popular are the LifeHammer, which has a hardened-steel point to help crack open the window, and the ResQMe keychain, which uses a spring-loaded mechanism to shatter glass. Make sure these tools are within reach, otherwise you'll never get to them in time. If you've failed to get the window rolled down or broken, you still have a small chance to escape. Once water fills the car, the pressure will be equalized and you’ll be able to open the door. However, doing this will be quite challenging because you will need to hold your breath in a highly stressful situation.
Number 7 - Save Yourself From Choking If you’re choking and no one is around, you can actually perform the Heimlich Maneuver on yourself! Place your fist above your navel while you grab your first with your other hand. Lean over a chair or counter and push your fist towards yourself in an upward thrust.
Number 8 – Wait at a Green Light Try to give yourself 2-3 seconds before you go through that green light, especially if it's a busy intersection. A large percentage of deadly vehicle accidents occur because some driver wanted to beat the red light. Waiting those precious few seconds makes sure you don't take that risk.
Number 9 - Sharp Object in Wounds Medical experts say that you shouldn’t remove a knife or any other sharp object from a wound. It sure sounds uncomfortable, but in the case of a knife, if you end up being stabbed by someone, don’t pull out the knife because it actually prevents bleeding. To further minimize the bleeding, tie a cloth around it until medical help arrives.
Number 10 – Getting Lost On A Hike Hiking through the wilderness can be a great way to relax and get away from it all. You get to enjoy fresh air, nature, beautiful scenery, and it’s also good for your body. But, if you ever get lost out there, it can be scary. I’m sure you’ve seen those TV shows where people get lost in a large landscape. They literally lose sense of direction! If this ever happens to you, try to find a river or fence. River streams always flow downhill and will always join a larger body of water that may help you regain your bearings. If you find a fence, this usually means buildings and roads are nearby and should lead to civilization.
Number 11 - Stop Using Your Cell Phone While Walking This may sound obvious, but there’s some serious science behind it. According to some health and safety consultants, the combination of walking and using your cell phone puts a huge strain on your brain, even if you think you're a lot smarter than others. Using your phone while walking can make you lose track of your surroundings and can result in an accident. This is especially true if you’re texting while walking! So the next time you have to use your phone somewhere in the middle of the road, I suggest you stop first, and then use it. Of course not in the middle of the road, but move aside so you're not blocking traffic or find a bench where you can relax, focus on that phone call or text and once you’re done, you can resume your walk.
Number 12 - That Gut Feeling If you feel something is not right with a person, situation or a place, you are probably right. Do not ignore these instincts. In these situations, do not be afraid to be rude, just leave. By being aware of these simple tips, you can help save your life or someone else's. Do you know any other useful survival tips? Share them in the comments below!

Before this episode begins, I am so happy to say that this is the 100th episode of MDR! I guess I knew we'd reach it one day, but still can't believe it. It has truly felt like it's flown by, but the countless memories I have are a reminder of the past year and a half, and all 100 episodes. I am so appreciative of the support on this project, it has been so much fun to bring to life, and I can't thank everyone enough for letting us get to this milestone. Enjoy the episode <3
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the queens return to the workroom after Sharris' elimination
🏁Kami CF: Coming back from the last elimination, I feel like we need at least two to three business days to decompress. It was wild!
Steph: Well...how y'all doin'?
the queens look around the room in silence
Whorechata: I just wanted to say something. Things got really out of hand earlier, and I know it was hard for all of us. But if there was any group to go through this with, I'm glad it was you all.
Wren: Aw, thank you. I feel the same wa-
Whorechata: I mean really, there's no group I'd want to go through being safe with. It was such an intense moment, but you all held me down.
Sue: ...
Anthyy: That's not where I thought you were going with that!
Whorechata: Oh and I guess the Sharris thing was unfortunate too, but the real tragedy was just so much worse.
🏁Whorechata CF: Whew, let me try and hold back these tears. I knew this competition would get intense, but I never knew the level it would get to. So when Micro called me safe, it was a wake up call about just how nasty things can get here. A disaster, truly.
Morgs: I don't want to excuse what Sharris said. It was definitely not a nice thing to say.
Wren: I swear there's a "but" coming.
Steph: Wren, this is a family show...
Morgs: But, I have to be real and say that I'm sad to see her gone. She was someone I was really close with, and I know that this meant so much.
Blondie: You can be sad that your friend isn't here anymore, but you really can't be sad that her toxic energy was removed from this environment.
Morgs: My relationship with Sharris wasn't toxic. I know she did some of you wrong. But that wasn't my experience.
🏁Morgs CF: I feel like I'm put between a rock and Jackie Cox's face right now. All of the other queens are allowed to react however they want to when it comes to one of their friends going home. But when I do it, it feels like I'm not really allowed to feel sad about it.
Anthyy: I never saw myself picking Sharris to go home, especially this early. But I can reveal that I chose her lipstick. And I do feel for Morgs, that's your sister. What it came down to was that I needed to make sure the competition was kept as drama free as possible.
Morgs: I understand, it's okay.
🏁Anthyy CF: Morgs and Sharris were two people I had an alliance with. Even before we came here, I knew we'd look out for each other. However, it comes down to what feels right on a human level, and Sharris took things too far with Wren. I had to take a stand, even if it meant sending home an ally.
Wren: Full tea, what Sharris said didn't really bother me. I've heard worse, and I'm sure I'll hear worse in the future.
Blondie: That's not fair to you, though.
Wren: It's okay! You all know that me loving myself isn't an issue, I'm not about to let that get to me.
🏁Wren CF: I mean, how did Sharris want me to react? Did she want this to be the part where you bring out the tiny violin and switch everything to black and white while I wistfully look through a window while a single tear falls down my well defined cheekbones? Girl bye.
Blondie: One thing's for sure, people proved who they really were. Some of you who rode for what Sharris was saying, I won't forget that.
Fleur rolls her eyes and laughs
🏁Blondie CF: My relationship with Fleur has gone down to a zero. Or scratch that, a negative two. We do run in similar circles, and I was expecting that to mean something in this competition. And it did for the first day or so. But when the pressure got turned up, Fleur showed her true colors. I need space from her right now, or else I'll pop off, and I'm not trying to be a fighter again. All that screaming messes up your vocal chords, and Fleur is not worth that!
Fleur: The vagueness is killing me.
Blondie: I'm not being vague, I'm just not giving you the attention you're craving.
Fleur: Blondie, be so real right now. Do you think I'm scared of you? Do you think there's any reason why I should be scared of you in this competition?
Blondie: Based on who won a challenge, maybe!
Fleur: Oh right, I forgot you won a challenge. Or did you even win it? It felt a lot like Zodya carrying you.
Blondie: The win is still sitting pretty. Something not everyone can say!
🏁Fleur CF: Blondie, I tried. I tried to defy the odds and actually get along with you here. But you've just proven to me that everyone here is truly awful. I'm not worried about anyone here being able to take me out. So why not give them hell and make them all miserable? That sounds even nicer than a crown. Yes, that'll do just fine. Get ready for it, you woke up the bitch. Well, the inner bitch. The outer bitch has been here the whole time. You know what I meant. And edit some nice villain music under all of that. It's showtime!
The Next Day
the queens dance into the workroom and over to the table
🏁Kami CF: It's a new day in the workroom, and I'm hoping the next challenge is something like baking cupcakes. That might be the only thing capable of bringing us back together. But for real, that would be so fun...
Zodya: Sue, I have to ask how you felt during the last lipsync.
Sue: I was fine. Really, I was so fine! And side note, but the sheets in the hotel are really great at absorbing tears. Or so I've been told.
🏁Sue CF: I really thought that last week could've been it for me. Everything felt so right, but it just wasn't enough. I'm desperate to prove myself as a strong competitor here, and someone that people should be afraid of. But without a win, it's hard to do that.
Whorechata: I was surprised at the top two, and that's only a moderate read.
Zodya: I'm scared for this answer, but who would you have taken out of the top?
Anthyy: And I know you might say me, but I don't really care. I know I turned it out, mama.
Whorechata: I would have replaced both of you! I think Sue should've been up there. And the other spot would have to go to a beautiful queen, full of talent, starts with a W...
Wren: Aw, me?
Whorechata: No, me.
Wren: Oh! Not sure why I'm even surprised by that at this point.
the workroom door swings open and Micro walks in, wearing a tailored white suit with a matching hat and cherry red lip
Micro: Hello queens!
Steph: Alright, pimp mama!
Micro: Last week, things got a little tense. And uh, that might be a bit of an understatement. Which is why for your next challenge, it would make sense to do something a little more lighthearted.
Kami: Yes please!
Micro: But you know how we do things around here. For your next challenge, you'll be killing each other.
Blondie: Oh dear god.
Micro: With your acting, of course! The ten of you will be randomly split into two teams of five. In this group, you will be in charge of producing a plot, trailer, and captivating poster for the next big horror movie. How you choose to work within your team, that's up to you. But if I were you, I'd be sure to contribute if you want to avoid the bottom. And on the runway, category is "Pretty Little Prosthetics". Good luck, and get ready to scream!
🏁Blondie CF: For our challenge this week, we're split into teams as we create a horror movie. On my team, we have Fleur, Kami, Whorechata, and Zodya. And on the other team, Anthyy, Morgs, Steph, Sue, and Wren. Less than thrilled to be on a team with Fleur, but it's a strong group, and I think our chances of winning are pretty solid!
the teams scatted through the workroom, with Blondie, Fleur, Kami, Whorechata, and Zodya talking by the couches
🏁Whorechata CF: It's starting to get to me that I haven't really been performing at the level I know I'm capable of here. I'm feeling a new sense of determination this week, and I have a whole list of ideas for this challenge. It's time to prove why I'm here.
Whorechata: So...I have ideas.
Fleur: There's a first for everything!
Whorechata: I'm thinking it could be cool to have the movie be shown from two different perspectives. The same story, but you see it differently depending on who it's focusing on. A sort of play on how the same situation can be perceived differently by different people.
Zodya: Wait, I love that?
Kami: That's a really great idea.
Whorechata: I know, that's why I said it! I mean...thanks!
🏁Kami CF: I do tend to feel stressed in group challenges. Especially with this big of a group. There are five of us. There might be more room to hide, but it's also so much harder to stand out. I want my voice to be heard, and I want to shine, but I'm not sure how.
Fleur: I'll volunteer to work on the poster.
Kami: Nice! Do you want help on that?
Fleur: Hmm, I think I can do it on my own.
🏁Fleur CF: First of all, I'd rather eat sand than work with anyone on my team. And, the poster is a huge part of this challenge. If I do it on my own, that means all the credit goes to me. Maybe a bad idea if the poster turns out ugly, but I'm not too worried about that. My only worry now is what to wear for the lipsync this week!
Zodya: Blondie, do you have an idea of what you're working on?
Blondie: I'll do whatever you need. Put me wherever and give me something to do.
Whorechata: Work with me on the script. I need someone to read through it and make sure it makes sense. One little issue, can you read?
Blondie: You bitch.
🏁Whorechata CF: I didn't plan on taking a leader position this week, but it kinda fell into place. We're getting some good work done, most of us at least. Kami, I know she wants to contribute, but I don't know what she's done yet? And that's starting to worry me. We might not be able to get this done in time...
the team of Anthyy, Morgs, Steph, Sue, and Wren talk around the table
Anthyy: Ladies, ready to win? I need this one!
Wren: Oh please, you do not need another win right now. I'm already getting the Greantee flashbacks as is!
🏁Wren CF: Being on a team with Anthyy is really scary. I like her, we get along. But if we do well, that means another win for her. At a certain point, we need to stop her.
Sue: I feel like I could work on the poster? I can do my best with that!
Wren: That's perfect. Do we want ours to be a parody of iconic movies, or should it be fully original?
Morgs: I would maybe bring those ideas together. It can be a new and fresh idea, but still referencing certain ideas that have worked before.
Wren: I like that, I like that.
Anthyy: I would feel most comfortable working on the poster.
Steph: I think Sue mentioned wanting to work on that.
Anthyy: I don't want to take it away from her of course.
Sue: No, it's okay! Whatever is best for the team.
Anthyy: Are you sure?
Sue: If that's what will make our team strong, that's what we should do.
Anthyy: Thank you Sue, such a queen! Morgs, do you want to get some work done on this?
Morgs: Anything for you, well of course!
the team works on their script before coming back together to go over their progress
Anthyy: I have the outfits for the poster almost done. But don't worry, they'll be done.
Wren: Not to be shady, but what were the two of you doing for all that time? You were gone for awhile, and didn't get anything done.
Morgs: She just said she was working on the outfits and that they're almost done.
Wren: The two of you talked a lot about what you were going to contribute, I'm not seeing much of anything. You need to do your part in the group.
Anthyy: We are. Don't diminish our work!
Wren: I don't see what work I'm diminishing...
🏁Wren CF: Maybe I need to appoint myself as the team leader, because we are not making enough progress. Anthyy and Morgs are like the two friends in school who work together on all the projects, but never get anything done because they're talking the whole time. We have serious work to do!
Morgs: I've been adding to the script, Anthyy's done the outfits, we've done more than enough.
Wren: That's not what I asked you two to do. Morgs, you were supposed to look over what I was doing, not add your own stuff.
Morgs: I get that, but I'm not going to sit back and do nothing.
Wren: Well it feels like you're either doing nothing, or just making things worse.
🏁Anthyy CF: Wren is making me and Morgs feel horrible during this challenge. We're doing the work, more than some other people in the team! But she ignores that since they're friends. It's making me question if I want to even be here, because she's making me feel so bad right now.
the teams continue to work, as Whorechata goes over to the other team
Whorechata: So like, what if we had more time?
Steph: We have to be on the runway soon, I don't think that's an option.
Whorechata: If we all ask for a few more hours, maybe Micro will give it to us.
🏁Whorechata CF: What we have so far is good. But time is our biggest issue. If we can get a little extra, I know we can pull it all together. And it helps the other team too, it makes sense.
Anthyy: I don't think we need the extra time.
Wren: We don't, I know we don't.
🏁Wren CF: Your poor time management is not my fault. We were given the time we were given. If you can't make that work, start packing your bags.
Whorechata: But would you be against it?
Anthyy: I'm not making a scene over extra time, but we don't need it.
Whorechata: So what I'm hearing is that I can ask for more time...
Morgs: I wouldn't be mad with more time.
Sue: I'm happy to make it work either way.
Whorechata: Perfect!
Whorechata leaves the workroom to ask a producer about extra time, before realizing there are no producers, only Micro. She drags Micro into the workroom while she's halfway done with getting ready for the runway
Micro: Chile, what now?
Whorechata: You know how much we love you, right? And how you really don't even need a corset, no matter what everyone says about your waist.
Micro: Excuse me?
Whorechata: What I'm saying is, we need a little more time for the challenge.
Micro: And everyone's good with that?
Whorechata: They'd love it!
Micro: I'm asking them...not you.
Whorechata: Sorry, I'm just speaking for the people. I'm motherly like that.
Micro: Does anyone strongly object to a few more hours for the challenge.
Anthyy and Wren hesitate before raising their hands, and bringing them back down when nobody else objects
Micro: Alright, you can have a few more hours. But you better use it and make this the best challenge yet.
Whorechata: Mwah, thank you!
🏁Wren CF: When Micro says that there's an extension, I start to see red. Our group does not need this extra time. We may not have everything done right now, but when we hit the runway, it would've been ready.
Micro leaves the workroom and the queens talk while getting ready by the mirrors
Wren: This is such bullshit, just so you all know.
Kami: What happened?
Wren: This whole extra time.
Kami: Were you guys done with your work?
Wren: ...that's not the point. We would've been done with it.
Anthyy: To me, it just feels like riggory. Micro wants the underdogs to win this week, so she's giving you more time.
Zodya: Underdogs?
Anthyy: I don't mean that in a shady way. I'm just saying that our team seemed stronger, and Micro wanted to make it less obvious. It's clear to me.
Wren: Exactly.
🏁Zodya CF: I don't know what Anthyy and Wren are trying to get at with this. I saw their work, it's nowhere near done. And in what world are we the underdogs? Anthyy sees everything by the numbers, but that isn't the only thing that matters in a challenge like this.
Anthyy: Look, it doesn't matter. Congrats on winning this week, woohoo!
Runway
the lights flicker and an electric magenta light floods the runway as Micro struts down the center
Micro Episode 5 Look
Micro: Welcome back to the runway of Micro's Drag Race: All Stars Two! This week, the queens were challenged with working in teams to come up with original horror film concepts. And joining me on the judging panel is a queen with killer creativity, Lisbon!
Lisbon Guest Judging Look
Micro: Lisbon, thank you for being here!
Lisbon: Anything for you...as long as you give me a crown one day.
Micro: Ha!
Lisbon: I'm not joking...oh at all.
Micro: Oh. I'll see what I can do about that! Do you have any terrifying moments from your time on MDR that might inspire you in a challenge like this?
Lisbon: Why yes, I have quite a few! Season One Episode Twelve, All Stars One Episode Twelve, XDRVTW Episode Six. I'd have to say those really stick out.
Micro: Any reason?
Lisbon: Nope, none at all! Lisbon pulls out her voodoo dolls of Unieke, Tiwa, and Crystal
Micro: Well, that is not at all troubling! You ready to get into things?
Lisbon: Please, before I turn these dolls into a pile of fluff.
Micro: Alright! First up on the runway, category is "Pretty Little Prosthetics"!
"Bad Juju" by Jujubee plays
Anthyy: Tonight on the runway the theme is prosthetics! And honey trust me this theme is just asking itself for it to be a creppy spooky lewk, but i already served that last week and on episode 1 an literally thorught the whle halloween special for miss Xtina so this time i wanted to make sure i am as girly as i can be with this prostehtics them! But also there is another layer to it i would never just go for a look and dont do nothing behing to it. Tonight on the runway i am channeling a broken porcelain ballerina doll. My whole dress is made out of glass and i am walking very carefully but stunning-ly by the runway. Her story is that her soul is trapped inside a ballerina's figure body and as you can see on the skin an thorughout her body she is slowly turning into that sad ballerina with the glass pieces cutting through her skin,, thats what the prostheticas are in my look! they modify her whole face, she is sad on the glass side, she is trapped and she is bleeding! but in pink! cause pretty girls have pink blood! Don't try and check it though! This runway also need to have a personal touch for me to feel good about it and tonight i wanted to honur my grandma, since she always wanted to become a ballerina but never made it! so granny tonight! you are the prettiest glass ballerina on the mainstage of the biggest compeitiotn!
Anthyy Look
Blondie: KERMI! I AM READY FOR MY CLOSE-UP MON AMOUR! Tonight I am representing the original camp/fashion icon Miss Piggy! I am wearing prosthetic ears, a nose, and a cute wiggly tail! I am also wearing more passing than usual to create that big girl magic energy, so not only am I appropriating fat people, but pigs as well! The dress is completely made by moi and completely bedazzled, I get actual pearls and diamond encrusted headband, and I styled the 40 inch weave myself! I am taking a huge risk going camp, but I rather go out looking like a pig, than actually being one (cough cough Alex cough cough) . And you don't like it, expect this karate chop! HI-YA!
Blondie Look
Fleur: People say I am two faced which I don't necessarily agree with because I say what I want when I want but I just wanted to pay homage to the losers of my past arguements who call me two faced by wearing a prosthetic head! Two heads is always better than one head, am I right
Fleur Look
Kami: For my prosthetics lewk I am getting down and dirty mawma! I just wanted to do something fun this week, so I have gone with this sort of pig prosthetic thingy. This is for my fellow vegan/vegetarian qweens! #ISTANDWITHVEGANTEACHER
Kami Look
Morgs: Silicon manufacturing with your own skin using inorganic compounds of negotiated slurp products for your bodacious perfect size scabs snack for youthful glow anti aging properties may turn vou slime new products for you soon including waters I discussed with Wren stay tune #microfracking
Morgs Look
Steph: for my prosthetic look tonight i wanted to gag everyone by showing that i can be green with envy and still be pretty. just look at my skin and my long nose and she’s bald! also that rat is just a little scrumptious snack for later YUMMY YUMMY!! what’s not to love. i love a long soft prosthetic nose, ears, and chinnnn. if ur chin ain’t long, you’re just wrong!
Steph Look
Sue: So for this runway I am serving you the end of the world but she I still a bad bitch because uwu.
Sue Look
Whorechata: On the runway tonight I am feeling very SAFE! I am a kraken craking backs mawma! She is giving a full squid head prosthetic this evening. I am ready to wreck holes and boats tonight!!!
Whorechata Look
Wren: Today on the runway I am giving you Ratrina Ratson, heir to the Ratson throne. She is DRIPPING in like a million fucking layers of jewels, necklaces, bracelets, and silver. When she moves it sounds like windchimes. I have been consistently getting the critique that I don't drag things up enough, and I hope thisll change that. This is what happens if the rats in Cinderella were sent to the ball instead of her, Cinderella has rats in it right? I'm literally just realizing while typing this that I have never seen Cinderella.
Wren Look
Zodya: For this runway, I am showing off a look inspired by the Dilophosaurus! I have used prosthetics to make myself look fully reptilian, including my large, colorful flaps of skin off my face and hands. And don’t forget to mention my talons, as well as the horns sprouting out throughout my body. Don’t mess with me, queens, or else I’ll tear you apart and eat you alive…in Minecraft!
Zodya Look
-------------------------
Micro: Thank you ladies. You all look gorgeous, or terrifyingly disturbing. But hey, these looks will definitely be hard to forget. Now, let's take a look at your horror movie scripts.
Team 1: https://docs.google.com/document/d/1e-6bIAzNsvFOqKMMaqR7z5Y2ca503HZnzg15Ym4GfLc/edit#
Team 2: https://docs.google.com/document/d/1EoPn63HhkzwHNf1O4zJJ_Zj0U7tk07x96rx_iCZO4jg/edit?usp=sharing
https://youtu.be/eVFuGpRHkdU
Critiques
Micro: Based on your performances tonight, Lisbon and I have formed some opinions. It's time for your critiques.
Micro: First up, Team 1 (Blondie, Fleur, Kami, Whorechata, Zodya)!
Lisbon: Well, hello ladies… and Fleur. This concept was really interesting! I like that you weren’t afraid to approach it more seriously and it felt very atmospheric. However, it fell a little flat for me I guess? The addition of the hallucinations felt odd and left me wondering if Desireé or whatever was like- magic? I think this felt like a solid horror short story but I feel like it lacked imagination and was pretty middle of the road content wise. As for your runways… Blondie, I really love this look as I am the Miss Piggy extraordinaire but I wish it was elevated a little more. It’s giving Ariana meets Miss Piggy which I love but it’s definitely a bit more pedestrian than I’d like for All Stars. Fleur this is one of my top looks of the night you look absolutely horrid, no note really other than the glitter bouquet feels a wee bit cheap. Kami, this is cunt. No notes. Lucky, you look good! It’s a great look, I just want more mug I suppose. Zodya this is fierce, I love a concept that is well executed! One note and this is mainly a personal preference, I wish the face was more cunt less monster, but obviously that’s nitpicking.
Micro: Hello pretty ladies!! I think within this group, you all have such clear strengths, and I was curious to see how that would work in a team format. And I have to say, I’m really impressed by what you came up with. Starting with the poster, I think it captures that eery feeling and the split down the poster played perfectly into the story of the movie. I think some more contrast on the poster could’ve made it pop even more, but I thought it was nicely done! In the plot, I think this was structured a little more as a scene or trailer, rather than it being an overall summary of what the film would be about and the journey it would take us on. It was well written, I just think it ended up being overshadowed by the trailer since the vibe was quite similar between the two. Speaking of the trailer, it was so gripping. I was reading as fast as I could to see what would happen next, and that level of suspense isn’t easy to achieve. My one little nitpick would be that I wish the split perspectives were showcased more, but really fantastic work. On the runway, solid looks from each of you! Kami, I love the campiness of this look, and how you and Blondie played into the pig elements of the movie. Very clever! Fleur, this is the blend of concept and glamour that you do so well, nicely done. Lucky and Zodya, these creature looks can be tough to hold onto the fashion, but you both managed to pull it off. The scaling is grand and extravagant, two of the strongest looks of the night. Overall, very impressed by your group!
Micro: Next, Team 2 (Anthyy, Morgs, Steph, Sue, Wren)!
Lisbon: You guys… acting challenges are hard and I get that but this thing? Was super fun!!! Oh my god!!! I think taking the camp and parody route is a risk that is well worth taking because this was really good! Troglodyte was a standout in my opinion, but everyone had their moments. This was such a fun watch and you mixed two horror franchises really well! Micro is a lot scarier though to be honest. My issue tonight with this team is the runways as opposed to the other team over there. Starting with Anthyy, I love the concept as a former dancer, I just know this execution could’ve been a little more en pointe. I’m hilarious. I just wish it was more clearly prosthetic. Morgs, this is a well executed cliché with a fun twist. I’ve seen and was expecting a booby girl but I like that you are pink, this runway isn’t winning any awards though. Steph… girl… these prosthetics are so good… but this dress is god awful. You are giving Party City girl, and that’s the point blank truth. Sue. Meh. It’s fine, just not mind blowing. WREN WHY ARE YOU A RAT? This look is train wreck central. Those are necklace and earring PNGs on that dress and I don’t even know what’s going on with your face. Rat? Why? But like, this group had a phenomenal challenge, but was challenged with looks.
Micro: This team is full of some creative creative ladies, so I was really excited to see y’all in a team together. And I just have to say, the execution of this was incredibly well done. The poster, I love the custom looks, the dark shadowy feel, the scary ass “person” in the back, and the little “probably not though” at the bottom. That was a really fun little comedic touch that gave the poster some depth. I have to be honest, I was a little worried when I saw that the concept was so similar to Drag Race, just with a darker twist. I think for a challenge like this, it could’ve been an opportunity to go balls to the wall. But within the concept, you found really nuanced ways of telling the story. The character building and storytelling was next level, and it made me so invested in what was happening. The audio as well, in the words of Wendy Williams, “it was scuh-ary”. I think the way you structured everything as well was something we could actually see with a plot and trailer, clean and concise. The twisted humor throughout the trailer added lots of special touches, I loved to see it. On the runway, some serves were served! Anthyy, this dark ballerina moment is so pure, but also has darker levels beneath the surface. Steph, I think the actual prosthetic work here is amazing. But the dress, I wish it was so much more!! Morgs and Sue, I love how you both took a more standard fashion silhouette, and infused that prosthetic twist throughout. Wren, rat queen! This week was truly a return to the originality and dedication you showcased on Season Six, and this runway proves that. It’s weird, it doesn’t make sense, it’s glamorous, it checks all the boxes. Nicely done. Overall, great work from this team!!
Micro: Thank you ladies. This week, you worked in teams. But your individual work is what matters here. When I call your name, please step forward.
Micro: Anthyy, Fleur, Morgs, Steph, Zodya. The five of you are safe. You may step to the back of the stage.
🏁Anthyy CF: Disappointed to only be safe, but this week was really awful for me, and I'm just glad I was able to make it through.
Micro: Blondie Dahl. On the runway, you were a blushing bacon bride.
Micro: Whorechata Grande. In the challenge, you had us all questioning reality.
Micro: Wren Wyvern. This week, you scurried your way to the top.
Micro: Whorechata, Wren. Congratulations, you are the top two queens of the week!
🏁Whorechata CF: And that's how you do it.
🏁Wren CF: Yes!! Fuck yes!! Finally I get my moment, this is what I've been waiting for!
Micro: Blondie, you are safe.
Blondie: Better than getting the pork chop!
Micro: Sadly, that means Kami and Sue, you are the bottom queens of the week.
🏁Kami CF: This is a horrible feeling. I know how badly I want this, and the thought of my dream being cut short, it's heartbreaking.
🏁Sue CF: I'm devastated right now. I wanted this to be the week where I got to the top, not fall to the bottom. I don't want to be the reason Kami goes home, but I need to fight for my spot.
Micro: Whorechata, Wren. In a moment, you will lipsync for your legacy and for the right to eliminate one of the bottom queens. Head backstage to Untucked and deliberate.
Untucked
the queens enter Untucked
🏁Zodya CF: The bottom two this week is crushing to see. You don't want it to be you, but it stings seeing such amazing people in the bottom. For once, I am glad to not be in the top.
Kami: First and foremost, congratulations! Not the ideal situation, but the two of you crushed it, and we need to celebrate that.
Wren: Aw, thank you. I don't want to be obnoxious with how I'm feeling, but this just feels amazing. Like, ahhhhh!!
Whorechata: I told myself that I would be able to win this challenge if I set my mind to it. And look at me now! It makes me feel great.
Steph: I'm obviously really happy for the two of you, but devastated at who's in the bottom. I really didn't expect this.
Sue: I thought I gave it my all this week. But when you hear the critiques, it's hard not to feel like you could've done more. I guess that's what I'm feeling right now.
Steph: Aw, Sue. I thought you were great.
Sue: Thanks. This just, it means more to me than I thought it did? And to go from feeling like I was picking up steam to totally crashing, it's not a slay moment.
Steph: Very not slay.
Blondie: Whatever happens, you two have brought so much to this. It means a lot that I can call you my sisters.
Morgs: Did anyone have issues working with their team?
Zodya: I think we all got along!
Kami: There was a clear end goal of what we wanted to get done. It would've been nice to feel like we all had the chance to do our fair share, but it was a good experience overall.
Whorechata: I know you wanted to do more. But it's up to you to step in and make sure you're involved. You'll get left behind if you wait for us to bring you in.
Kami: Yeah, I get it. It's just a lot of emotions, sorry.
Whorechata: Hey, you're good.
Anthyy: I thought we worked really well. We all brought our own unique twist, and it came out great in my eyes.
Morgs giggles
🏁Anthyy CF: The other team does not need to know how bad things were for us. If they know, then they'll think I'm not good at working in a team. They need to think that everything went perfectly!
Kami: I would love the opportunity to speak with the top queens if that's alright. Just plead my case a bit.
Sue: That would be nice for me as well.
🏁Sue CF: I want to prove to the top queens this week that I deserve to be here. I regret letting Anthyy take over for the poster. But a lot of the love that the characters got, I helped with that. This isn't my time to go, I know it isn't.
Whorechata: Alright, let's chat!
Kami talks with Whorechata and mentions their connection to Season Five, and how she wants to represent for that. She shares that during Season Five, she felt like she was overshadowed by Moof, and unable to really stand on her own as a strong competitor. Being in the bottom made her realize how badly she wants this, and moving forward, she's dedicated to giving everything she has to this competition
Sue talks with Wren and Wren says that she thought Sue would've been in the top this week. Wren tells Sue that her heart is being pulled in two different directions. While she's gotten close with Kami, she can't overlook her long friendship with Sue. Sue tells Wren that she stands by what she did in the challenge, and wishes she took more responsibility for her contributions
while the top and bottom queens deliberate, Anthyy and Morgs chat by the touch up mirrors
Anthyy: Honestly, I'm over it.
Morgs: Oh no, over what?
Anthyy: I feel like I need to leave maybe. The way Wren made me feel during the challenge, and saying we weren't doing enough.
🏁Anthyy CF: When we were working on the challenge, Wren said multiple times that she didn't think Morgs and I were doing enough. And to me, that felt like a really shady way of ganging up on us to make sure none of the praise for the challenge got shown to us. I felt myself getting closer with Wren, but her questioning my work ethic, it really broke me.
Morgs: You can't leave. You're doing too well.
Anthyy: I didn't come here to deal with all this stress. I came here to win, and the pressure is eating away at me. And now for someone to be coming after me, I can't do it anymore.
🏁Morgs CF: Losing Anthyy isn't an option right now. She's the closest person I have here, and I know that she would regret leaving. That's my girl, I need to make sure she's alright.
Morgs: I will cry if you go home, and you don't want to make me cry.
Anthyy: No, I don't want that! I know I need to fight through this, but it's really hard. I'm not sure what I'll do.
the queens return to the runway
Micro: Welcome back queens! Will the top two queens of the week please step forward.
Whorechata Lipsync Look
Wren Lipsync Look
Micro: Prior to tonight, you were asked to prepare a lipsync performance of "Die Young" by Kesha.
https://youtu.be/NOubzHCUt48
Micro: This is your chance to impress me, and earn the right to give one of the bottom queens...the chop.
🏁Whorechata CF: Little do they know, I put pockets all up in here. Give me all the lipsticks, send 'em all home!
🏁Wren CF: Oh bitch, I'm ready for this! I need to give these girls a few lessons.
Micro: Good luck, and don't fuck it up!
Read the lipsync here!
Micro: Well, that was something! I've made my decision.
...
...
Micro: Wren Wyvern. You're a winner, baby!
🏁Wren CF: I did it!! If you asked me how I felt a few hours ago, I would've said that I was questioning my place here. But this little taste of victory, it snapped me right back into place.
Micro: Whorechata. You are safe to slay another day. You may step to the back of the stage.
Whorechata: Safe, of course. Smile through the pain, smile through the pain.
Micro: You may step to the back of the stage.
Whorechata: I mean, I could. But what if I stood here? Would I be a winner.
Micro: ...no. No, you would not.
Whorechata: Shh, no more words.
Micro: Now, will the bottom queens please step forward.
Kami and Sue step to the front of the stage with shaky hands
Micro: I won't lie, this sucks. Both of you are such special queens in this competition. Wren. With great power comes great responsibility.
Wren: Ugh, this is the worst part.
Micro: Which queen have you chosen...to get the chop?
Wren: Ultimately I believe with one of you I would not be in the top and you were such a joy to have on our team and you did a lot of the conceptualizing. I am not about to have my Bebe Zahara Benet moment so the person I have chosen is…
...
...
Wren: Kami.
Wren's Lipstick Choice
Kami smiles and wipes away a tear as Micro and the other queens get emotional
Wren: I'm so sorry.
Kami: It's all good, I promise!
🏁Kami CF: I wanted this. I wanted this so bad. But I'm leaving this competition as a better queen than I was when I walked in. Seeing people believe in me gave me permission to believe in myself. My time will come.
Micro: Kami. You are one of the kindest, genuine, and most talented queens to ever grace this stage.
Kami: I appreciate that more than I can say. It might not have ended the way I wanted, but I'm forever grateful for this experience.
Micro: Sadly, I must ask you to sashay away.
Kami walks to the back of the stage as Anthyy leads a crowd of queens up on stage to embrace Kami before she leaves
Kami: Love you all. Until we meet again!
Micro: Whew. Congratulations to the nine of you for making it through another week. I know I get all "whaaaa" and a little "oh my damn" at these eliminations, but this one hit different. And they're only getting harder each week. Keep up the great work, and let the music play!
"Banjo" by Bebe Zahara Benet plays
Next Time on Micro's Drag Race: All Stars
Micro: Get ready for the buffoonery, riggory, and tomfoolery of "Robbed: The Musical!".
Anthyy: I don't know if I can do this anymore. It's all too much.
🏁Wren CF: The competition is being flipped on its head. Things can change so quickly.
Track Record
Cast Shot w/ Placements

https://preview.redd.it/mas77l5vk04b1.jpg?width=1280&format=pjpg&auto=webp&s=80e755964f562a1c58d4b126faba6cde3454d465
20 Amazing Uses Of Toothpaste
Toothpaste comes in many different flavors, whitening strengths, and brands, and it does a great job keeping your teeth clean and healthy. Assuming you actually use it of course… But, there are many amazing uses for toothpaste, aside from cleaning your teeth! In fact, there’s very little that tooth paste cannot do, so try a couple of these toothpaste hacks and see for yourself! It doesn’t cost much, so why not have a little fun with it? Let’s discover a few awesome ways to use toothpaste!
Number 1 - Eliminate Nasty Odors It’s easy to get left with smelly hands and fingers after cooking, especially with garlic, onions, fish, or any other pungent ingredient. These odors can actually make their way into your skin cells, which is why they hang around for so long. You can use toothpaste to remove these odors by simply rubbing a bit on your hands and rinsing them clean.
Number 2 – Relieve a Burn Burning yourself is no fun! It really hurts, and the pain seems to linger on forever. The next time you happen to burn your hand or fingers, try this simple remedy to ease the pain. First, run some cold water over the burn for a few minutes, as you normally would. Then cover the affected area with tooth paste for a soothing and cooling solution.
Number 3 - Repair Scratched CDs and DVDs While digital disks are slowly becoming a thing of the past, most of us do have a collection of CD's, and at least a rack full of DVD’s. And surely, you’re familiar with the joy of having a scratched disk… You know… listening to your favorite song, and it starts skipping or it just skips to the next song. Well, there’s a quick and easy fix! Toothpaste of course! It can be used to safely and effectively remove scratches from your CD’s and DVD’s. You just have to rub a little bit of toothpaste on the disk with a soft cloth and then wipe it clean.
Number 4 – Clean a Hair Straightener Girls, you’ve probably noticed that over time your flat iron starts to develop a grimy coating on the surface of the plates. This is caused by a build-up of everything from hair spray to mousse, shampoo, gel, or whatever else that you put in your hair. But, you can easily remove all this buildup. All you need to do is rub some toothpaste on the plates, and buff them clean with a microfiber cloth.
Number 5 - Clear Up Pimples Forget those expensive acne treatments. You can get great results with a cheap tube of plain white toothpaste! The ingredients in toothpaste dries up acne and leaves you with clear skin. Just dab a small amount on your pimples before going to bed. And when you wake up in the morning, you should see a huge improvement!
Number 6 - Polish Silver Jewelry Silver jewelry loses its shine over time. However, a little bit of toothpaste and an old toothbrush can bring back the sparkle. Just dampen the toothbrush and add a touch of toothpaste. Scrub your jewelry gently and then rinse clean with warm water. Simple as that!
Number 7 – Clean Your Nails A whitening toothpaste with peroxide will remove that unsightly orange or yellow tinge that nails tend to develop from dark nail polish or excessive smoking. All you have to do is apply a little toothpaste to a nail brush and scrub gently over your nails.
Number 8 - Freshen Up Your Car Toothpaste can easily eliminate odors in your car. If you want your car to smell minty fresh, just put a quarter sized amount of toothpaste onto a paper towel, and fold it in half. Leave it under your seat, and the toothpaste will make your entire car smell … well, like: toothpaste.
Number 9 - Treat Poison Ivy Stings If you happen to get a rash or a sting from poison ivy, use toothpaste to take away the worst of the irritation. Gently apply a bit to the affected area and leave it on for about 10 minutes. Then, wash it off with some cold water. You can repeat this until the stinging sensation subsides.
Number 10 – Style Your Hair Not a lot of people know that gel toothpaste contains some of the same ingredients as commercial hair gel products – which is certainly something to think about… However, the next time you’re heading for a night out, but realize you’ve run out of hair gel, just slick a little bit of toothpaste on your hair. This simple toothpaste hack will keep your stray hairs in place all night long!
Number 11 - Clean Baby Bottles & Containers It’s not uncommon for baby bottles to develop a slightly sour odor. But, you can get rid of this smell with toothpaste and a regular bottle scrubbing brush. Squeeze some toothpaste right into the bottle, and give it a good scrub. Be sure to rinse the bottles out thoroughly afterwards, because ingesting too much fluoride can make babies sick.
Number 12 - Reduce the Appearance of Bruises If you have a nasty bruise you want to get rid of it as soon as possible, you’re going to need two things. Some lotion, and you guessed it! A little bit of toothpaste! Now mix these two together, and apply the mixture to the bruise. Then cover the area with a large band aid. Leave it on overnight, and wash it off in the morning. Repeat these steps for another two or three nights, or until the bruise is gone.
Number 13 - Bring Old Shoes Back to Life Toothpaste can get those sorry looking leather shoes or trainers looking good again. Just apply some toothpaste directly to the dirtiest spots. Then, take an old rag or a brush, and scrub with a generous amount of pressure. Rinse off the toothpaste, and you got your shoes looking like new.
Number 14 - Deodorize Your Dog Dogs and skunks do not get along. In fact, dogs can find all sorts of smelly things to play with. The next time your pooch gets into something smelly, just wet his fur, and rub in some toothpaste. Massage his coat for about five minutes and then rinse him clean. The offensive odors will be gone!
Number 15 – Get Rid of Hair Dye Stains The next time you color your hair, make sure you have a bit of white toothpaste on hand for those color stains on your face, ears and neck. If your color runs and leaves a stain, just rub a bit of toothpaste on it and scrub the stain away.
Number 16 - Clean Your Refrigerator The seal around the door on refrigerators can get very dirty, and it can be quite difficult to clean. Simply add some toothpaste to a toothbrush and scrub away the grime. This will make your refrigerator sparkle like new.
Number 17 - Clean Walls If you have a child who aspires to be an artist and has chosen your walls as their canvas, you can easily remove those crayon marks with a damp cloth and a bit of toothpaste. Rub the stains vigorously in a circular motion, until they disappear. Then simply wipe off the residue with warm water.
Number 18 - Remove Gum from Hair I’m not sure how this even happens, but apparently it does. And it’s a sticky situation, that’s for sure! To get chewing gum out of hair fast and without having to reach for scissors, spread some toothpaste over the affected are and let it do it’s magic for a few minutes. The toothpaste will break down the sugars in the gum, and you’ll be able to lift it out much easier.
Number 19 - Buff Kitchen and Bathroom Faucets Instead of using a chemical based cleaning product, you can keep your kitchen and bathroom faucets looking bright – and all you need is some toothpaste! Grab a rag or a sponge, squeeze a little bit of toothpaste on it, and put yourself to work. Add a little bit of elbow grease and your faucets are going to look brand new in no time!
Number 20 - Repair Cell Phone Screens Cell phones have come a long way. But, they are still prone to scratches. Luckily you can remove minor scratches with this simple toothpaste hack! Lightly rub a dab of toothpaste over the scratched areas. Then, wipe it clean with a damp cloth and leave your phone to dry. Have you tried any of these toothpaste hacks? If you did, how did they work out for you? Let us know in the comments below!

Introduction

I started learning Japanese on March 22 2023. At the time of writing, It has been about 70-80 days since. Currently I would place myself at N4 level (now studying N3). I became very inspired to study Japanese after (a) visiting Niseko (Hokkaido) and (b) reading a post on Reddit about someone who claims to pass N1 from zero in 8.5 months.
The purpose of this post is to offer (a) alternative perspectives to learning Japanese, (b) prove that it is possible to learn quickly, (c) challenge some of the existing recommendations. This post is part one out of eight articles detailing my journey to N1 from zero in 8 months. Disclaimer, this post will be very long and ranty!
This post will cover some of the study techniques and experiments I’ve conducted for the first month, as well as the results of my experimentation and insights. As for the elephant in the room, I’m currently studying N3 after 60+ days into my Japanese learning journey. I’m sure many are skeptical or might presume that I have bad mastery of N5 and N4 content, but by the end of the post, I’m confident that I would have responded to them. This post is not created to discouarge anyone >< I just wanted to see if my studying tips can inspire or resonate with other people.
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Prior Knowledge

I started watching anime since Naruto. I think that was 15 years ago. I’m not particularly obsessed with Japanese culture but I do follow the mainstream anime like Bleach, Tokyo Ghoul, My Hero Academia, Attack on Titan, and most recently Demon Slayer. So I do possess 15 years of acclimatising to the sound of Japanese anime speech. However my Vocab is very limited. I know how to count from 1-99, konnichiwa and itadakemasu, and a couple more words that I might remember if I was prompted. I also know the hand signs from Naruto. Apart from that, I consider myself truly zero in Japanese knowledge.

While your brain can only hold 7-9 items in the short term memory at once, it does not mean you cannot study more than 9 items in a day.

I see most people on Reddit recommending 15-20 new cards on Anki. Personally I think this pace is way too slow, especially for the beginner. Most typical N5 vocab deck would have about 600-700 cards. 15cards/day means that it would take 40-50 days just to see all the cards. I also came across a study that says our short term brain cannot store more than 9 items at a time. This would seem to support support the recommendation of 15-20 vocabulary cards a day. While reading Moonwalking with Einstein, a book on the capabilities of the human memory, I read about a story of a guy who could draw the landscape of New York with shocking precision after flying pass the city on a helicopter once. The book also hinted at the idea that we possess some form of photographic memory.
And so, i tried to do about 50-100 new cards a day. Within 10 days, I’ve seen all the N5 Vocab. Around day 15 or so, i became concerned that cramming so many words in a day would mean that the retention rate will be low. So I tested myself on those 700 words and I think I got about 85% correct.
Personally i was very happy with that score. I thought I could do a lot worse. So clearly, trying to learn 100 new cards a day wasn’t detrimental to retention rate (I will address my thoughts on burnout on a later point). What is happening?
My hypothesis is that while we can’t store more 6-9 items in our short term memory, it doesn’t mean that when we study our 10th,11th, 20th or 100th item, our brain would completely reject the input. You are still imprinting something onto the brain. What this means is that while you should not expect to see a word once and remember it forever, it says nothing about the upper limit of how many words you can simultaneously start on the first stage of the SRS system. We all know that SRS takes time to turn short term memory into long term memory. It could take weeks or a few months. But if we can start 100 words on the SRS system vs 15-20 words, and there is no significant cost to doing more words, then starting 100 new cards a day will bring us to our destination much faster.

Self-fulfilling prophecy

When you read about many people agreeing that 15-20 new Anki card a day is a good pace, or that it takes 300-500 hours to pass N5, then it sets the expectation of what is normal. The reason I was able to Master N5 in approximately 150-200 hours and learn all its vocab a couple of weeks is because I did not pay attention to what other people can achieve.

How I use Anki

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From my survey on Reddit, it seems that people get overwhelm by the amount of reviews on Anki. And I think this reveals that the are doing reviews differently from how I do it.
When I do my Anki reviews, I only entertain two state of minds when marking the flash cards. The first is I know the answer (the answer pops into my brain instantaneously) and the second is I don’t know the answer (mind is blank). I do not try to recall the answer. Recalling takes time. If I try to recall the answer, it might take me upwards of a minute or two to remember it (and even then, I might still be wrong). Instead i like my Anki reviews to be snappy. It feels like I take about a fraction of a second to answer my Anki cards, although the Anki statistics tells me that I take 4second per card. Still fast either way. At 4s/card I can do 900 reviews in one hour.
Next is how I use Easy, Good, Again and Hard. The rule of thumb is to be more liberal than strict. I try to use Easy, instead of Good as much as I can because I don’t want my reviews to pile up. I almost never use Hard even if I get the card completely wrong. Speaking of reviews pilling up, we need to define what marking an Anki item as Good or Easy means to me.
For a lot of people it means aiming for perfection. That means that the person only click Easy or Good if his answer exactly matches the back side of the card. For myself I set an extremely low bar, as long the vague feeling of what I think the answer is somewhat matches the answer on the back side, I’m happy to give it a Good at least. Why? Because it’s the nature of Anki or SRS system to return cards you previously click Easy and Good. I don’t have to worry about being too forgiving on myself and being ignorant about the fact because I can always count on the card to return eventually. And if I a card I previously marked as Good, came back, and feels difficult, I would then make a mental note to study it in greater detail. Secondly, a lot of the 700 words in a typical N5 vocab deck are so common that you will encounter them all the time in the wild. This is called organic or natural SRS. If you are strict on your Anki at this stage, it can be quite an overkill in hindsight. Of course it may not feel like an overkill in the beginning because you are still gettting cards wrong.

Burnt out

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https://preview.redd.it/vnsx0umzk04b1.png?width=3840&format=png&auto=webp&s=c69555aa237a3e6bcf538db3014ef410aee3f34b
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Okay what about burnout. Surely I might be overdoing it, and wouldn’t burnout eventually catch up to me. Yes and no. I think the phenomenon of burnout is highly exaggerated. I don’t like to use the word burnt out whenever I’m feeling “burnt out” because it has a lot of negative connotations and because negative connotations can lead to self-fulfilling prophecies. Instead, I prefer to use the phrase, “I’m tired now”. I kind of compare myself to Shonen protagonists where there’s this big villain coming up and then some special training to level up. The special training is usually quite intense, and sometimes dangerous, and they will eventually be quite tired by the end of the training. But these protagonists always reemerge stronger with new abilities and can now overcome stronger foes.
Similarly, whenever I study too much, I would just acknowledge that I’m tired, watch some anime and something different. I’m usually okay by the next morning. I attribute my ability to resist burn out my thoughts and attitude.

Consistency, multimodality learning, and resourcefulness

Okay the N1 tango book is really too difficult for me. I bought it thinking i could get a headstart on N1 while concurrently studying N3. Its just too much at this point.
I only believe in one kind of consistency, and that is that you have to show up almost every day. But I don’t believe in the kind of consistency that requires me to be on a 365-day Anki/wanikani/immersion streak. This is also one factor that helps to protect burn out. When I feel like doing textbook learning, that’s what I’m going to do. If want to do pure Bunpro and Anki for the next 3 days without reading any textbook, that’s what I’ll do.
I also believe in the idea of multimodality learning. I use everything at my disposal:
All the textbooks (Genki, Minna no nihongo, Tae Kim)
YouTube videos (Misa ammo, game gengo, tokiniandy)
Podcast
Songs
Doing active immersion with anime
Changing my phone language to Japanese (this one unfortunately is a bad advice. I recommend to stay away from this if you are still at N5)
Posters
Instagram and TikTok accounts of Japanese tutors
Websites (tofugu, human Japanese, Japanese tutors’ blogs)
Apps (wanikani, language reactor, bunpro)
Japanese grammar dictionaries
Assessment books
Discord or Reddit or forums
Japanese classes
There’s often this debate on which is better, Genki vs Minna vs Tae kim. If cost or ability to procure them is not an issue, why not use all of them? It’s okay to have one source as your primary source. Mine was Genki 1. But when I wanted to understand a nuance that Genki does not explain well enough, I’ll usually consult my other sources. And if I’m bored of Genki, I can easily switch to Tae Kim, for a change of scenery. If I don’t feel like reading, Misa or Tokiniandy is there for me.
My observation is that many people are usually only using one modality to acquire a new skill. This is causing their journey to be unnecessarily monotonous.

Sloppy learning and conjugations

One very integral component of the Japanese language is conjugation. It’s especially important for the N5. Conjugations can allow you to express many meaning in Japanese. Learning how to conjugate accurately is going to be a struggle for any beginner(think godan and ichidan verbs and conjugating to masu, te, negative forms, etc).
A lot of Japanese textbook and assessment will make you do drills. I skipped all of them. Rather than trying to brute force your way to memorizing conjugations I employ a technique called sloppy learning(this phrase is borrowed from “Japan Like A Breeze” on patreon). I define sloppy learning as learning just enough to acquire the essence of the concept.
For example, ,whether the verbs is in its polite form, short form, negative form or past tense form etc, can be easily recognised by looking at the last few syllabus of a word. If a words end on a “ta”, it must be past tense form. If it ends on a “masu” it must be the polite/long form. This concept can literally be understood in 5 mins.
Thus for me. When conjugating oyogu (泳ぐ）into past tense form, I just conjugate it as oyogu-ta (oyogu +ta) Or sometimes oyota. Now oyota is wrong of course. But that’s all I need at this stage. I desire to understand Japanese, not to get full marks on conjugation drill table. You must always try to look at the big picture. Trying to do well on conjugation drills is an opportunity cost. Ultimately one needs to judge what is worth spending effort on. Hence the idea of sloppy learning is to be deliberate about what to focus on.
Once I can consistently remember that masu means polite and ta meant past, this is where I try to conjugate them correctly. Conjugations is difficult because they all don’t behave like ru verbs. You cannot simply drop the ru at the end of a word and append ta or masu to them. Oyogu for example doesn’t even have a ru ending.
The path I chose was to hope that I can organically (I like this word a lot, but it also sometimes means magically) , know how to conjugate correctly one day. And to a certain extent I acquired some intuition on conjugations without any active involvement from my part. I soon became aware that if a word ends in a gu or a ku, then instead of a ta, it might be ita or ida.
The break through came on day 35. When I couldn’t endure the fact that I wasn’t able to magically acquire conjugation intuition for free. So i goggled “why are godan verbs conjugate the way they are”. And Tofugu came to the rescue.
Essentially they introduced three concepts (a) double consanent with small tsu, (b) assimilation with n, and (c)consonant removal. After that article, conjugating became a breeze. In hindsight, my ability to conjugate only costed me the time to read one tofugu article (and one month of passively intuiting the conjugation patterns) Because I did not spend time on conjugation drills, i was able to progress to the other grammatical points in Genki 1. I didn’t remain stuck in one place for too long.And this is another aspect of sloppy learning. You learn just enough to move on to the next level, you don’t aim for perfection.
Your brain can’t do everything at once. Your brain cannot remember that masu means polite form, and all the rules for conjugating verbs to masu in one sitting. If you try to do that, you can remain stuck, despite already understanding the general idea of conjugation. Better to move on and let the intuition develop. If you judge that the intuition is not going to progress or progress quickly enough, you can always intervene later by supplementing with new knowledge.

Mnemonics when I get something wrong too often

Often there will be a vocab or grammar point that I always can’t seem to latch on. No vague feelings, no guesses, just an empty mind. When this happens, it can be a scary feeling. It may feel like you are not good enough.
Really the solution is very simple. Just add one more inferential step. When I first encountered the word bengoshi（弁護士） , my mind does not produce any intuition or pictures or feelings. What I did was to create a mnemonic, a story. How to relate a lawyer to the sound ben go shi? I managed to came up with “when the judge announces his judgement, the bench(jury) goes “shhhh””Sorry, I know it’s really bad. But when I created that story, bengoshi never stumped me again.I’ve seen a lot of criticism of mnemonics that I don’t agree with

1. ‘they are not for me”>>I’ve seen people said that Anki is not for me. Srs is not for me. While I believe in individual differences and effectiveness in different methodologies, I feel that sometimes people decide too quickly what is or isn’t for them. What is optimal may first have a learning curve in the beginning. And instead of saying that something is not for me and moving on to the next thing, we need to consider if it isn’t we ourselves that should change to make it fit for us.
2. “If I’m trying to memorize something, how does adding more things to remember help. Now I not only have to remember the word, but I need to remember the story to remember the word.”>> Between a story and a random string of number “89779012879” , the brain can remember the short story more easily than the string of number despite the story consisting of more words. It’s just how our brain works.

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On active immersion

Active immersion means trying to pick up words or trying to understand what is being said in Japanese media like anime or novels. Passive immersion means enjoying the content without really worrying about improving your Japanese.
On day 21 I tried active immersion with Weathering with You. I came to the conclusion that active immersion is not efficient for the new learner. I can imagine myself doing a lot of sentence mining and active immersion in the future (spoiler, I’m now on day 70-80 and I’m immersing a lot more now). But definitely a hard no for me to recommend new comers as the only and primary form of learning Japanese.

Why textbook learning and structural learning is important for fast gains.

Textbook learning is great for fast gains because it prioritises for you. Textbooks are not prepared by a random person. They are usually prepared while respecting certain pedagogical principles in mind by a team of qualified academics. While appealing to authority doesn’t make it correct, we should at least be cognisant that the textbooks might be doing a few things right.
One of those pedagogical principles is incremental or progressive learning. Building knowledge upon what was previously learnt.
Another principle is foundational concepts. A textbook will usually introduce foundational concepts that act as a scaffold for everything else as early as possible. And because textbook learning is progressive, it means that the difficulty is always going to feel just about right. In active immersion the difficulty can be wild because it does not respect your level of Japanese proficiency.
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Completing N5 in 30 days.

In this 30 days, I was not only learning Japanese, but also learning how to learn. They call it building a plane while flying it hahahah. The principles outlined here helped me to finish N5 content at an insane rate. I was spending about 6-8 hours a day on Japanese (in chunks). So one point not stated here is time. There's no way around time investment.
On the 30th day I did a lot of mock tests and I performed quite well (80-90% correct).When I started on N4 on day 31, I was really surprised by the bump in difficulty. I gave myself 30 days to clear N4. That was the hardest 30 days in my Japanese learning journey. I’m fact I had a better time when I was studying for N3 on day 65 onwards. In my next post I’ll share why N4 was harder than N5 and N3 for me and share some more insights. Hope this has been helpful in offering new perspectives. Thank you for reading this long rant of mine.

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