Limited solutions. Sounds about right.

Thanks, I didn't properly read the title. Is this a gaming simulator or a research simulator or some other purpose?

Fishing, tourism (e.g. whale and polar bear watching) and research? I'm guessing.

Tried Gusto which was more expensive but didn't have the same issues. The main reason we used these companies was because of the ongoing "what shall we have to eat tonight?" dilemma and if we had a few meals already chosen in a bag this issue was less of a problem.

After 6 months we had built up a decent number of recipe cards we liked (from both HF and G). We stopped our subscriptions and now we meal plan a week in advance and if we want inspiration we choose some random meals from the cards and make sure we have the ingredients next time we go shopping.

We used to get Hello Fresh but found the quality control became abysmal. Started off with an occasional ingredient missing which I can understand happening from time to time. After a year or so it got to the point that nearly 1 in 3 boxes came with multiple missing ingredients. Last recipe was some salmon and broccoli dish with spices to add flavour. 2/3 spices were missing and so was the broccoli!

Stopped after that fiasco.

I made a list of drugs for pain relief as that was what was asked for. There are very few situations (arguably none) in which all drugs are practical.

Expecting any drug to replace opioid is very unrealistic at this time and as I have commented on, dealing with chronic pains should be multidisciplinary and not entirely reliant on just pharmaceutical therapy for the most effective way of tackling the issue.

One of the largest barriers is tackling patient (and indeed many healthcare provider) mindsets and psychologies. Opioid rotation is not a long term solution. Opioid reduction is the main aim but requires a huge turnaround of thinking/effort/money.

Prevention is better than cure generally. Stopping the opioid problem in a patient beforenit deveoops into a massive chronic issue is far better than trying to sort it when they aren on 160mg BD and it's five years down the line. One situation that can be worked on is the acute pain apatient who comes to hospital (e.g. After a trauma). If the analgesia is effectively tackled then, with the likes of the medications I have mentioned, and they get discharged without the need for ever escalating opioid prescriptions, how is that a bad thing? If you disagree and you think they should just get ever escalating doses of single agents then, again, that's your opinion.

As of yet there is no panacea and I doubt there ever will be. Based on your name I'm guessing that you are somehow involved in the pharmaceutical industry? If this is the case then no doubt you are aware of how difficult it is to create a drug that has decent efficacy, acceptable tolerance and safety profile and a cost efficient process of manufacturing, distribution and marketing.

I never said

Firstly my post was simply a list of analgesics. That was what was asked for.

Secondly you may think that. And you are obviously entitled to your opinion. Your opinion is not seemingly well based in fact. Or perhaps maybe your reply is by someone who who doesn't know about outpatient or chronic pain use. I don't know.

I mention paracetamol, naproxen, ibuprofen, diclofenac, gabapentin, pregabalin, duloxetine, magnesium, local anaesthetics, heath and cold therapies, all of which are available and appropriate for some outpatient or chronic use. So basically the majority of what I listed.

Ketamine is very variable in terms of side effects depending on the doses you use. I doubt it would be good for long term use but acutely it is awesome because it remains cardiovascular stable so it's great for trauma patients who have lost loads of blood, it's a bronchodilator so it's great for asthmatics and you don't have as much respiratory/airway loss like other anaesthetic induction agents. But that is all from a general anaesthetic dosing point of view.

At lower doses I've used it for dressing changes on burns patients and for manipulating kids dislocated limbs. You give a small dose, wait for them to go into a sort of fugue state and then pop the shoulder back in.

It is associated with the potential for profound hallucinations and increased salivation though. It provides a dissociated consciousness. One patient described it as like he was watching what we were doing to him as if it was like watching a TV show. No pain at all but it didn't feel real. Some hate that feeling, some don't care.

Again though I suspect long term use, which I am not familiar with,comes with side effects and problems.

Nerve blocks can last between a few hours and a full day. Depends on what you use, where it is used and how much. But it's labour intensive. Not really something that can be done every day. Plus there is alway the risk that the needle causes damage to the nerve if the person isn't careful with it.

A few places for chronic pain give IV lidocaine infusions. You come in for a few hours, get the infusion with monitoring. Then go home the next day. Again labour intensive and so often the funding isn't available to have it in many locations.

The best therapies in terms of long term benefits are usually physiotherapy and psychology. Ultimately if a pain becomes a chronic pain, the neural pathways alter and essentially don't work how they should do. Therefore removing the pain entirely often becomes impossible and those two therapies help the most because they help the patients accept and deal with the pain so they can get on with life. Unfortunately many patients are unwilling to accept this reality and believe there is a magic cure, a silver bullet, a perfect pill that sorts everything out.

Correct in that it would be great if we had more drugs to choose from and yes, like all drugs they all have side effects, pros and cons and are situational. No drug is perfect.

Plus I listed analgesics because that is what someone asked for a list of but I didn't mean that all are suitable for chronic pain. Very little is. In fact the best therapies often aren't pharmaceutical for chronic pain.

R.e. steroid side effects they include increase in glucose levels, reduction in immune system response, a decrease in endogenous steroid production, increaser risk of GI bleeding and weight gain/hunger. Very unlikely to get these from a single injection like your friend though and actually it's unclear why single shot steroids remain so effective for as long as they sometimes do.

Wrong. If you have a foot amputated I can block the pain completely with a nerve block of just 20mls of local anaesthetic in the correct locations. Or I can give you ketamine and your pain is no longer an issue.

Similarly I know patients who cry out with their pains and they are on 160mg of morphine twice a day with extra opioid doses in between. Blatantly if they are crying out, the opioid are nit effective.

I've anaesthetised patients for operations, given them 20mg morphine and they are still in severe pain in recovery. Then you give them some IV paracetamol and diclofenac and the pain goes from 10/10 to them happy and chatting.

It all depends on the situation.

This is a massive topic that has began to spread. Here is the UK we are trying to get a handle on it, though the start was a bit different. Opioid drugs became licensed for use for cancer pains and were able to be prescribed.for GPs. Overtime they began to be prescribed for other pains as well and as a result many patients got put on them for pains that thy wouldn't die from.

Unfortunately one issue is the opiod addiction that resulted, but actually, two other issues compound the problem massively.

Firstly over time patients develop tolerance. That is, the body essentially gets used to the opioid dose and needs more to have he same effect. What may have started with a pain needing 30mg of codeine a couple of times a day can progress over years to the same person needing 120 mg of morphine a day. GPs just kept raising he dose because that was often a.quicker/easier action than tackling the root problem. Chronic pain clinics are underfunded, have huge waiting lists and any success from them can take.weeks/months etc from the patient's initial consultation,.compared to a 15 second.raise in.the prescription dose.

Secondly, some.patients can develop opioid induced hyperalgesia. The pain pathways alter and thr opioid itself.can stimulate it causing pain. The patient is already.addicted to the drug and at this point the pain is chronic, so explaining that they need to reduce the dose is often met with refusal and disbelief (understandably).

Opioid can be very useful in the short term but long term they can be terrible.

Some non-opoid analgesics include: paracetamol NSAIDs e.g. ibuprofen, diclofenac, naproxen aspirin Ketamine Duloxetine (used for.neuropathic pain) Gabapentinoids such as gabapentin and pregabalin (also for.neuropathic pain) Local anaesthetics such as lidocaine, bupivacaine, ropivacaine (can be used in creams/gels/injections) Clonidine Magnesium Alcohol (studies have found it to be superior than paracetamol in certain quantities though obviously is also addictive!) Heat/cold therapies Steroids such as dexamethasone can provide some analgesic effect TENS machines Nitrous oxide

Many of these are situational e.g. if you have a deep pain than local anaesthetic cream likely won't penetrate deep enough, but a deep injection or nerve block of local anaesthic such as bupivacaine may work wonders.

Ha, jokes on you. My dick doesn't have teeth.

Might not be a thesis but definitely an oral exam.

Why not enjoy the experience of a great tasting beer without the hangover the next day? Why not savour the refreshing and crisp malt barley flavour as much as you want without worrying about having to get a taxi home? Michelob. Awesome beer. Alcohol free. (Warning, not suitable for vegetarians or people with haemochromatosis).

I thought the issues with EU bailing out and major financial troubles a few years back would have had a major impact on the likes of Greece.

Didn't say the graph was bad. Just that taken in isolation it can be misleading. Also, I apparently misinterpreted the title - I have replied to OP on this. Basically, OP says it * isn't* relative, it's absolute. Despite the title.

Ah, I misunderstood then. The word relative in the title of the post made me interpret the data as being relative percentage points, not absolute. My bad, I suppose.

My point is, taken in isolation this data can be very misleading. If Luxembourg previously only had 1% of their energy from renewable sources and increased to 1.7% (70% increase), they would have the same place on the chart, but who would give them kudos for 98.3% non-renewable energy?

Thing is, if the base number is small, it is a heck of a lot easier to achieve a significant increase to a less small number, than to start with a big number and achieve a small increase.

I wouldn't worry. Her followup single "You're fairly narcissistic" didn't do anywhere near as well and the next one "You're quite self involved" didn't even chart.

I can't believe nobody seems to be commenting on the use of "rad" for the best days. Bodacious dude, cowabunga!