Transaction coordinator salary

Binance Support Thread

2023.06.05 07:01 AutoModerator Binance Support Thread

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submitted by AutoModerator to binance [link] [comments]

2023.06.05 05:03 DrAJay30 Tired of HH, Working on Med B Business, Need Part Time job while chasing my dreams

I'm a PRN DPT in home health (HH). I love the flexibility, autonomy, and not having to be in a building all day. But I must be honest, although I still have a deep passion for helping the elderly, I am over traditional physical therapy. #1 I felt like I was lied to through school. I don't feel like I got the real taste of reality when in clinicals. It one of those things where you know something isn't for you, but shoot I was already 2-2 1/2 years in. I'm tired of getting emails about limited visits regarding insufficient insurance coverage, even when the patient really needs it; having to fight for visits with other disciplines; not truly feeling valued; imposter syndrome occasionally due to admins questioning my decisions on how many visits I plot. Like HONEY I went to school for a purpose! I wouldn't waste visits on those that don't need it as well as jeopardize my license with waste of services! So insulting. To add additional insult to injury, it doesn't help seeing the coordination notes on how much they make off PT with the insurance companies (although I understand they may not receive that full amount, but still).
So, I want to start my own business with Medicare part B and cash based services. I admittedly have been self sabotaging myself by getting comfortable off the money I make with HH and life in general. I do not care for any other setting than HH. Tried them all, HH is better fit despite paperwork. I've been saving, needing to establish LLC, liability on business, logo, all that.. I believe I have reached my last rope with traditional therapy. I want to bring an ADAPTIVE way for the elderly to remain functionally mobile. I've been having this urge to leave for a few months, and based on how my stress has been with HH, it's time for a change.
Does anyone know different occupations that I can look into part time? Even if I needed to take some courses and get certificate for? SOMETHING QUICK! Like 6-12 months or less if courses are needed. I would hope for the salary to continue to be above $70,000 if I could help it (although I make more) but I do understand I may have to bend with salary.
submitted by DrAJay30 to physicaltherapy [link] [comments]

2023.06.05 03:30 nonsuspect Appreciate any feedback

submitted by nonsuspect to resumes [link] [comments]

2023.06.05 01:57 Connor12312 One of the Greatest Hitters I've Seen In OOTP

One of the Greatest Hitters I've Seen In OOTP submitted by Connor12312 to OOTP [link] [comments]

2023.06.05 01:29 anti_goblinism I have no incentive to live

The deal sucks. All our food is killing us slowly with potassium-40 and radiocarbon yet we still need to work for it. The air quality is trash, not even the CO2 but the NOx, SOx, and ambient free radicals slowly killing us with oxidative stress. The economy is rampant with price-fixing, bid-rigging, and corruption that make living much more expensive. Pretty much all the women are gold-diggers (therefore wh043s), so love isn't actually real and s3x + companionship are both just transactions. The least productive people and industries/businesses seem to make more and live far better than those who can actually produce what we need (front line, the enterprises/bosses making them are all corrupt). Organized criminal enterprises get away with most of what they do and the "legitimate" businesses seem to be less and less different from them. The people that are supposed to be regulating all of this are either asleep at the wheel or all being paid off or insider trading or something, their salaries are undeserved and wasteful. Arguably worst of all, everyone is complacently participating in this whether they realize it or not with seemingly no regard for any of the harm caused. I'm rooting for the asteroid, humanity deserves to be erased; me, you, everyone. This world is irreversibly fucked and seems to just slide further and further backwards, thank god we've finally got some new wars happening at least there's some entertainment. This species is vermin. Unless you're profiting off the misery you're not incentivised to live. Hope y'all enjoy the remaining years of your miserable, lazy, and corrupt lives, I'll see you all in hell.
submitted by anti_goblinism to SuicideWatch [link] [comments]

2023.06.05 00:42 gruntrax How do I do a wrap around loan as a seller?

I am looking to do a wrap around mortgage on my property. My current mortgage is assumable so there are no issues there. My questions is, do I need a realtor for a transaction like this or a real estate attorney? Also how will this be serviced? Do I just hire any mortgage servicing company to receive payments from the new buyer or can I coordinate with my current lender to do the servicing?
submitted by gruntrax to RealEstate [link] [comments]

2023.06.04 21:06 Accomplished_Fix_949 ROLLUPS - Save Time, Save Money

Blockchain are advancing toward creating a web2 like transaction feel for decentralized application to thrive even more. How can this be achieved? L2 Rollups is the answer to this.
What are L2 Rollups all about?
Layer 2 solutions are protocols that operate on top of an already existing Layer 1 blockchain.
The goal of Layer 2 solutions is to improve the scalability, privacy, and other characteristics of a Layer 1 blockchain (such as Bitcoin or Ethereum).

How does Rollups work and why is it essential for Blockchain scalability?
Rollups works by Rolling up (as the name implies) together multiple transactions into a single transaction, which is then processed off-chain by smart contracts whilst still maintaining security. This significantly reduces the amount of data that needs to be stored on the blockchain, increasing transaction throughput and reducing costs by 50-100%.
Blockchain like Ethereum, for example, struggles with network congestion, high transaction fees, and slow output. Rollups tech will help reduce transaction confirmation time but unlike other chains that are adopting ZK-Rollups, gas fees are still going to be at its high.
There's a lot of alternatives to Ethereum which are also working on releasing the L2 Rollups tech. Arbitrum & Syscoin are two L2 alternatives I find interesting, but why is that?

What's is Syscoin?
Syscoin is a decentralized and open-source project founded in 2014 whose NEVM blockchain combines the best of Bitcoin and Ethereum in a single coordinated modular platform. Syscoin is a dual-chain Blockchain with a UTXO & NEVM side that supports smart contracts for deployment of DApp just like Ethereum EVM. Syscoin L1 chain through it's PoDA feature already creates and makes it easy for Rollux L2 which is SYS unique brand of ZK-Rollup to be built on its base layer.
SYS is a Stable and decentralized modular L1 Blockchain which also support the fast rising L2 upgrades that will be more convenient.

Rollux L2 SYS
What is Syscoin Rollux?
Syscoin Rollux is the ultimate EVM rollup platform rooted in Bitcoin’s PoW for unparalleled security, scalability, and affordability. The #Rollux L2 will enhance the usability and ease of using DApps built on the SYS chain. The SYS ecosystem has a unique UTXO & NEVM dual chain architecture, it's design is built to scale. Backed up by a relentless team that keeps building.

What sets Syscoin L2 Rollux apart from the rest of the L2's which is set to be released on mainnet on June 28th is it's extremely low gas fees compared to ETH which is still at its high regardless of its L2 which is still in development.
With Syscoin Rollux, transaction confirmation time will be much like blinking an eye. With up to 250k TPS under 1 second (already tested and confirmed on testnet), DApps will have the ability to function without having to wait for transactions to confirm due to congestion.

There's a lot of great and improved features coming on the Syscoin ecosystem. Pali V2 web browser extension which support both chain (UTXO & NEVM) and also a mobile version too!! The native dex Pegasys is also getting an improvement as it will also support the L2 for Seemless and low cost transactions.

Most importantly is the fact that a lot of new web3 DApps, gameFi will be built on the Rollux L2.
submitted by Accomplished_Fix_949 to SysCoin [link] [comments]

2023.06.04 18:49 NuggedClarp Help me analyze this seller financing deal

Looking for my first investment property.
Assumptions: Tax Rate-1.2% Landlord Insurance-.525% Vacancy rate-6.4% Maintenance Estimate-1% Property Management-9% (only utilized in cap rate) Rehab: $20,000 Rent: $2,595 ARV: $250,000
Subject to: 1st mortgage: $145,000 @ 4.125%= PITI $1,308.42 2nd mortgage: $33,000 @ 4.625% = PI $236.31
Entry fee: $40,000 including closing costs, assignment fee, cash to seller, transaction coordination fee, and notes servicing fee
Calculations: 10.0% Cap Rate 1.04% Rent to Value 15.0% COC 12.8% COC if 2nd mortgage is paid off
Am I missing anything? This deal sounds like a great opportunity to get my feet wet in the industry. Of course I still have to do research on the area, rehab costs, inspection and all that jazz.
submitted by NuggedClarp to realestateinvesting [link] [comments]

2023.06.04 18:48 sandman730 CBA Basics

This is based on the CBA, MOU, and various CapFriendly FAQs.
If you have any questions, feel free to comment, or message me.
Note: Various games played thresholds for may be pro-rated due to the shortened 2019-20 and 2020-21 seasons. Consult CapFriendly or message me if you have any questions.
All dates below are tentative. Check the schedule for more up-to-date information.

Salary Cap

The upper limit is $83.5M (projected), and the lower limit is $61.0M (projected). Though you are allowed to exceed the upper limit by 10% in the offseason, we will require you to have a plan for how to get back under the cap by the end of the sim.


For the sake of simplifying contracts, all contract negotiations and signings will be done using average annual value (AAV). Salary structure and signing bonuses will not be considered, with the exceptions of complying with minimum salaries ($775k for the 2023-24 season and beyond) and maximum salaries (an AAV equal to 20% of the current salary cap upper limit).

Basic Definitions

Contract & Roster Limits

During the regular season (before the day of the Trade Deadline) each team may have a maximum of 23 players on their Active Roster, and a minimum of 18 skaters and 2 goalies.
Each club may have a maximum of 50 SPCs, and must have a minimum of 24 players and 3 goalkeepers. In this sim, we will also require each team to have at least 40 SPCs by the end. Players who meet the following conditions do not count towards this contract limit:
  1. Are 18 or 19 years old
  2. Are in a junior league
  3. Have not played 11 NHL games in one season
Note: the roster sheets currently assume every player eligible for this exemption is assigned to Juniors. If you wish to have that player(s) on your opening day roster, please ask me to correct this (as it will affect the number of contract slots you have available).
A club's reserve list (signed players, unsigned draft picks, and defected players) may not exceed 90 players.

Buried Contracts

For one-way NHL contracts of players reassigned to the AHL, the players' salary cap hit, minus the sum of the minimum NHL salary (for the respective season) and $375k, still counts towards the team’s salary cap total. This implies up to $1.15M can be buried this season per contract.
If a player signs a multi-year contract at 35 years or older (as of June 30 prior to the effective contract), the player's individual cap hit counts against the teams cap hit regardless of whether, or where, the player is active. However, a team will receive a $100k relief off of the team's salary cap hit, if a 35+ contract player is playing in the minor leagues after the first year of their contract.

Entry-Level Contracts

Players younger than 25 as of September 15 of the year of their first NHL contract must sign an ELC, all of which are two-way contracts with a maximum AAV of $950k (players drafted in 2022) or $925k (players drafted prior to 2022). The length of an ELC depends on the player's age:
European players (players drafted from a team outside North America or undrafted players) ages 25-27 must sign a one-year ELC.
If a player signed to an ELC is 18 or 19 years old, and does not play in a minimum of 10 NHL games (including both regular season and playoffs), their contract is considered to "slide", or extend, by one year. Signing bonuses do not slide, which can change the AAV of the player's contract.

Contract Length

Clubs may sign a player to an SPC with a term of up to 8 years only if that player was on such club's Reserve List as of and since the most recent Trade Deadline. For UFAs, this right expires when the player hits free agency (i.e., on Sun. June 25th, 11:59pm ET). Otherwise, the term limit for SPCs is 7 years.

No-Trade Clauses

A No-Move Clause (NMC), No-Trade Clause (NTC), or Modified No-Trade Clause (M-NTC) can be added to a player's contract in the years after they are eligible as a Group 3 player (7 accrued seasons or 27 years old). These clauses restrict the player from being traded without his consent. An NMC also restricts a player from being placed on waivers and being assigned to minors without his consent. These clauses do not exempt a player from a buyout or contract termination.

Performance Bonuses

Clubs may pay players that meet one of the following criteria a performance bonus:
  1. The player is on an ELC.
  2. The player has signed a one-year contract and is over 35 years old.
  3. The player has signed a one-year contract after returning from a long-term injury (has played 400 or more games, and spent 100 or more days on the Injured Reserve in the last year of their most recent contract).
Performance bonuses count against the cap, however a team can only exceed the upper limit by a maximum of 7.5% (the overage of which counts towards the next season's cap hit).

Group 6 Unrestricted Free Agents

A player whose contract is expiring and meets all of the following conditions shall become a Group 6 UFA:
  1. The player is 25 years or older (as of June 30th).
  2. The player has completed 3 or more professional seasons - qualified by 11 or more professional games (for an 18/19 year old player), or 1 or more professional games (for a player 20 or older) while under an SPC.
  3. The player has played fewer than 80 NHL games for a skater, or 28 NHL games of 30 minutes or greater for a goaltender.

Restricted Free Agents

Qualifying Offers

A qualifying offer (QO) is an official one-year SPC offer. Clubs have until Sun. June 25th, 5pm ET to submit their QOs. Submitting a QO gives the club the right of first refusal to match any offer sheet submitted, or receive draft pick compensation. If the player rejects the qualifying offer, they remain a RFA and their rights are retained by the club. If a player does not receive a qualifying offer, he becomes a UFA.
A minimum QO is calculated from the player's base salary (excluding all bonuses) as follows:
The QO must be a one-way offer if the following three requirements are met (a goaltender is considered to have played a game if they are on the bench as a backup):
  1. The player played in 180 NHL games in the previous three seasons.
  2. The player played in 60 NHL games in the previous season.
  3. The player did not clear waivers in the previous season.
Qualifying offers expire on Wed. July 12th, 5pm ET.
Note: If an RFA has signed a contract in another league, the NHL club may extend a QO to retain that player's rights. These players are marked on the roster sheets as signed in another league.

Offer Sheet Compensation

Only Group 2 and 4 RFAs may be signed to an offer sheet. However, clubs only receive draft pick compensation for Group 2 RFAs.
Compensation must be entirely in the next draft (for this sim: 2024), unless multiple of the same round of pick are required (e.g. two first rounders). In that case, you may skip one year (e.g. two 1sts could be 2023 and 2024 OR 2023 and 2025 OR 2024 and 2025).
Compensation is determined by the AAV outlined in the offer made by submitting club. The AAV for an offer sheet, which determines the compensation required, is derived by dividing the total contract value amount by the lesser of: number of years offered, or 5 years. The AAV thresholds are readjusted each season, and is based on the average league salary for that season.
Compensation for the 2022 offseason is as follows:
AAV (1-5 years) AAV (6 years) AAV (7 years) Compensation
$1,386,490 or less $1,155,408 or less $990,350 or less No compensation
$1,386,491 - $2,100,742 $1,155,409 - $1,750,618 $990,351 - $1,500,530 One 3rd Round Pick
$2,100,743 - $4,201,488 $1,750,619 - $3,501,240 $1,500,531 - $3,001,063 One 2nd Round Pick
$4,201,489 - $6,302,230 $3,501,241 - $5,251,858 $3,001,064 - $4,501,593 One 1st Round Pick, One 3rd Round Pick
$6,302,231 - $8,402,975 $5,251,859 - $7,002,479 $4,501,594 - $6,002,125 One 1st Round Pick, One 2nd Round Pick, One 3rd Round Pick
$8,402,976 - $10,503,720 $7,002,480 - $8,753,100 $6,002,126 - $7,502,657 Two 1st Round Picks, One 2nd Round Pick, One 3rd Round Pick
$10,503,721 or more $8,753,101 or more $7,502,658 or more Four 1st Round Picks
The club that receives an Offer Sheet has 7 days to match the offer or accept the draft pick compensation. If the receiving club matches the Offer Sheet, they are bound to the contract details outlined in the offer, must respect all aspects of the contract (such as any NTCs), and cannot trade that player for 1 year from the date of the contract signing.


Teams are permitted to buyout a player's contract to obtain a reduced salary cap hit over a period of twice the remaining length of the contract. The buyout amount is a function of the players age at the time of the buyout, and are as follows:
The team still takes a cap hit, and the cap hit by year is calculated as follows:
  1. Multiply the remaining salary (excluding signing bonuses) by the buyout amount (as determined by age) to obtain the total buyout cost
  2. Spread the total buyout cost evenly over twice the remaining contract years
  3. Determine the savings by subtracting the annual buyout cost from Step 2. by the player's salary (excluding signing bonuses)
  4. Determine the remaining cap hit by subtracting the savings from Step 3. by the player's AAV (including signing bonuses)
A player can only be bought out after clearing unconditional waivers. A waiver-claim by another team pre-empts the buyout process. If a player has a no-movement clause, the player can reject the option of waivers and proceed directly to the buyout process.
A 35+ contract that is bought out receives no salary cap relief. An injured player (who was injured as a result of his job) is entitled his remaining salary, so long as such injury continues, and therefore cannot be bought out.


When a player is reassigned from the NHL to another league, they must pass through waivers (unless they are exempt).
Waivers requests are processed each day at 2pm ET, and are subject to a 24 hour claim period, expiring at 2pm ET the following day.
The sim will have two waivers windows: unconditional waivers (for a buyouts) runs from Mon. June 19th until Sun. June 25th and the normal waiver window will run from Thu. August 3rd until Sat. August 12th.
Waivers priority is determined by the lowest percentage of possible standings points at the time of the waivers request (or when outside the regular season or through October 31st by the standings of the previous season). Tie breakers: lowest ROW percentage, fewest number of points in head-to-head games (excluding "odd games"), lowest goal differential per game. Therefore, waivers priority throughout the sim is as follows:
Order Team Order Team Order Team
1 ANA 12 OTT 22 MIN
2 CBJ 13 BUF 23 LAK
3 CHI 14 PIT 24 NYR
4 SJS 15 NSH 25 DAL
5 MTL 16 FLA 26 COL
6 ARI 17 CGY 27 EDM
7 PHI 18 NYI 28 VGK
8 WSH 19 WPG 29 TOR
9 DET 20 TBL 30 NJD
10 STL 21 SEA 31 CAR
11 VAN 32 BOS

Waiver Exemptions

Age is defined as follows:
For players 20 years or older, the year in which they play their first professional game under NHL contract is their first year towards the waiver exemption.
Whichever comes first in this table indicates when a player is no longer exempt:
Age Years from Signing (Skaters) NHL Games Played (Skaters) Years from Signing (Goalies) NHL Games Played (Goalies)
18 5 160 6 80
19 4 160 5 80
20 3 160 4 80
21 3 80 4 60
22 3 70 4 60
23 3 60 3 60
24 2 60 2 60
25+ 1 1
There is an exception (to the above) for 18 and 19 year olds: if a skater plays 11 NHL games or more, the year exemption will reduce to 3, and the following two season will count against this regardless of games played. For goalies, the year exemption will reduce to 4, and the following three season will count against this regardless of games played.
  1. A player does not need to pass through waivers if he has not been on the NHL active roster for a cumulative 30 days since last clearing waivers, and has not played in 10 or more NHL games.
  2. Any player who has consented to a Conditioning Loan can be loaned to a minor league club for a maximum of 14 days without passing through waivers.
  3. A player who was previously on long-term injured reserve (LTIR), may be loaned to a minor league club for a maximum of 6 days or 3 games for the purpose of determining if the player is fit to play. This player does not need to pass through waivers
Examples of players that do or do not require waivers.

Long Term Injured Reserve

There are two approaches to use LTIR for cap relief:
  1. Put the player on LTIR before the season starts. You can be over at the start of the season, but only get relief for how much the contract is over at the time he is placed on LTIR. Note: offseason cap accounting applies.
  2. Put the player on LTIR after the start of the season. You need to be under the cap at the beginning of the season, but get full relief.
The LTIR salary relief cannot be used to pay bonuses. Any excess relief does not accumulate.
At this point, the following players are eligible for LTIR: Ryan Ellis (PHI), Gabriel Landeskog (COL), Bryan Little (ARI), Carey Price (MTL), Brent Seabrook (TBL), and Shea Weber (ARI). GMs can petition the commissioners to add players to this list, including relevant information such as the player, injury, and timeline for return.

Retained Salary Transactions

When a team trades a player, they have the option to retain a part of his salary (and cap hit). The team who retains the salary pays the retained percentage of the salary, and retains the percentage of the cap hit (until the contract expires). The following requirements must be met:
  1. The percentage retained cannot exceed 50% of the player’s salary (including all bonuses) and cap hit.
  2. The same percentage must be retained for both the player’s salary and cap hit, and cannot be modified year-to-year. As a result, the same amount must be retained through the remainder of the contract.
  3. All teams are limited to a maximum of 3 retained salary contracts per season.
  4. Teams cannot retain an aggregate amount of more than 15% of the Salary Cap Upper Limit.
  5. Players’ contracts are limited to 2 retained salary transactions per contract.
Once a retained salary transaction occurs, there are various limitations:
Such transactions will require a compelling explanation.

Salary Arbitration

We are not doing salary arbitration as part of this sim. If you feel that a GM and/or agent is negotiating for an RFA in bad faith, contact a commissioner.


Performance bonuses count against the cap, however a team can only exceed the upper limit by a maximum of 7.5% (the overage of which counts towards the next season's cap hit).
Teams may not commit more salary to next season than 110% the current salary cap (i.e. exceed their tagging space).
Players claimed off waivers cannot be traded to another club (until the termination of Playoffs of the season in which he was acquired) unless he is first offered on the same terms to the club(s) that previously issued a claim (and the offer has been refused).
If you have any questions, feel free to comment below or DM sandman730. If we need to clarify some things, we will do so.
submitted by sandman730 to hockeyoffseason23 [link] [comments]

2023.06.04 18:28 sandman730 Rules & Schedule

Welcome to all GMs and AGMs to this years' edition of the /hockey annual offseason sim!


I will be personally editing all the spreadsheets, keeping them updated throughout the sim and they can all be found on the sidebar as well as in the chat channel.
Please message sandman730 if anything is incorrect or you wish to make changes on your roster sheet.

Tentative Sim Schedule

Mon. June 12th - Sim Discord Invites
Thu. June 15th - Sim Begins and Rosters Frozen (2pm ET)
Sun. June 18th - Deadline for GMs to Submit Plans (2pm ET)
Mon. June 19th - Trade Period Begins (2pm ET) (Provided GMs have an Approved Plan)
Mon. June 19th - Buyout Period Begins (2pm ET)
Thu. June 22nd - Deadline to Submit Trades Involving Players/Prospects for the NHL Draft (8pm ET)
Fri. June 23rd - NHL Draft Rounds 1-3 (8pm ET)
Sat. June 24th - NHL Draft Rounds 4-7 (2pm ET) (No Trades Allowed)
Sat. June 24th - Last Chance to Place Players on Waivers for a Buyout (2pm ET)
Sun. June 25th - Deadline for Qualifying Offers (5pm ET)
Sun. June 25th - Buyout Period Ends (5pm ET)
Sun. June 25th - Last Chance for Clubs to Sign UFAs to an 8 Year SPC (11:59pm ET)
Mon. June 26th - Free Agency Roster Freeze (12pm ET) (Discussion allowed, but no moves finalized)
Thu. June 29th - Free Agency Begins (12pm ET)
Wed. July 12th - Qualifying Offers Expire (5pm ET)
Thu. August 3rd - Waiver Window Opens (2pm ET)
Fri. August 11th - Last Chance to Place Players on Waivers (2pm ET)
Sat. August 12th - Rosters Due (5pm ET)
Sun. August 13th - End of Sim (Reviewing Rosters/Making Recaps/Etc.)
Google Calendar


For information about the cap and CBA, read this post and feel free to ask sandman730 any questions.

IRL Moves

Since we are in sim-mode, IRL moves do not apply to the sim, except for five key exceptions:
  1. Players retiring (if they retire IRL, they're out of the sim and cannot be signed),
  2. Player suspensions (ex: Slava Voynov),
  3. Transactions involving a foreign professional entering NHL,
  4. An NHL player signing in another league (ex: Liiga),
  5. Players being placed on long-term injured reserve.
Regarding the 3rd point, if the player announces he is officially returning to the NHL or he signs IRL with an NHL team, then he is available to sign. Until then, he cannot be signed.
Coach hirings/firings, AHL contracts, relocation, etc. are not part of this sim.

Keep it Realistic

You can't be perfect since plenty of teams could go many ways. If your team is clearly rebuilding, you should continue to rebuild and help the process.
Try not to acquire guys just for the purpose of flipping them later. We're not outright banning it since it happens IRL sometimes, but it's super uncommon, especially for bigger names. Rebuilding teams rarely take cap dumps to help out other teams in exchange for late round picks. If it is a fair trade, it can still be accepted. There will need to be incentive for teams to acquire cap dumps. Don't include unnecessary pieces or trade picks too far out (trading picks after 2024 will require a compelling reason). Don't trade the rights to retired players.
We are asking each GM for an initial offseason plan. This plan includes basic things like which direction the team is headed this summer, but with slightly more detail such as whether they will hope to pursue more options via trades or free agency, how they will deal with their cap space (or lack thereof), etc. You will not be able to sign or trade anyone until your plans are submitted and approved. If you wish to amend your plan, submit it via mod mail, including your reasoning for the amendment.
[GM Plan Form]()
Throughout free agency, the mod team will reach out to GMs to see if they are changing their plans due to transactions that have taken place in the sim (i.e. missing out on free agents, changes in the trade market, etc.).


We realize GMs want to be more active than their real-life counterparts but we will be pretty strict on allowing trades in the sim. When you submit a trade or signing, both parties must send the trade in to the office of the commissioner (via mod mail). You also must include a justification as to why the trade makes sense for your party including how it will affect the cap, lineup and future roster decisions. Please use the below template. All players, picks, additional terms, rights to players, and salary retention amounts must be specified and identical in both parties' submissions.
Before making a trade, we encourage you to find multiple comparable trades which will convince us that the trade is realistic. Please do not compare each trade to the Matt Duchene to Ottawa trade and say "Well, it's more realistic than that one".
We will do our best to announce the trades right away as they come in. Do not post pending trades in other threads until they are posted. Please allow us at least 24 hours to approve trades and for graphics to be prepared.
Try not to blow your load, especially on the first day. Be patient, especially with trades. Just try. You'll thank us later. Those who follow this advice usually will find incredible bargains and can take advantage of other GM's mistakes.

Trade Submission Template

We would like teams to use the following template when submitting trades to ensure all relevant information is included.
Team A receives:
Team B receives:
Corresponding moves: (players sent down, called up, or put on waivers; answer "none" if not applicable)
Cap/salary implications:
Other options pursued:
Long-term implications:
I certify that I own the assets I am trading away; my team remains roster & cap compliant; I have complied with any no-trade lists; etc.


NYR receives: Tyler Motte
WPG receives: 2023 4th Round Pick (WPG)
Corresponding moves: None
Cap/salary implications: The Rangers can take the remainder of Motte's $1,225,000 cap hit.
Goal: The Rangers are looking to add depth for a playoff push. The Canucks are looking to acquire future assets for a player on an expiring contract.
Justification: The Rangers are solidly in a playoff position and are looking to buy at the deadline. Motte can fill a 4th line role.
Comparables: SEA traded Mason Appleton to WPG for a 2023 4th before the 2022 TDL. MTL traded Nick Cousins to VGK for a 2021 4th before the 2020 TDL.
Other options pursued: The Rangers also tried to acquire Derick Brassard and Vladislav Namestnikov, but were unable to make a deal work.
Long-term implications: The Rangers are willing to give up a mid-round pick to add depth now.
I certify that I own the assets I am trading away; my team remains roster & cap compliant; I have complied with any no-trade lists; etc.

No-Trade/No-Movement Clauses

These will be handled by TBD. If you wish to trade a player with a No-Trade or No-Movement Clause, you must message them, requesting a list of teams a player can or cannot be traded to, or if a player would be willing to waive his No-Movement Clause. Please give them at least 24 hours to fulfill such requests.

Trading UFA Rights

We have tried this in the past and some agents felt obligated to have the UFA sign in the city that acquired the players' rights. We feel it would be best if every team gets a fair chance so this year we will NOT be allowing trading for UFA rights. This will also hopefully lead to fewer trades and more UFA signings.
Additionally, we will not allow you to sign and trade UFAs or pending UFAs.

Conditional Picks

You cannot trade picks with conditions, with some exceptions:
  • Lottery protection
  • Higheloweetc. of multiple picks in a given round
  • Settling scenarios based on previous trade conditions
We realize it happens in real life, but it is hard to track from experience and hopefully it will cut down on the amount of unnecessary trade conditions.

Unfair Value

To avoid exploitation and chaos in the trade market, we sometimes need to step in to preserve the sim's integrity. This may be somewhat subjective, so the trade committee will discuss and vote on most trades. Your trade will go through more smoothly if you provide ample justification and can offer comparable trades. Some common issues include:
  • Undervaluing cap space or salary - Since there is no real money involved in this simulation and no accountability to owners or future cap issues, people can undervalue these assets. Please provide examples of comparable trades.
  • Undervaluing future draft picks - Similarly, since there is no accountability within the sim for these assets, unnecessarily adding late draft picks or too high draft picks can be problematic. Again, provide examples of comparable trades.
  • Differing opinions on the value of players or prospects - These usually will go through, but may require further explanation.


sandman730, meatb4ll, and TBD are gonna be the “veto panel” and we are gonna take it very seriously. If the vote is unanimous 3-0 either way, then we will accept/reject the trade or signing. If it is 2-1 either way, then we will ask TBD for their opinions and votes. We will then come to a decision with the majority winning. There are a number of reasons why a trade or signing may be vetoed by the trade committee:
  • Violates the CBA (ex: puts a team over the contract limit)
  • Involves NTCs (i.e., the player would block the trade)
  • Puts a team over the cap or roster limit (or under the floor), without them having a clear plan for how to get back under (or over)
  • Violates other house rules (ex: trading UFAs)
  • Unrealistic (see above)
  • Unfair value (see above)
  • Goes against their plan (or goes too far all-in on either the present or future)
meatb4ll will communicate veto decisions and discussions.

Entry Draft

Rounds 1-3 of the draft will take place on the chat channel on Fri. June 23rd at 8pm ET. We kindly ask that everyone attends this in the chat since it will go a lot smoother not having to wait for GMs and it is one of the most exciting parts of the sim in terms of trades and activity. This is the one day we hope to have all GMs and AGMs alike participate since we require your cooperation. Draft day trades involving players/prospects must be submitted 24 hours before the start of the draft (Thu. June 22nd at 8pm ET). Trades made during the draft (involving draft picks) must be submitted via DM to the commissioners.
On Sat. June 24th at 2pm ET, we will host Rounds 4-7 for those who would like to participate. It is not mandatory, you will just be auto-picked if you don’t show up. There will not be any trading allowed for this portion of the draft.
If a GM cannot make it either night, you are welcome to appoint an AGM to draft for the team, submit a custom auto-draft list, or respect our auto-draft list (Bob McKenzie, then Future Considerations). Please confirm this via mod mail or (if mid-draft) via DM to the commissioners.
Please make your selections as promptly as possible to ensure the draft runs smoothly for everyone. Do not delay your selection to make a meme/image (you are welcome to post them afterwards). We will allow 2 min per selection for Rounds 1-3 and 1 min for Rounds 4-7. Each team will be allowed a 2 min timeout (one per team). We also will take a brief intermission (~10 min) between rounds.
If you wish to draft players not listed on the Elite Prospects Draft Board, you must petition the commissioners via mod mail before the start of the draft.

Qualifying Offers

GMs will need to submit a list of who they are sending Qualifying Offers to, among RFAs, and who they are letting test free agency (becoming UFAs). We will have a thread for this and they will be due by Sun. June 25th at 5pm ET (don’t pull a Dale Tallon). If you have further questions about this process, read about it in the CBA post and message a commissioner or leave a comment if you have further questions.

Free Agency

We will have 3 RFA agents and 4 UFA agents who have chosen the clients they will represent. Not every RFA/UFA will need an agent and you can find the lists on the spreadsheet, but generally, if the player played 15+ NHL games last season, he will require an agent. For the rest of the RFAs (those marked "Commissioners"), if they were qualified both in the sim and IRL, we will wait until they get an IRL contract and match it in the sim; if they were only qualified in the sim, they will be signed for their qualifying offers. For the rest of the UFAs, message the commissioners (via mod mail) with a contract offer. Please include a justification as to why the signing makes sense for your party including, for GMs, how it will affect the cap, lineup and future roster decisions. Please use the below template.
When both a GM and agent have come to a finalized deal, both sides need to submit the contract offer to the mods (via mod mail).
This contract offer must include the cap hit, term, any no-trade clauses, and any performance bonuses. Please keep it realistic as it could cause a domino effect when using comparables.
There will be the possibility for offer sheets, however, right now we are not sure the best way to determine who the player would actually pick. Ideas are encouraged. That being said, it’s more likely a player would choose a contender, hometown, long contract, good place in the lineup, or high salary rather than just picking at random. We also want to mention how rare offer sheets are in real life.
Agents have been sworn under the Oath of Bettman that they will be honest, realistic, and of course fun.
NHL CBA contract rules apply (more information here). Signing a player in free agency and then trading the player is prohibited.

Signing Submission Template

We would like teams to use the following template when submitting signing to ensure all relevant information is included.
Other clauses: (NTC/NMC, performance bonuses, etc.; answer "none" if not applicable)
Corresponding moves: (players sent down, called up, or put on waivers; answer "none" if not applicable)
Cap/salary implications:
Other options pursued:
Long-term implications:
I certify that my team remains roster & cap compliant.


Team: Columbus Blue Jackets
Player: Jack Roslovic
Year(s): 2
AAV: $4,000,000
Other clauses: None
Corresponding moves: None
Cap/salary implications: The Blue Jackets still have ~$22.8M in cap space for 2022-23, which should be sufficient for our needs.
Goal: The Blue Jackets are looking to keep a local player who has played well for the team.
Justification: While Roslovic had an excellent 2020-21 season, he regressed in 2021-22. A short term deal allows him to demonstrate that he can continue to be a valuable player without hamstringing us with a burdensome contract should he underperform.
Comparables: Ryan Spooner signed with NYR for 2yr x $4M in the 2018 offseason. Chris Tierney signed with OTT for 2yr x $3.5M in the 2020 offseason. Ryan Strome signed with NYR for 2yr x $4.5M in the 2020 offseason.
Other options pursued: None, Roslovic was a RFA that we wished to keep.
Long-term implications: While this contract will walk Roslovic to UFA status, we hope that he continues to perform well and we are able to sign a more long-term extension with him once Voracek's contract is off our books.
I certify that my team remains roster & cap compliant.


Players with one year remaining on a multi-year contract are also eligible for extensions. We are allowing each team to extend one such player, provided the AAV is over $6M. Message the Commissioners (via mod mail) with a competitive offer, and an explanation for why you want to extend the player.

GM vs Assistant GM

The GM is the one who makes the final decisions and who other GMs should message. You are encouraged to speak to anyone including Assistants, but for trades and updates on where they stand, please contact the GMs. The assistants are here to serve as a second opinion, fill in on things the GM might have made unclear, and ultimately serve as backups in case the GM needs to be replaced, for example on draft day.


PLAY NICE. If people act like dicks in trade/FA negotiations, particularly in agreeing to something and then going back on their word, PM the admins and we'll take care of it. Repeat offenders will get removed from the sim. Racism, homophobia, and other forms of bigotry will not be tolerated. No politics.
If you have any questions, feel free to comment below or DM any commissioner. If we need to clarify some things, we will do so.
submitted by sandman730 to hockeyoffseason23 [link] [comments]

2023.06.04 17:49 philmcp Marketing Coordinator at RocketAir (4 day week, 100% salary)

Marketing Coordinator at RocketAir (4 day week, 100% salary) submitted by philmcp to 4dayweekjobs [link] [comments]

2023.06.04 15:31 LimitlessTraveller Bank statements question - use of top-up debit card

I have been using top-up debit cards for all my payments online and offline for the past 2 years. The reason for using these is an extra layer of security and also due to the rewards they offer.
This has resulted in my bank statements only showing few transactions a month: salary, top-ups to my debit card and maybe sending money to friends for food, drinks and whatnot.
Will having bank statements like this affect me in any way in the future if I apply to a mortgage or any other process that requires me to provide bank statements?
The way I see it is that it looks like an unusual spending record.
submitted by LimitlessTraveller to UKPersonalFinance [link] [comments]

2023.06.04 14:34 Dirtclodkoolaid AMA RESOLUTION 235

“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”
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.”
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.
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.
CDC Spider (CDC Scientists Preserving Integrity, Diligence and Ethics in Research)
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. 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
Actual Study
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:
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:
(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.
(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.
Richard Holt, BS Pharm, PharmD, MBA Chair, Alaska Board of Pharmacy
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:
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.
(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.
submitted by Dirtclodkoolaid to ChronicPain [link] [comments]

2023.06.04 14:22 Jlaw118 How do business dividends work in terms of paying tax?

I hope this is the right sub but there’s no UK business ones and it crosses over with personal. I can’t make sense of this when googling it.
To put into perspective, in just shy of three weeks I’m leaving my job and starting a business which will be a LTD company.
I would like to pay myself quarterly dividends as my salary. I just don’t understand the tax side of it.
I understand the basic rate is 8.75% with a tax free allowance of £1,000. However I don’t understand if my business pays that, or if I do on a self assessment?
If my business pays it, do I still need to do a self assessment?
If I have to pay it, what does the self assessment take into account?
I will putting all expenses onto company bank accounts, and running the transactions and accounting through Xero. Do I really have to do a self assessment if I’m already running business accounts and paying tax on them?
Please can somebody explain it all to me? Thanks in advance!
submitted by Jlaw118 to UKPersonalFinance [link] [comments]

2023.06.04 14:08 Death_Turner PNB Rupay credit card apply issue

PNB Rupay credit card apply issue
I am trying to get PNB rupay credit card and it is throwing me this error, has anyone applied for the card and got the same issue or do we need to apply it offline?
I want to use it for UPI transactions
submitted by Death_Turner to CreditCardsIndia [link] [comments]

2023.06.04 13:21 axedlens This week in MultiversX (29.05.2023 - 04.06.2023)

This week in MultiversX (29.05.2023 - 04.06.2023)
We have grown. As a network, community, and ecosystem.
Time to bring $EGLD and the @MultiversX network as far and wide as possible.
Weekly #multiversxtech 🛠️
This week in MultiversX
  • The Great Heist: 284 submissions are undergoing internal reviews, now that the hacking competition has concluded and the Safe Vault proved its resilience to attacks. Special thanks to everyone who contributed in any form.
  • Jungle DEX has been merged into xExchange. 20 liquidity pools have been ported over together with the automated listing process for USDC pairs and several UI improvements.
  • Working on a block execution improvement proposal that could increase the network TPS capacity with the same HW minimum requirements.
Other notable achievements:
  • Mainnet upgrade v1.4.17.0
  • Analyzed and started working on full archive nodes synchronization process improvements
  • Lauchpad upgrade
  • Guardians competition monitoring
  • Finished ws conn template integration into firehose
  • Started updating sovereign chain and notifier and integrate latest ws host features
  • Bug-hunt and bug-fix on the elastic indexer
  • Guardian service internal audit fixes
  • Work continues on the go-testing framework on the possibility to run parallel tests, reducing the necessity of a large test time
  • Increased code coverage on common and genesis packages
  • KYC service: refactoring & bug fixing
  • Bughunt and fix memory grow issue on DEX service
  • Continued the implementation on the part where the node will send the config on the Web Socket
  • Grafana and prometheus monitoring setup
  • Implement collections analytics list
  • Deployed escrow endpoints improvements on DEX service
  • Debug and fixes on timescaleDB continuous aggregates
  • System test and bug-hunt and bug-fix on the api route /transaction/cost
  • mxpy guardian signing: testing and fixes
  • Consensus configurable finality implementation + testing
  • Analysis of useful metrics that should be extracted from a node's owner point of view
  • xExchange code updates
  • Upgraded several contracts to the latest version
  • Completed trie sync optimizations feature that comes with ~20% improve for trie syncing time
  • Finished prototype of the static API via VM hooks, and updated internal tests to use it
  • Launchpad code updates
  • Completed testing and merging for sharded persister storage feature
  • Working on distributed locking solution for TCS database operations
  • Digital cash contract test updates
  • Smart contract migration to new repository
  • Further testing & updates on the concentrated liquidity base implementation SC
  • Blockchain-etl / big-query, progress and try-outs with mainnet data
  • Concept for securing card balances using blockchain concepts
  • Orchestrator support for ComplyAdvantage APIs
  • Finished VM output log updates + dependencies
  • MultiversX API new unit tests added
  • Started a refactor of the state package
  • Finished integration of the new balanced data tries feature
  • Bughunt for missing snapshot trie nodes
  • xLaunchpad / KYC testing
  • DEX Experimental Tokens testing
  • Further development of VM-targeted system tests
  • Boosted metastaking tests
  • mx-sdk-py-exchange integration of wrapped egld contract & new python notebooks for manual and easy interactions
  • Usability analysis & tests of community EGLD exchange pairs creation flow
  • SC specifications for xPortal Mystery-box lottery
  • Coordinating efforts to move audited contracts into a new repo, easily accessible by the community
  • Specifications for new launchpad SC
  • More work on Governance module for xExchange
  • Sovereign Shard staking and factory SC
  • New Safe price test setup
“Stay Hungry Stay Foolish” and tune in soon for more of the #multiversxtech which powers the @MultiversX ecosystem.
Check out our progress & get involved 👇
Source: Twitter @ccorcov
submitted by axedlens to elrondnetwork [link] [comments]

2023.06.04 07:53 avant_nz Looking for a very blunt and honest review of resume please 🙏 . Returning to career after 10yr hiatus.

Hi, after a 10 year hiatus from my career in property and Real Estate following a really rough divorce and reflection period, I’m wanting to get back on the horse. I’m really not getting much traction or response from employers and I may have burnt a few bridges but I’ve tried to stay on top of things by reeducating, and starting back at low level jobs. My concern is that my resume has TMI. Any suggestions would be appreciated
submitted by avant_nz to Resume [link] [comments]

2023.06.04 04:39 summer10419 Long post but desperate for advice

So recently I’ve had a few issues come up with my NF regarding expectations, roles & responsibilities, and boundaries. Full disclosure we don’t have a contract (I’ve been with them for 3.5 years) I know bad move on my part but I didn’t stumble onto this thread until probably a year ago so didn’t realize this was a thing. Context follows for those who want it. If not, skip the next paragraph.
I’m salaried (still get time and a half after 40 hours) and some weeks I may only work 25, making this a pretty good gig. Full transparency, i make roughly 30k/year taxed. We landed on this after I told my NF I wasn’t making enough to live so I could either drop down to set hours to get a second job or I would need to be paid more. My hours are weird (6:30am-8 some mornings to bring kids to school) and then the afternoons and some weekends. Their biggest concern was having care when kids were sick from school, working through holiday breaks, date nights, etc. so the expectation was that I would make this set amount and be available up to 40 hours a week. I also started coming in to do moderate house cleaning (kitchen, living room, vacuuming) and do weekly grocery shopping (going to 3-5 stores every week) This has since become somewhat of a nightmare. I never have a set schedule made before the start of a week so often I’m getting my hours the day prior (including weekends) so my ability to make plans in advance even in my personal life is nonexistent.
This past week, dad texted me about babysitting for a date night, told me the reservation time was 6:30 and asked if I could work “until” to which I agreed. Previously mom said she had to work that day, but given conversation with dad afterwards, I was under the impression that 6:30 was new time they needed me. Mom texted me the night before to confirm I was coming in at 8am. Very confused I mentioned I thought the reservations were at 6:30. She said she had to work and that me being with the kids all day was priority number one. I explained I understood, was just confused based on conversation with dad. She then proceeded to tell me “just know he has no idea what’s going on with the kids at anytime so in the future, reach out and double check with me to confirm final schedule” followed by “and if you can’t do tomorrow, that’s okay. I’m really tired I wouldn’t mind an excuse not to go” Honestly, the whole interaction made me super uncomfortable because I felt that mom was in a way asking me to fall on the sword so she could skip her dinner without upsetting him and blame it on me not wanting to work a 12+ hour day. Additionally, it’s putting a lot of the responsibility on me to work out my own hours and coordination of schedules because they don’t communicate with each other beforehand, during, or after asking me to do things? It’s a lot of “check with him and figure it out” or “check with him and tell me what he says” I feel like they should be speaking with each other and then asking me for the things they need once they know the schedule.
I get to work the next day and I’m asked to do all of the laundry from a 10 day vacation (both child and adult on top of the normal laundry that was at the house—four loads total) which took me off guard because typically I’m asked to not wash adult clothes (she has certain things that are delicate etc) but I do that happily because I want to be helpful. This week I was also asked to do a grocery run to get “essentials” with no list so their fridge would be stacked when they got home from vacation and do a two hour round trip drive to go get their dog from boarding.
They end up going to dinner and 5B has epic tantrum right before bed, which is not out of the norm as he has some pretty moderate to severe behavioral struggles. They ended up coming home around 8:30 and mom went up to do damage control because he was still crying and upset and I was folding/putting away laundry. She came back downstairs and made it a point to tell me that 5B said “he didn’t think I should be their nanny anymore and that I don’t love him”. I know kids say things they don’t mean all the time but the fact that she would make a point to tell me that…. I don’t know if it felt like a threat that I might lose my job but more so a jab to insinuate that I’m a bad nanny. I’ve tried numerous times to have discussions with them about how they want me to handle his tantrums because he will scream at me and tell me to get out of the room he’s in, go away, hit me, tell me he hates me etc and on top of that will refuse to do anything i ask (including bath, bedtime routine, etc). I have never been able to get a solid answer or feedback on this and it’s left me feeling very helpless.
Finally today I get a text of a pile of food on the floor (all stuff she asked me to buy specifically for her over the last few weeks) and a text that says “All of this is expired…please always feel free to toss out anything expired”. Cleaning out the fridge has never been stated as one of my responsibilities, although from time to time I will take it upon myself to clear out leftovers I know are old and am always on top of making sure the kids aren’t eating moldy fruit or expired yogurt. I respond and explain I’m usually hesitant to throw away the adults stuff (do you guys throw away like $50+ of food out of your NF’s fridge????) but said if she would like me to add that to my list of weekly responsibilities, I’m happy to do so. She leaves me on read and later sends me a second full grocery list to do tomorrow. Did I mention I pay for their groceries and have to wait to be reimbursed by dad? He still owes me $300 from the grocery trip two days ago. :)
I feel frustrated because there seems to be a lot of animosity around me not doing specific things that I’m unaware are expected of me or doing things in a way they don’t agree with. They don’t take the initiative to address things (unless it’s something really big) and now I feel like I need to call a meeting or something to clear the air and address the backhanded comments. The work environment is starting to get so uncomfortable it’s making me question if I want to continue with them.
If anyone has advice on how to handle this, how to ask for a meeting, if I should quit, AITA, literally anything is appreciated.
submitted by summer10419 to Nanny [link] [comments]

2023.06.03 23:54 sokravtsov Community Manager

Community Manager
Location: Remote
We're looking for an experienced and energetic Community Manager to join Papaya, our fast-growing blockchain-based platform that connects content creators with their fans.
  1. Develop a community management strategy to increase engagement, retention, and growth across all social platforms (Twitter, Telegram, Discord, etc.)
  2. Moderate the day-to-day activities in our community forums, ensuring a positive and inclusive environment.
  3. Identify and analyze issues, patterns, and trends in community questions and feedback.
  4. Coordinate with marketing and development teams to communicate project updates and answer community inquiries.
  5. Encourage and manage user-generated content and community competitions.
  6. Regularly report on community feedback, concerns, and suggestions to the team.
  1. 2+ years of experience in community management, preferably in the tech or blockchain sector.
  2. Exceptional verbal and written communication skills in English.
  3. Familiarity with blockchain, cryptocurrencies, and the content creator landscape is a must.
  4. Excellent interpersonal skills and a passion for meeting and engaging with new people.
  5. Ability to multitask and manage multiple projects concurrently.
  6. Experience with social media management tools and analytics.
What we offer:
  1. The opportunity to be a part of an innovative, fast-growing startup disrupting the content creator space.
  2. Competitive salary and the potential for growth within the company.
  3. A remote and flexible work environment.
If you are a proactive, creative, and team-oriented individual who is passionate about community building and the blockchain sector, we would love to hear from you!
To apply, please send your resume and a cover letter detailing your experience and why you would be a good fit for our team.
Papaya is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

CommunityManagement #Web3 #CryptoJobs #BlockchainJobs #SocialMediaManagement #StartupJobs #TechJobs #RemoteWork #Marketing #Communication #CommunityBuilding #ContentCreation

submitted by sokravtsov to u/sokravtsov [link] [comments]

2023.06.03 23:12 IDE_IS_LIFE Anybody else disappointed by the price of the upcoming Quest 3?

Might not bother me too much if the price of $499 applied to my country (Canada), but it doesn't. Due to our dollar difference, that means quest 3 will be $670 plus tax. In my region, tax is 15% which means without accessories, buying a quest 3 would cost approximately $771. That's pretty brutal :( Times like this I really hate having such a weak dollar vs Americans. If I wanted to save money for one for launch without selling my Quest 2 (because I'd like to give it to my partner so we can both play VR together) it'll probably be $200 per month to make sure I've got enough set aside for around October.
Ah well, it's not unfair or unjust or anything and I'm not enraged about this or something, just a kick in the pants to again see buzz about an affordable piece of tech that's just plain less affordable to me because of where I live and the purchasing power that comes with that.
Anyone else feel similarly? Or maybe you feel differently? It'd be cool to see discussion surrounding the price point.
EDIT FOR CLARIFICATION: I'm not just referring to our conversion rate, I neglected to touch on the fact that our purchasing power in Canada is weaker than the US. In my field of work for example, the average salary for my type of job is nearly identical just across the border from me, but while I may earn a paycheck with a similar dollar figure as someone across the border from me, their goods don't end up being priced as high to offset the dollar difference in our currencies. A company selling a product to the US isn't going to want to earn LESS profit by selling something (like Quest 3 at the same dollar value in Canada as the US because a $499 USD purchase and a $499 CAD purchase isn't the same to them. So, if they want to make the same profit from a Canadian as they would an American after the Canadian purchase is converted to USD for their coffers, they have to raise the price to $670 CAD so that after conversion the currency they received in the transaction is worth the same as what the Americans paid for the same item. BUT we don't earn proportionally more money to offset our weaker dollar value, so it effectively means we just have less buying power. This is understandable and fine and just the reality, and I know this. I was simply expressing disappointment that the Quest 3s "affordable price" was set with Americans in mind I think which means that just due to how our economies work, it's just not as affordable to us in the same way.)
EDIT 2: I'm also not just pointing out that its more expensive, it's that technology has a history of becoming "cheaper, lighter, and faster" over time as progress is made in realms of manufacturing and research and development. On top of that, Quest 1 was more expensive than the Quest 2, and the Quest 2 is a superior device in a technical capacity. It did more and costed less and that was a mere year after Q1. It feels like a step backwards to have Q3 coming out 3 years after Q2 and going in reverse on the price. If Q2 came out cheaper than its predecessor while being a big leap forward in power then I hope to god that a Q3 that costs MORE than its predecessor is going to be a quantum leap forward otherwise its just worse value I guess. That's kind of compounded especially if we still need end up needing to buy a bunch of accessories to make it a worthwhile device (a headstrap that doesn't suck, a battery to make it usable for a reasonable period of time, a facial interface that doesn't either hurt your face or limit your FOV or cause rashes. The price difference would be worth it if this is all solved because then its just offsetting the prices you'd pay for rectify the shortcomings of the cheaper offering.)
submitted by IDE_IS_LIFE to OculusQuest [link] [comments]

2023.06.03 21:57 Buck_Joffrey Wealth Formula Episode 371: Ask Buck June 2023

Catch the full episode:
Buck: Welcome back to the show, everyone. And today it's just me. Like old times. And we're going to take questions from the audience. There's actually no audience here in my room, in my office here. But I'm going to take questions from you. And we'll start with the question from Mike. Mike, here you go. Hello, Buckets. Mike Kaye from Melbourne Beach, Florida.
Mike: I was wondering if you were looking at any opportunities out there in regards to investing in distressed assets. I've noticed that rates have gone up in a lot of operators like Western wealth aren't cash flowing and are actually looking for more capital because they've got themselves into trouble. And if rates stay higher than expected, there could be some some pretty good deals as far as bailing folks out.
Buck: So I wanted to get your thoughts on if you were looking for anything out there as far as funds or whatever it may maybe create some opportunity here. Thanks, Mike. Thanks for the question, Mike. The answer well, let's start with this. Obviously, there's a lot of distress in the system right now. Interest rates have gone up a the steepest slope in American history.
And as you might expect, that has not been good for operators, particularly those who relied heavily on floating debt. You know, and this is important, I think, to understand what's going on a little bit, because you might be wondering why in the world would you use floating debt anyway? Well, if it's a long term hold, it never would really make sense to do that kind of short term debt.
However, and with these larger assets, the problem is fixing debt. If your plan is to, you know, ultimately sell. And, you know, 18 to 24 months, you are going to end up with an extremely high prepayment penalty. And so in those situations, the extremely short hold are the shorter hold models, you know, generally ran on floating rate. So if you're again, your business model is to get in and out in 18 months, it doesn't make sense to lock in the rates.
So obviously now they would be better off if we had. But everyone has a plan until they get punched in the face. Right. That is from Mike Tyson, not from me. But that's that's kind of what's happening across the board here, especially for floating rates. And as for looking into creating this fund, which, you know, maybe you got a rescue fund or something like that, that the answer was whether I, I think that that's potentially something to do is, well, yeah, it's certainly something to consider.
And I have thought about it. These are essentially these sort of preferred equity positions, essentially become the lender. So there's not like any tax benefits or anything like that. But so, you know, I have thought about this, but but before doing anything like that, I want to make sure, you know, the economics makes sense for everyone against, again, perhaps one of the most appealing parts of this fund might actually to be getting into some second positions and maybe be first in line if the property fails and you know it or is distressed, it needs to be taken over.
But I really need to think about it because I also want everyone to have as much dry powder as possible. And because, again, it is no fun to be in this environment and those people who are going to make money are going to be the ones that have like nerves of steel that, you know, are okay to feel like, okay, I'm losing some money on one hand, but there's an opportunity to buy distressed assets on the other side.
And that's where real money is made. And again, it's a psychological thing that happens in every cycle. And the key is to try to keep your wits about you and learn, you know, learn whatever lessons you have to learn and move on and deploy. I certainly am not one who is not learned from this experience. Myself, I absolutely have, and I think it'll make me a better investor going forward.
Unfortunately, we're still in the midst of this mess right now. But anyway, bottom line is the answer is yes, potentially. I've thought about it. And I think like those kinds of preferred equity, essentially debt being in the second position behind the main lender, that is that's potentially appealing. And certainly as an investor, I think it's appealing because essentially you're you're in a lending position. You're not you know, you're not in an equity position, so you're superior to the equity position. Hopefully that helps. All right. Let's go on to the next question here. So it's from John.
John: Hi, this is John Valentino. I listened to your excellent podcast every Sunday morning on my run, walk and find them uniquely interesting and helpful amongst a sea of podcasts that aren't.
Buck: Yesterday you mentioned Terry Loughlin and your late in life swimming experience. I'm 68 now and at 55 I decided to learn to swim. I researched all of Terry's stuff and ended up using a local swimming coach here in Fresno, California, who knew Terry and who had a lot of experience. He had me swimming, breathing and flipped, turning very quickly.
Four years ago when we visited Maui, I did a two mile ocean swim with some master swimmers. I now swam about a mile and a half every Sunday with which the swim coach they taught me. And I do that. I listen to your podcast. I'm sure we could get you swimming and breathing properly very quickly. He Fresno's not too far from Montecito. Good luck with your swimming and let me know if you'd like me to hook you up with Rich. The swim coach.
Buck: Well, John, thanks for that. That makes for a lighter moment in this sea of despair. Ha ha ha. That's funny, kid at sea of despair. He's swimming. Anyway, for those of you who don't know what John is referring to, I'll just take a minute because, you know, taking questions from all kinds.
All types of questions here is back in 2016, I think it was 16, I listened to Tim Ferriss podcast about how he spent his whole life trying to swim and unsuccessfully, I'd say, met up a guy, met up with a guy named Terry Loughlin, who taught his total immersion technique or tie. So I decided, well, gosh, you know, basically Tim Ferriss was talking about my story, like he spent his entire, like, you know, didn't learn to swim as a little kid and then all this and trying to catch up and no one could teach him.
And that was kind of where I was. I do like him numerous, like tries added back in my twenties and thirties, and then I kind of had given up. Then I contacted Terry. He was in New York, upstate New York. So he actually flew out there. I was in Chicago at the time and he taught me to swim in about 2 to 3 hours and it was really unbelievable to me.
And the only thing I didn't learn how to do during that visit was to breathe. And unfortunately, that was so that was like I was there for like a day and a half. And that was the part I didn't get to. So now I can swim, but only as long as I can hold my breath because I can't seem to, you know, I can't breathe and swim at the same time.
Unfortunately, Terry had, end stage cancer. When I saw him and I believe I was his last student before he died a couple of months later, and he'd actually stopped teaching for a while, you know, before I got to be the lucky one that he decided he had enough strength to go back for. So lucky for me. So but yeah, I would love to, you know, John, shoot me an email, you know, where I am and I get well for Malcolm Connect me to your guy.
And I think Fresno might be a little far, but if he's as good as Terry, maybe I could. Maybe I could learn to breathe in a day, too. So, hey, anyway, thanks. Thanks for that. Let's go on to the next question here. All right. This one's from I think it's Garima.
Garima: I am looking to become a real professional on studies. We've been doing real estate for a little bit but wanted to do this. I really need help. If you can guide me well and see.
Buck: Well, I don't know. I can do my best about that, Garima. And first of all, I have to preface this as I always do, that what I'm about to say is not legal or any kind of tax advice. I'm not a tax professional. My degree is in medicine. I'm a former board certified surgeon, but that doesn't qualify me for much. And this in this arena, it's just my understanding of the tax law, which, you know, I spent a fair amount of time thinking about. So it's not like what I'm saying should not be listened to, I think.
But on the other hand, the liability issues, I have to make very clear consult with your own tax professional before anything anyway. So again, probably the best thing I can do in terms of guiding is tell you what I know about the qualification as real estate professionals status. And by the way, I should also point out that the benefits that I'm going to talk about, there's a lot of this similar benefits without having the status in short term rentals.
And that episode, I believe, is 354. So go back and listen to that one. It's I thought that was a pretty interesting episode. But why is agreement talking about this RFP short for a real estate professional So everyone is on the same page? What is the real estate professional designation? Why is it useful? Well, a real estate professional is not the same thing, is in a real estate agent or a real estate broker, which are basically involved with real estate transactions.
They're involved as like the middleman. Right. That's not really the business of real estate. The real estate professional is someone who is who is materially involved with the business of owning and operating business. And the reason that this is important, we'll get to in a minute, but I'm going to go into the qualification parts of this. And again, I'm not giving you advice and basically telling you what I can gather from the IRS website And basically the material participation is one of the first things.
So you can't you can't be a limited partner in a bunch of real estate and call yourself a real estate professional. You have to have some activities that are truly owning and, you know, operating real estate. I mean, you have to be involved in the management operations of your rental properties, right? So the level of involvement is different than obviously if, you know, even if you have a propertyif you have a property manager or whatever, it's still going to be more active than if you're just a limited partner.
But another one of the things that you have to qualify for is you have to spend more than 50% of your total working hours in real estate activities. So in other words, if you know, if you've got a full-time job, you can't really qualify as a real estate professional. There has to be more hours than any other profession. Right? Your participation in real estate activities has to exceed anything else that you're doing in terms of business and employment. There's also something called the 750-hour test, which you must spend at least 750 hours per year on real estate activities. And some of these things that you can do include property management or rent collection or maintenance or advertising, other related issues, acquisitions, underwriting, etc.
I mean, there's a lot of things that, you know, once you own real estate, you can be an active owner, right? So anywhere that's... So why would you want this designation? Because it sounds onerous to go and try to make sure you've got all these things if you're not already doing it. Well, as you may know, the real estate income itself, that real estate income itself is considered passive income.
Right. And similarly, the losses from real estate in the form of depreciation are considered passive losses for most people. Those passive losses cannot be applied to any active income, right? So if you have an income of $500,000 and you happen to have $500,000 of depreciation or paper losses, you couldn't use those losses to offset your personal active income.
The reason is that one is active and one is passive. So you can't do that. And unfortunately, unless maybe you or your spouse, rather, with whom you file jointly is a real estate professional. So in this case, what would happen is those passive losses from real estate would become activated, in other words, their active losses. And you can, you know, you can offset anything with active losses, right.
And even W-2 income. So that's the idea. So, again, theoretically, check with your legal, you know, and tax people and hopefully they know what they're talking about. But see, if you're a C, if you're a doctor, you're making, again, $500,000. And let's say your spouse, who's a real estate professional, generated maybe $50,000 in income, but $300,000 of paper losses, you can deduct that $300,000 from the salary, that is earned income on the doctor's side.
So basically, that is what the huge, big deal is about this real estate professional status. And again, I'm not a tax professional, but this is something that a lot of people in our group do, and it is, you know, following the tax code, that's the key. So Garima, bottom line is I don't know how else I can guide you other than to give you information.
But, you know, I guess what I would do if I were you is, you know, try to figure out how you can actually, you know, get yourself qualified as a real estate professional and make sure that, you know, you fit those criteria and talk to your tax person about it. Okay. Next question is from Mark Hammons. Mark's question deals with tax law, and I'm not sure it's appropriate for this forum.
Feel free to pass on if you feel like addressing it. Well, it's another question. Well, you know how I feel about that. I'll tell you what I think. But
don't take it as tax advice in any sort of way. But okay, so here's the question Mark says. He says, I'm a partner in an LLC that was formed for residential development.
Our project is nearing completion, and this year it will take business income to be taxed at a 20% LLC rate. I will receive income from the sale of raw land and taxed as long-term capital gains. I'm a full-time physician and not actively involved in the business of land development. Can I offset any of this income with accumulated passive losses and leases?
Thanks, Mark, for all you do. Thank you, Mark. And well, as you may have gathered from the previous question and the answer that I gave Garima, you are a full-time physician, my friend, and therefore you do not qualify as a real estate professional, and therefore you cannot use those passive losses against your active income as a physician, and you are stuck in that stratification of income hell, which is that you've got these great-looking losses on the passive side and this great income on the active side, and you cannot do anything about it.
So now, if your wife was doing this real estate stuff and qualified as a real estate professional based on the criteria I mentioned earlier, then you would theoretically be able to apply those passive losses to active income, and boom, all of a sudden, you would have what it is you are hoping for. And anyway, but I do have people in our group who are literally, you know, with that spouse set up.
Well, that's why I brought it up, right, where they literally had a spouse quit their job so that they can switch to real estate professional status. And although their cash flow may constitute a theoretical pay cut from their job, the generated losses, paper losses, are being applied to the larger active income stack. There, in many cases, justifies that because they may make a total gross amount of income that's less.
But because of those passive losses, they actually get to keep more. So that's a complicated answer to a simple question. In my non-professional opinion, Mark, you are kind of screwed. Can't do that anyway. All right. So the next series of questions is from Terry. And let's see, let's start with the first one. Is this one. My understanding is there are U.S. dollars held overseas in the United States.
What would be the impact to the value of the dollar if the overseas cash had to be converted to CBDCs, which is central bank decentralized coins? Well, I'm no expert on this, but from what I know, I'm not sure it would have a material effect on anything overseas because as I understand, CBDCs is a little more than using distributed ledgers instead of central ledgers for digital money, right?
Because the thing is, you have to remember that 90% of the U.S. dollars are digital-only already. They do not exist in the physical world already. So what difference does it make if it's on a single ledger or if it's on a distributed ledger? I'm not sure that it does. As I understand it, the idea would be essentially to make it into like a software update almost, right, where the new digital currencies would be CBDCs.
But of course, I could be wrong, and my understanding of the plan that the U.S. has there is it could be wrong. I'm sure there's a larger plan eventually to use this as a way of maximizing tax revenues and tracking people's spending and that kind of thing. But in the short term, I don't really see how it has repercussions for money overseas.
But if somebody knows of something that would cause that, certainly email me. But I don't know that. Okay. This question is also from Terry. He says, "Rising interest rates have had an impact on existing multifamily operators, and it seems like part of the multifamily model relies on interest rate value being lower than cap rates." That's correct. "Combined with the multiplier effect of low cap rates for value-add projects, do you see cap rates going up until interest rates come down?"
How high can cap rates go before the value-add model is no longer viable? Are rents still rising fast enough to offset interest hikes? Okay. So yes, I do see cap rates going up. Remember, in order for debt to make sense, the interest rates must be lower than the cap rate. So if your borrowing rate is 5%, then your cap rate needs to be above that in order to have positive cash flow.
Otherwise, you're amplifying your losses. That said, often, you know, you may have seen in some cases operators buying things and they'll consider buying things like that. If there's an obvious thing that's going to drive up net operating income pretty quickly. But right now we are seeing rising cap rates. Now, as for the value-add model being viable, I would say that yes, the value-add model is viable in all interest rate environments and with all cap rates because remember, folks, real estate was not people didn't just start making money on value-add.
This has been around for some time, right? There are plenty of people who got rich off of value-add real estate in the eighties despite double-digit interest rates in double-digit cap rates. So what has created so much distress in this system is not the absolute interest rates. It's the pace at which the interest rates went up.
They're the moving goalposts. You see, every time you underwrite a property, you have to model in interest rates and reversion cap rates. And if rates are not stable, it's very difficult to underwrite. And that's why these real estate markets right now have been so illiquid. There really are no stable variables to underwrite with. Rightly, you got to have the goalposts, you got to know where the goalposts are so you can play the game right.
Once you have that stability, though, you can underwrite again, and in value-add real estate, the money isn't made based on interest rates being high or low, but it is made by ultimately creating a positive delta in the net operating income. And that can happen in all interest rate and cap rate environments. So I don't see it being an end to value-add real estate at all.
In fact, one could argue that if you're, say, you're buying real estate, which hopefully we are in the fall, and you're getting great deals on it, you know, the rates are high, but the numbers are making sense. You do your normal net operating income, you do your normal value-add program, you try to increase NOI, and you get lucky.
And by the time you're ready to sell, interest rates have actually come down. Well, in that case, you're going to actually probably get, you know, more for your property than you would otherwise if rates were stable. So I actually don't see this as something that is ending anything. In fact, I think those who, again, take advantage of a higher-rate environment and buy into assets that make sense at high interest rates could seriously make money in the next, you know, several years.
So let's see, the last question from Terry is, "What are your thoughts on portfolio allocation between real estate stocks, cash value insurance, gold, crypto, and cash?" Well, I might not be the best person to ask about portfolio allocation because I think my portfolio would make most money managers think, right? I'm about 75% real estate, maybe 5-7% crypto, mostly Bitcoin, Ethereum, and the remaining investments are things that I believe are uncorrelated.
The most stable thing is, you know, I'm a big fan of cash value life insurance in part because, I mean, it is so stable. I mean, seriously, it is incredibly stable. If you look at the environment that we're in right now, it makes you, again, think you should be buying more cash value life insurance. It's extremely stable.
And this is why it was such a big deal during the Great Depression. People lived through the Depression and had no faith in anything except for cash value life insurance, which is what they were buying. But anyway, I think, in particular, I'm talking about these strategies that we're calling, well, formula banking or various leverage dials, wealth accelerators, things like that.
So there's that. I'm also obviously into other things that we have in our group. We're involved with like ATMs, which, you know, don't seem to have much correlation with the economy per se because people who use that still needed it. Good times or bad and did well even through COVID. You know, there's also things that we're doing, like I'm invested in things like, you know, cargo ships that are delivering essential oil and gas to the country, things like that, where again, it's not something that is significantly correlated with the rest of the markets.
And I think that's one of the things to really make sure that you're not... I mean, listen, I guess in my case, being 75% real estate, I mean, it's not a good time to be 75% real estate right now. Right. I probably... I mean, if I did the numbers, I'm probably less than 75% real estate now because I probably lost quite a bit of value in the real estate.
But I'm not even going to look at that right now for this purpose. But ultimately, though, you know, listen, personal finance should be personal. I don't own stocks, although I'm not against stocks. I'm just, you know, not a guy who really owns stocks except for some big, really, you know, asymmetric plays in the energy space, you know, through Mercatus and things like that.
I don't own any physical gold, although again, I've talked about possibly wanting to do that. I don't really want to right now, but I'm hoarding cash right now because I think there are going to be tremendous buying opportunities in real estate with distressed assets, and I think that's going to be the name of the game in Q4. So but again, I do not think it's a good idea to listen to me about portfolios.
I think I think it's if you want those kinds of things, you probably should, you know, talk to others, talk to, talk to, you know, our RIA's, things like that. But to me, again, personal finance is really personal. And for me, I'm, you know, I'm pretty aggressive on some of the things that I have a lot of belief in.
So, okay. Well, I guess that's my last question. Before I go, I want to remind you that there's another actually, there's actually another podcast that I do now, which is, you know, it's kind of just taking something that I was spending a lot of time learning about and and and trying to process myself and turning it into another show so that I could share with you.
The show is called CPO, CPO. You can find it on pretty much all of the ways that you find this show and
hopefully on YouTube soon too. We haven't quite gotten to YouTube, I think, but the show is, I think, very interesting because, you know, we talk about wealth on the show, but I mean, you know, what do what is more what's more coveted than, you know, actually having health because then your wealth is actually useful.
So a lot of Sabio is really about various types of longevity and wellness type stuff on the science that we know out there. Really interesting stuff to me and would love for you to check it out again at Sabio with Buck Joffrey. Check it out and let me know if you like it. Give me a positive review. That's it for me.
This week on Wealth Formula podcast, this is Buck Joffrey signing off.
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2023.06.03 21:56 DivingSiren June 2023 International Buy/Sell/Trade Thread

This is the place for all your B/S/T that is NOT within North America. You can find that thread here!
If you're outside North America or within and willing to ship internationally, this is the place for you!
Just remember to put your location in your post!
Before you post please give the following rules a read:
Check out our Trading Safety Guidelines Post for helpful tips to protect yourself in trades.
Please feel free to message the Mods with any questions or concerns.
This is the place for all your B/S/T that is NOT within North America. You can find that thread here!
If you're outside North America or within and willing to ship internationally, this is the place for you!
Just remember to put your location in your post!
Before you post please give the following rules a read:
Check out our Trading Safety Guidelines Post for helpful tips to protect yourself in trades.
Please feel free to message the Mods with any questions or concerns.
submitted by DivingSiren to LushCosmetics [link] [comments]