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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!

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

"Beat Em'!"
Sometime among the events of the very first Kinder Cosmic...
The director of the United States Space Force marches back and forth before a gathered group of several hardened space marines all standing at attention within a large training room as he addresses the group with a general Patton like speech.
USSF Director: Ladies and gentlemen...We are at the precipice of the dawn of a new age!
*The group murmurs amongst one another curiously.
USSF Director: Time and time again threats from opposing galaxies, dimensions, and outer worlds; some beyond the very realm of human comprehension have descended upon our little blue marble suspended in space and threatened our quality of life, our society, our safety, our sovereignty and our very existence!
*Several members of the group shudder and gasp as the director continues his sermon.
USSF Director: If the citizens of this United States, no...The very world itself are to maintain our status qu-
*The group diverts their attention behind the director towards the sound of a loud, laborious sigh.
*The director shoots a disapproving glare at the alien grey known as Alpha as he continues to speak.
USSF Director: As of late, the only force standing between the citizens of this planet and total annihilation has been...
The lady astronaut and appointed liaison to the greys; one Luna Valentina gently pushes the little grey alien known as Jorg towards the middle of the room as she whispers in his earholes.
Luna: ...Go ahead, Jorg!
*Dressed in a bright red silk dress and miniskirt with a purple bandanna tied tightly around the crown of his head; Jorg stares at the hem of his dress with either side clasped tightly within his hands as he swings his hips from side to side and hums happily as the dress flutters back and forth.
The USSF Director sighs apathetically as he continues to speak, pointing at the little grey now standing beside him.
USSF Director: W-What...
*The Director shields his mouth and whispers to Alpha and Luna as Jorg continues swaying unmoved and unbothered.
USSF Director: What th-....What is this?
*Luna laughs and smiles as she replies patiently.
Luna: The only way I could get him to cooperate is if I let him wear his dress!
*The Director stares at Jorg still humming and fluttering from side to side and then Alpha confusedly.
Alpha: He thinks it makes him stronger...
*Luna giggles as she follows Alpha’s words.
Luna: He...he doesn't understand how feminism works!
*The Director stares at the flamboyant grey and then Alpha once more.
*Alpha throws his hands up as he replies.
Alpha: Who the hell am I to tell him otherwise? As far as I know it probably does!
*The USSF Director sighs frustratedly as he quips.
USSF Director: Jesus fucking Christ...Can he fight wearing it?
*Alpha smirks mischievously as he speaks.
Alpha: ...Jorg? Jorg can fight in anything, anywhere, at anytime!
USSF Director: Fine...Well I guess we'll conti-
*Suddenly the Director is interrupted by a massive, muscled and imposing Sergeant who addresses the group obnoxiously.
Sergeant: Why is that little alien wearing a fuckin' miniskirt!?
Luna snaps defensively.
Luna: HE'S IN TOUCH WITH HIS FEMININE SIDE!
*A private nearby mutters knowingly.
Private: Well, I heard that lil' shit is completely unhinged!
*The group of hardened space marines murmur amongst one another as Luna plants her hands on her hips and speaks once more.
Luna: NO HE ISN’T! HE SAVED YOUR IGNORANT ASSES!
*The Sergeant points at the preoccupied grey as he speaks once again.
Sergeant: That scrawny, 80 lbs, ugly ass little critter? Saved what? Ru Paul's drag race?
*The private glares at the Sergeant standing beside him confusedly as he continues to speak.
Private: Where the hell have you been man!? You didn't hear about what happened in Tulsa?
*The Sergeant cuts a sidelong glance at the private as he continues to speak.
Sargeant: Stationed abroad... No phones, or internet, or TV, or electricity, or running water...not even a fuckin working toilet! So no...I don't know "what happened in Tulsa".
Private: ...Oh. Well I HEARD he leveled half a city fighting some interstellar Lovecraftian planet killer...
USSF Director: OFFICIALLY THAT WAS A LEVEL 4 EARTHQUAKE!
Private: SURE BOSS! whatever y'all say, it's not like it hasn't been cycling all over Tiktok for months...
USSF Director: RUSSIAN PROPAGANDA! A DIVERSIONARY TACTIC TO UNDERMINE UNITED ST-
*Alpha sighs again loudly.
*As the group continues to bicker incessantly the USSF Commander from "Kinder Cosmic: Paradise Lost" strolls into the training room and smiles with a large grin as he leans against a supply depots consignment widow and addresses it's quartermaster casually.
Commander: Has it started yet!?
QuarterMaster: ....Has what started yet?
*The Commander grins mischievously as he continues to speak.
Commander: Say...Are you a bettin' man?
Quarter Master: On what exactly?
Commander: Costello over there of course!
*The Quarter Master stares at the grey still preoccupied with his pretty dress and then the Commander once again.
Quarter Master: That sick lookin, effeminate little space midget against ALL OF THEM!?
*The Commander smiles knowingly.
Commander: You bet your ass!
*The QuarterMaster doubles a glance back and forth between the grey and the Commander as he speaks.
QuarterMaster: How drunk are you?
Commander: VERY!
QuarterMaster: How much do you wanna put down on him?
*The Commander reaches into his pocket then slams several stacks of money upon the window's table as he speaks.
Commander: My ENTIRE goddamned pension!
*The Quarter Master stares at the little grey smiling as he swings in his pretty red dress and then the hardened military veterans and finally, the grinning Commander once more.
Quarter Master: You're on!
*The USSF Director silences the gathered, bickering and murmuring group as he interjects.
USSF Director: QUIET!
*The group of military commandos quickly stand at attention as the USSF Director commences pacing and continues his addressment once again while Luna smiles knowingly and Alpha shakes his head from side to side...also knowingly.
USSF Director: THE POINT IS! That we're facing a potential threat that is completely out of human understanding, the very laws of physics itself and our current martial capabilities!
*The USSF Director points at the greys; Alpha’s arms folded as he stands like a solemn statue and Jorg still hyperfocused as he busily plays with his red dress.
USSF Director: Although they ARE friendl-
*Alpha’s face sours distastefully as he hisses underbreath.
Alpha: Pshhh...
*The Director darts a sharp glare at Alpha who returns it with a twisted, smug expression and then at Luna who shrugs her shoulders casually.
USSF Director: ....Although they ARE NOT THE ENEMY we can not let the future of humanity...
*The Director stares at Jorg who is still absolutely lost within his own world as he continues to speak.
USSF Director: ...Rest upon the strapless shoulder blades of one four and a half foot; morally and mentally compromised little...whatever in the hell this thing is.
*The Director points towards Jorg as he flutters and sways repeatedly.
*Luna retorts defensively as Alpha comments sarcastically.
Luna: HEY!
Alpha: Well...I mean, he's right. Man's still kinda a misguided idiot but when he's right he's right!
*The Director glares at Alpha once more as his subordinates murmur and contemplate his directive aloud amongst one another.
Private: We are so, so, so completely and utterly screwed...
*The Sergeant standing besides the private shrugs apathetically as he speaks.
Sergeant: I don't see what the big deal is...
*The director marches to and fro once again as he continues to speak.
USSF Director: That being said! The ONLY WAY to adjust our combat to this new enemy is simulated combat WITH THE ENEMY!
Private: I'M NOT FIGHTING THOSE THINGS!
*Alpha smiles slyly and quips sarcastically as The Director retorts with a commanding tone.
Alpha: ....Sissy!
USSF Director: Oh yes you will private! Unless of course you want... AN EXTRA WORK DETAIL!
Private: GOD-DAMNIT!
*The Director grins as he continues to speak.
USSF Director: Besides! You'll only be facing a single extraterrestrial opponent today, Alpha has adamantly refused to participate in this exercise...
*Alpha retorts sharply.
Alpha: I said, "You can go fuck yourself", that's what I said.
*Luna erupts with a riotous laughter as the USSF Director glares at Alpha in return.
*The Sergeant points towards Jorg still playing with his fluttering dress.
Sergeant: And lil' Miss Doubtfire over here? HE'S supposed to be our opponent!?
*Luna beams with pride as she retorts.
Luna: I wouldn't underestimate Jorg! He's wildly talented!
Sergeant: At what!? Martha Stewart style homesteading?
*The group snickers as Luna giggles and returns a mischievous grin and then quips once more.
Luna: THAT TOO!
*Alpha clarifies casually as the group murmurs and looks on at the little grey still lost amongst the surrounding atmosphere.
Alpha: Consent for Jorg is kind of a non-issue, he's barely aware of where he is half the time. When goaded he does have a certain instinctive enthusiasm for martial combat under the right conditions. I don't even know where he learned it, he just came back one day and knew it innately. Like a telekinetic amalgamation of something between Ong-Bak and Jet Li...
*The Private stares at the little grey in suspended disbelief.
Private: Under...what conditions?
*Alpha grins knowingly; as he responds.
Alpha: Basically...You've got to manage to piss him off.
Private: "Piss him off?"
*The Sergeant cracks his knuckles as he smiles belligerently.
Sergeant: Well this should be easy!
*Alpha shrugs unknowingly.
Alpha: Maybe...Sometimes it is and sometimes it isn't! To evoke this reaction from Jorg or to "Piss him off"; it is like this ingrained psychological trigger. It isn't so much guided as a form of premeditated anger as a kind of pro-active defense mechanism. He's not even really fully aware when he does it. I think it may be a kind of "Fight or Flight" reaction he just does. Except Jorg...well...Jorg pretty much always chooses to fight.
*The privates eyes widen curiously as he stares the little grey up and down before him.
Private: Is he...is he dangerous!?
*The USSF Commander laughs heartily as he slams his hand upon the provisional warehouse window and retorts excitedly.
USSF Commander: YOU CAN BET YOUR ASS HE IS!
*The QuarterMaster glares at the USSF Commander as he chimes in.
QuarterMaster: I wanna replace my bet!
*The USSF Commander replies snarkily.
USSF Commander: TOO LATE ASSHOLE!
*Alpha, Luna, The Director and the group of soldiers all divert their attention towards the Commander and QuarterMaster until Alpha continues speaking.
Alpha: Jorg!? Dangerous? I mean...IF YOU DESERVE IT then I dunno...
*Alpha shrugs apathetically.
Alpha: ...Maybe? I really doubt he'd actively kill anyone though.
*The private throws his hands into the air and addresses Alpha frustratedly as the group murmurs amongst themselves once more.
Private: THE FUCK YOU MEAN "MAYBE" AND YOU "DOUBT HE'LL KILL ANYONE"!?
*Alpha shrugs once more...
Alpha: It's Jorg...Jorg is Jorg! You'll see...
*The private stares at the two greys one after another then retorts underbreath as he turns to walk away.
Private: I'm so not fuckin doing this...
USSF Director: MORE WORK DETAIL!
Private: GODDAMNIT!
Sergeant: Well I think they're full of shit...
Private: THEY TORE APART AN ENTIRE MILITARY BASE "JUST BECAUSE".
Sergeant: Of Non-combatant "week-long warriors" I bet! Might as well be a buncha national guardsmen...I mean...JUST LOOK AT HIM!
*The Sergeant points towards Jorg still swaying giddily.
Sergeant: ...There's no way in hell that little queer fella could take a seasoned soldier!
*Luna retorts defensively.
Luna: JORG ISN’T GAY! HE'S JUST SENSITIVE AND HE'S VERY SPECIAL!
*Luna cuts her gaze towards Alpha seeking confirmation.
Luna: He isn't...is he?
*Alpha shrugs unknowingly and apathetically as the group murmurs amongst themselves once more.
*The Private suddenly turns then approaches a series of lockers and containment bins stowing riot gear, defensive equipment and padded suits much like one that would be used to disarm a bomb or train a K-9 attack dog as nearly all of his peers follow suit...
Private: I'm not fucking with this lil dude without my PPE!
*The Sergeant snorts obnoxiously in response as he watches.
Sergeant: I don't need that crap...Besides, it's hard to move or fight with all that bullshit on! Whatchu gonna do? Bumper car bang him to death with it?
*The Private shrugs undisturbed.
Private: ....Whatever!
The crowd gathers all around the little grey warily; some armed with things like MMA gloves, hand-wraps, Batons and extended martial defense metallic rods as they all approach the grey from all angles.
Suspicious and cautious at exactly what the little grey might do and exactly how he might respond.
That is all but one, the boisterous military Sergeant who readies himself and then throws the very first strike at the seemingly defenseless and unsuspecting Jorg.
Without ever even lifting his eyes from the hem of his dress, in a matter of moments warping the surrounding spectators very perception of time; Jorg shifts his head slightly towards the left as the Sergeant's fist narrowly misses the grey by a hair's length.
*The USSF Commander slams his hand upon the provisional warehouses window once more as he retorts giddily.
USSF Commander: HAH!
What happens next can best be described through the conveyance of a matter of collective very short-lived and somewhat difficulty perceived moments.
The next soldier and the next and the next and the next; all of them simultaneously rush towards the little grey slinging their fists and their weapons towards the inattentive and unbothered little grey.
Jorg bobs, weaves, and feints his big grey bandanna wrapped head not unlike a hyperactive, super-powered Muhammad Ali; as fist and all flies from every perceivable angle, not ever touching him...not even once, his attention still diverted towards his fluttering dress all the while.
Another military combatant rushes forewords and thrusts a kick towards the grey; to which he spins out of reach with seamless grace as yet another kick comes flying from it's opposing direction to which the grey quickly ducks then loops his body around from underneath...still playing with the hem of his pretty red dress still humming to himself gleefully as Luna erupts with laughter.
Sergeant: What...what the hell IS THIS!?
Luna: I TOLD YOU!
Private: He....He never even LOOKED at us...NOT ONCE!
*The Director stares at Luna and Alpha then questions them curiously.
USSF Director: Why isn't he defending himself?
Alpha: ...Probably because Jorg doesn't see any of you as a threat.
*The boisterous military Sergeant walks towards Jorg then plants a single finger upon his forehead then slowly pushes him backwards; to which Jorg sways back then forwards then rests in the exact same position of which he'd originally been.
Sergeant: What do you mean he doesn't see us as a threat?
*Alpha responds casually.
Alpha: I mean exactly what I said! Jorg only reacts when driven towards it from an outside stimulus; when he himself, someone he cares about, or perhaps even others are under certain conditions of diress such as a threat or pressure or the friction of oncoming conflict. It is very difficult to tell exactly when this trigger will set off from an outside perspective but FOR JORG these lines are ingrained within his very being. It's like a reflex, he doesn't even have to think about it.
Private: How is it he can move so quickly like that? I could barely even see him doing it!
Alpha: Part of it is because Jorg instinctively compounds his telekinesis with Kinetic energy. The other is because he's clairvoyant, prophetic even. This doesn't just apply to the precepts of time or it's passage through the universe itself but also to an outside stimulus. But just like almost all things concerning Jorg; he isn't fully aware of what he's doing and what he does it its all interdependent on outside stimulus and outside perception and interpretation. In short, Jorg is like a living mirror in everything he does and reasons for doing them. A reflection of one's self whether they even realize it or not. He could punch through a two inch steel wall or bulletproof plate glass window faster than you could blink if he wanted to...
*Alpha shrugs casually.
Alpha: ...Only problem is it takes alot for Jorg to actively feel inclined to do so. Well...sometimes. All that being said apparently he sees absolutely none of you as an inclination for him to act...and so...he doesn't. He doesn't see any of you as a threat!
*The Sergeant fumes angrily and frustratedly as he stares at the preoccupied little alien frustratedly and then speaks angrily.
Sergeant: WHADDYA MEAN "HE DOESN'T SEE ME AS A THREAT"!? I'M A GODDAMNED NAVY SEAL! I DID TWO TOURS IN AZKABAN!
*Alpha replies to the Sergeant flatly and unflinching.
Alpha: Exactly what I just said...Your limited human capabilities and physicality to Jorg is a non-issue. You're not big enough, strong enough, forceful enough or physically capable through your own recognizance of being a perceivable threat to him.
*The Sergeant stands from the opposing side of the playful grey in the little red dress then angrily unbuttons and unholsters his service weapon as he holds it in both hands, pointed towards the ground.
*The USSF Commander laughs a riotous laugh as he spectates from the warehouse window some distance away then pounds the desk upon it once more as he goads the Sergeant playfully.
USSF Commander: YOU GET EM HOSS!
*The Commander quickly turns towards it's QuarterMaster then whispers as he winks towards his glare.
USSF Commander: ....Fucking idjit!
*Luna’s eyes widen with worry as she begins to speak.
Luna: I WOULDN'T DO TH-
*Alpha calmly places a gentle hand upon Luna’s shoulder as he knowingly interjects solemnly yet very mischievously.
Alpha: Nah....Let em'.
The Sergeant steadies his firearm upon the grey methodically as all of his compatriots watch onwards nervously.
And what happens next, again...Can best be explained by a breakdown of a series of events that through our perception of time unfolded within a matter of moments.
...But to Jorg himself? Well, that's another matter entirely.
Just like one perceptive light switch suddenly being flicked on from deep, deep, deep within Jorg’s psyche. The little grey suddenly raises his head; his black, saucer shaped eyes widened with a perfectly aligned subconscious awareness. One of them twitching erratically above a maddened grin as above and all throughout this training room; the loud deafening roar of electric guitar reverberates one ear-splitting and most deafening melody.
Loudly cutting through the awkward silence not unlike a high-powered circular saw this melody is that of the song "Beat It" the cover of an infamous Michael Jackson tune preformed by the band "Fall Out Boy".
https://youtu.be/Qt54wA7Z2LY
And as this guitar melody drones and roars throughout the intercom and sirens of the facility all around; As Alpha smirks smugly and Luna laughs...and then gasps. What follows suit could be quite accurately articulated as a series of movements so perceivably fast, powerful, and deadly accurate that one could quite convincingly say that Jorg DID move faster than a human could blink.
He quickly utilizes his telekinetic energy with one hand to jerk the firearm out from within the Sergeant's grasp not unlike a vaulted football ripped from between a running back's fingers. And as this pistol flies and spins towards Jorg he launches himself into the air, quickly preforming a spinning back kick that smacks against the gun sending it ricocheting and flipping once more until it hurtles directly dead center of the Sergeant's face sending him spiraling and sprawled out upon the ground nearby while the gun itself deflects, is thrown against a nearby wall and then misfires.
Space Marine: SHIT...MY LEG!
And as the lyrics of the song echo and vibrates all throughout this training room, quaking its walls and cushioned floormats with every progressing spoken word; the frightened private quickly turns to sprint in the other direction, absolutely ANY direction away from Jorg.
But little did he know; it was far, far, far too late...
Jorg harnesses his telekinetic energy to rip the man's legs out from beneath him, as he does Jorg quickly sprints forward, leaps into the air again like a telekinetic grasshopper then dead drops his knee into the private's back.
As Jorg "ground and pounds" the back of the privates combat protective headgear repeatedly in rapid succession; not unlike quick repeating Wing-Chun punches into the back of the man's head, striking and bouncing his forehead off of the training floor's cushioned material all to the rhythm of this melody. The surrounding marines look around at one another, murmuring in a stunned confusion as the private cries for help.
Private: G-G-GET I-
*WHACK! *BANG! *POW! *WHOMP! *THUMP-THUMP-THUMP!
Private: GET IT OFFA ME!
*The USSF Director points at the private then addresses the fearful combatants sternly.
USSF Director: ...WELL!? HELP HIM!
*One of the remaining combatants turns to kick Jorg off of the private when the grey quickly stops then pivots as if in anticipation of said strike; catches the man's ankle then smiles with a malevolent grin before twisting it with a loud *CRACK!
*Luna squints her eyes closed and winces painfully as Alpha grins a grin very much reflective of Jorg’s and they both comment.
Luna: Oooooooh!
Alpha: Fuck em'...
Elsewhere at the provisional warehouse window the USSF Commander slams his hand down upon the table once more as he also comments; smiling at the QuarterMaster with a shit eating grin all the while.
USSF Commander: That looked like it HURT LIKE HELL! GET EM' HOSS!
*The QuarterMaster also comments, sneering distastefully.
QuarterMaster: I fuckin' hate you...
Elsewhere amongst the whirlwind of rapid, successful strikes and all to a melody; Jorg now stands his miniskirt fluttering in training room's AC cooled air along with the motion of his movements with the Marine's now broken ankle held between the palms of his hands; the man still wailing with pain.
In an amount of time accumulating to less than the passage of a few seconds; the grey spins and leg sweeps the other man's remaining limb, tossing him upwards into the air before kicking him in the abdomen with a telekinetically reinforced strike that sends the man hurtling into and bouncing off of the nearest wall.
As another approaching soldier moves in to strike Jorg the grey quickly hops a foot into the air once more; then quickly plants a deflective side kick in rapid, fluid succession into the center of the man's chest which sends him staggering back just a few paces.
*The soldier hardens himself as he pounds his chest then closes in on Jorg once more.
Space Marine: IS THAT ALL YOU GOT!?
And as this melody continues to pound with a thunderous roar all throughout the training room; Jorg smiles a sadistic smile.
While the man races forwards to preform a takedown upon the little grey, Jorg quickly and acrobatically dips his head and upper abdomen towards the ground. With a certain level of martial flexibility mirroring that of a Shaolin Monk the grey lifts the pad of his foot from behind towards where his head originally was, arching it upwards and from behind his backside with his torso now angled downwards, he then slams the bottom of his foot into the Marine's forehead; stunning him instantaneously.
Jorg quickly rights his equilibrium and with a fluid, unceasing movement uses that very same leg to plant a telekinetically charged front kick into the man's sternum; sending him flying backwards and crashing into yet another padded wall.
Space Marine: YOU CRAZY LITTLE SHIT!
A remaining marine shouts at Jorg and then races towards him from a flanked position sending his own angled "axe kick" towards the grey's abdomen.
And as this melody pounds and reverberates the ether all around from every perceivable direction; without so much as a moments hesitation, forethought, or consideration Jorg side steps then archs his own leg around the own man's "Axe Kick" locking it into place.
*The Marine's eyes meet the grey's; whose deep, darkened saucer shaped eyes are deadlocked onto his own. Shining with a glossy, detached madness as the grey's smile widens. And with their legs locked in place, Jorg intentionally restricts the man's movement; the Marine's remaining free leg trembles as he utters words of fear and astonishment.
Space Marine: Oh....SHI-
*Before the man can even get the words out the grey hops into the air with his remaining leg with the other still locked in place, then uses his free leg to dropkick the soldier dead center of his chest with another telekinetically reinforced strike before quickly releasing his leglock to send the man vaulting into another padded wall not unlike a human bullet.
And as this resounding melody finally tolls onwards towards it's completion; the little grey still stands in the middle of this training room. In the exact spot in which he'd originally began; surrounded by moaning, bloody, blackened and bruised human cadavers.
Who at this point are each and all very, very much alive; though perhaps their pride...not so much.
*Luna shakes her head from side to side as the USSF Director speaks.
USSF Director: Well...we're never doing that again!
*Alpha stares at the director and smiles with an air of apathy.
Alpha: I could have told you but you'd never have listened...
*The private spits a mouthful of blood onto the ground as he slowly gathers his strength to try to lift himself from it, next to the still unconscious Sergeant lying face down on the floormat beside him.
Private: We are so...so...so fucked.
*At the provisional warehouse window the QuarterMaster counts out the last of his debt and then slams it upon the table towards the USSF Commander's outstretched smile now grinning from ear to ear.
USSF Commander: It was nice doin' business with you!
QuarterMaster: Shut the hell up...