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Guideline Summary
Guideline Title
Supporting clients on methadone maintenance treatment.
Bibliographic Source(s)
Registered Nurses' Association of Ontario (RNAO). Supporting clients on methadone maintenance treatment. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2009 Jul. 113 p. [147 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)
  • Opioid misuse
  • Opioid dependence
Guideline Category
Counseling
Evaluation
Management
Prevention
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Nursing
Obstetrics and Gynecology
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Nurses
Guideline Objective(s)

To provide nurses with recommendations, based on the best available evidence, related to nursing knowledge and support for clients who are either a potential candidate for or already on methadone maintenance treatment (MMT) for opioid dependence

Target Population

Any youth, adult or older adult either already on methadone maintenance treatment (MMT) or those who are potential candidates for MMT

Note: Particular attention is given to priority populations (for whom there are particular physiological implications of MMT).

Interventions and Practices Considered
  1. Assessment, management and treatment of patients either already on methadone maintenance treatment (MMT) or those who are potential candidates for MMT through:
    • Incorporation of skills and knowledge of addiction, including the social determinants of health on addiction
    • Maintaining awareness of current and evolving perceptions, attitudes and biases, and beliefs
    • Informing clients of available treatment options and efficacy of those, including MMT
    • Understanding the pharmacokinetics of methadone
    • Performing the "8 rights" to ensure safe administration
    • Appropriately interpreting drug screening results
    • Understanding acute and chronic pain management
    • Providing referral, monitoring, and health promotion interventions
  2. Nursing education recommendations and strategies directed at the competencies required for practice
  3. Organization and policy recommendations and strategies directed at practice settings and the environment in order to facilitate nurses' practice
Major Outcomes Considered
  • Social and healthcare costs
  • Methadone toxicity
  • Concurrent disorders
  • Mortality

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The search strategy utilized during the development of this guideline focused on two key areas: 1) Identification of clinical practice guidelines published on the topic of methadone maintenance for the treatment of opioid dependence; and 2) Identification of systematic reviews and primary studies published in this area from 2000 to 2008.

Database Search

A database search for existing evidence related to methadone maintenance treatment (MMT) was conducted by a university health sciences librarian. An initial search of the MEDLINE, Embase, CINAHL, PsycInfo and Cochrane Library databases for guidelines, primary studies and systematic reviews published from 2000 to 2008 was conducted using the following search terms "Aboriginal/First Nations", "Addictions", "Addictions Nursing", "Advocacy", "Assessment", "Child care", "Concurrent Disorders", "Corrections", "Detention centres", "Drug interactions", "Fetal alcohol syndrome", "Harm reduction", "Health Promotion", "Hepatitis B", "Hepatitis C", "Heroin dependence", "HIV", "Immigration status", "Injection drug use", "Inmates", "Interventions", "Jail nursing", "Mental illness", "Methadone", "Methadone maintenance therapy", "Methadone/therapeutic use", "Morphine dependence", "Narcotic abuse", "Needle exchange", "Neonatal abstinence syndrome", "Nursing", "Opiate abuse", "Opiate dependence", "Opiates", "Opioids", "Pain and chemical dependence", "Poverty", "Pregnancy", "Prisoners", "PTSD", "Quality of life", "Safety", "Sexual assault/sexual abuse", "Social determinants of health", "Stigma", "Street drugs", "Substance abuse", "Substance abuse treatment", "Substance dependence", "Substance misuse", "Substance-related disorders", and "Urine toxicology". As directed by the consensus panel, supplemental literature searches were conducted where needed.

Structured Website Search

One individual searched an established list of websites for content related to the topic area in January 2008. This list of websites was compiled based on existing knowledge of evidence-based practice websites, known guideline developers, and recommendations from the literature. Presence or absence of guidelines was noted for each site searched, as well as the date searched. Some websites did not house guidelines, but directed readers to another website or source for guideline retrieval. Guidelines were either downloaded if full versions were available, or were ordered by telephone or email.

Search Engine Web Search

In addition, a website search for existing practice guidelines related to MMT was conducted via the search engine Google (www.google.com External Web Site Policy), using key search terms. One individual conducted this search, and noted the results of the search, the websites reviewed and date found, and wrote a summary of the results.

Hand Search/Panel Contributions

Panel members were asked to review their personal archives to identify guidelines not previously found via the search strategies noted above. One guideline was identified, but through panel consensus, was agreed to be outside the scope of the guideline, and was therefore not included in the review.

Search Results

The search strategy described above resulted in the retrieval of more than 1342 abstracts on the topic of supporting clients on MMT. These abstracts were then screened by a research assistant in order to identify duplications and assess for inclusion and exclusion criteria established by the panel.

Several international guidelines related to MMT were critically appraised and chosen to inform the development of this guideline. Eleven clinical practice guidelines were identified that met the following initial inclusion criteria:

  • Published in English
  • Developed in 2000 or later
  • Strictly on the topic of MMT for the treatment of opioid dependence
  • Evidence-based
  • Available and accessible for retrieval

Members of the development panel critically appraised the 11 guidelines using the Appraisal of Guidelines for Research and Evaluation Instrument. This review resulted in the decision that four of these 11 guidelines were relevant to the scope of the current guideline, and would be used to inform the development process.

In addition panel members sourced additional information (existing evidence – articles, literature, peer-reviewed and grey literature) to support and refine recommendations.

Number of Source Documents

Four guidelines and 1342 abstracts were reviewed.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Types of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

In January, 2008, a multidisciplinary panel with expertise in practice, education and research, from hospital, community, corrections and academic settings, was convened under the auspices of the Registered Nurses' Association of Ontario (RNAO).

Members of the development panel critically appraised the 11 guidelines using the Appraisal of Guidelines for Research and Evaluation Instrument (AGREE Collaboration, 2001). This review resulted in the decision that four of these 11 guidelines were relevant to the scope of the current guideline, and would be used to inform the development process.

The panel members formed into subgroups to undergo specific activities using the short-listed guidelines, evidence summaries, studies and other literature, for the purpose of drafting recommendations for nursing assessment and interventions. Community representatives were consulted for input and feedback. This process resulted in the development of practice, education, and organization and policy recommendations. The panel members as a whole reviewed the first draft of recommendations, discussed gaps, reviewed the evidence and came to consensus on a final set of recommendations.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

Substance misuse, which includes opioid misuse and dependence, is associated with high social costs. As Canada is the fifth highest consumer of opioids in the world, and opioid dependence is associated with high social and personal costs when individuals are not treated, this best practice guideline focuses on the issue of opioid misuse and MMT, which is used to treat opioid dependence.

The costs of untreated opioid addiction include health care, law enforcement (and other criminality related costs), social assistance and loss of economic productivity. In 1999, the annual social cost of untreated opioid dependence was estimated to be $5.3 million (Canadian). It has been estimated that 13.5 million people worldwide misuse opioids, with the majority (9.7 million) using heroin. In the past, heroin was the most commonly misused opioid in Canada. However, opioid misuse patterns are changing. Currently, more health-care providers are recognizing addiction as a health issue that is largely due to the increased availability of prescription opioids. Canadians are the highest per capita consumers of prescription opioids. Opioid dependence is a substantial public health concern in Canada and worldwide.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The completed draft was submitted to a set of external stakeholders for review and feedback. Stakeholders represented various health-care professional groups, clients and families, as well as professional associations. External stakeholders were provided with specific questions for comment, as well as the opportunity to give overall feedback and general impressions.

The feedback from stakeholders was compiled and reviewed by the development panel. Discussion and consensus resulted in revisions to the draft document prior to publication.

Recommendations

Major Recommendations

The levels of evidence supporting the recommendations (Ia, Ib, IIa, IIb, III, IV) are defined at the end of the "Major Recommendations" field. See the original guideline document for additional information provided in the "Discussion of Evidence," "Practice Boxes," and "Clinical Vignettes."

Practice Recommendations

Recommendation 1

Nurses incorporate specific skills and knowledge of addictions in their everyday practice.

(Type IV Evidence)

Recommendation 1a

Nurses incorporate knowledge of maternal and child health related to opioid use.

(Type IV Evidence)

Recommendation 1b

Nurses consider the ethical, legal and social context of harm reduction/addiction treatment programming.

(Type IV Evidence)

Recommendation 2

Nurses have knowledge of the impact of the social determinants of health on addictions.

(Type Ib-IV Evidence)

Recommendation 2a

Nurses consider the holistic needs of a client as integral to the success of a client's treatment.

(Type IV Evidence)

Recommendation 3

Nurses practice reflectively to maintain continued awareness of their current and evolving perceptions, attitudes and biases, values and beliefs when working with clients with addictions (including those on methadone maintenance treatment [MMT]).

(Type IV Evidence)

Recommendation 3a

Nurses provide care in keeping with the principles of cultural safety and cultural competence.

(Type IV Evidence)

Recommendation 4

Nurses inform their clients of available treatment options for opioid dependency (including MMT) on an ongoing basis.

(Type IV Evidence)

Recommendation 5

Nurses need to be aware of the efficacy of MMT as a substitution therapy for opioid dependence.

(Type IV Evidence)

Recommendation 6

Nurses will have an understanding of the pharmacokinetics of methadone.

(Type III-IV Evidence)

Recommendation 6a

Nurses will be aware of the pharmacodynamics of methadone.

(Type III-IV Evidence)

Recommendation 6b

Nurses integrate their understanding about the pharmacokinetics and pharmacodynamics of methadone to be aware of the side effects and drug-to-drug interactions that may occur.

(Type III-IV Evidence)

Recommendation 7

Nurses will uphold standards of practice by performing the "8 rights," as appropriate, to ensure safe administration of methadone.

(Type IV Evidence)

Recommendation 7a

Nurses will be knowledgeable of the College of Physicians and Surgeons of Ontario criteria for take-home doses (carries) to reduce harm to the client and community**.

**For those practicing outside of Ontario, please check within your jurisdiction.

(Type IV Evidence)

Recommendation 8

Nurses will have an understanding of the interpretation of urine drug screening results and their importance in the treatment of the client on methadone maintenance.

(Type IV Evidence)

Recommendation 9

Nurses will have an understanding of acute and chronic pain management for clients on MMT.

(Type IV Evidence)

Recommendation 10

Nurses provide referral, monitoring and health promotion interventions, as appropriate.

(Type Ia-IV Evidence)

Education Recommendations

Recommendation 11

Schools of nursing will integrate the principles of addiction care, including the concept of harm reduction into the undergraduate curriculum.

(Type IV Evidence)

Recommendation 11a

Undergraduate nursing curriculum will support evidence-based training and practice in the field of addictions.

(Type IV Evidence)

Recommendation 12

Nurses incorporate addictions knowledge (including MMT) into their ongoing everyday practice and continuing education.

(Type IV Evidence)

Recommendation 13

Nurses working in addictions have access to formal training and education to achieve competencies in practice and standards of practice in addictions and MMT.

(Type IV Evidence)

Organization & Policy Recommendation

Recommendation 14

Nurses advocate with policy makers for improved access to addictions care and treatment modalities, including MMT, as part of holistic, primary health care for all populations.

(Type IV Evidence)

Recommendation 15

Health care organizations have policies that reflect uniform approaches to the management of clients on methadone in all facilities, including seamless coordination of transfer and discharge between facilities for clients on MMT.

(Type IV Evidence)

Recommendation 16

Health care organizations provide mechanisms of support for nurses through orientation programs and ongoing professional development opportunities regarding addictions and treatment options including MMT.

(Type IV Evidence)

Recommendation 17

Nursing best practice guidelines can be successfully implemented only when there are adequate planning, resources, organizational and administrative supports, as well as appropriate facilitation. Organizations may wish to develop a plan for implementation that includes:

  • An assessment of organizational readiness and barriers to implementation.
  • Involvement of all members (whether in a direct or indirect supportive function) who will contribute to the implementation process.
  • Dedication of a qualified individual to provide the support needed for the education and implementation process.
  • Ongoing opportunities for discussion and education to reinforce the importance of best practices.
  • Opportunities for reflection on personal and organizational experience in implementing guidelines.

In this regard, a panel of nurses, researchers and administrators developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of the Registered Nurses' Association of Ontario (RNAO) guideline Supporting Clients on Methadone Maintenance Treatment.

(Type IV Evidence)

Definitions:

Types of Evidence

Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trials

Ib Evidence obtained from at least one randomized controlled trial

IIa Evidence obtained from at least one well-designed controlled study without randomization

IIb Evidence obtained from at least one other type of well-designed quasi-experimental study, without randomization

III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies

IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence is provided for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Studies have shown that clients who received treatment for substance abuse that included medical care, counseling and social services versus those who received usual care (i.e., follow-up to arrange counseling or referral sessions) showed greater improvement in their health status.
  • Benefits of methadone maintenance treatment (MMT) during the perinatal period include:
    • Improved gestational age
    • Increased birth weight
    • Decreased infant mortality
Potential Harms
  • The side effects associated with methadone may appear slowly. Since clients in a methadone maintenance treatment (MMT) program are generally served as outpatients with minimal opportunities for contact with their health-care providers, there is a risk that these harmful effects may not be observed in a timely manner.
  • Methadone has the potential to cause prolongation of the QT interval. When combined with drugs that have similar effects on the QT interval, the client is at greater risk for a fatal dysrhythmia such as Torsade des Pointes.
  • Nurses must be aware of the numerous medications that can alter the bioavailable concentration of methadone (see Appendix D in the original guideline document). Those interactions that may increase the concentration of methadone put the client at risk for overdose. When the interaction manifests as a decrease in the concentration, the client is at risk of experiencing withdrawal symptoms and cravings. These symptoms may in turn potentiate a relapse (see Appendix H in the original guideline document).

Contraindications

Contraindications

Certain opiate agonist-antagonist drugs used for pain control in labour and delivery (e.g., Stadol, Nubain) are contraindicated in women on methadone, as opiate agonist-antagonists can precipitate withdrawal.

Qualifying Statements

Qualifying Statements
  • These guidelines are not binding on nurses or the organizations that employ them. The use of these guidelines should be flexible based on individual needs and local circumstances. They neither constitute a liability nor discharge from liability. While every effort has been made to ensure the accuracy of the contents at the time of publication, neither the authors nor the Registered Nurses' Association of Ontario (RNAO) give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omission in the contents of this work.
  • This nursing best practice guideline is a comprehensive document that has been designed to provide an overview of the resources necessary to adequately support evidence-based nursing practice. It is to be reviewed and applied as a resource tool that addresses the specific needs of an organization or practice setting. The guideline is not offered as a "cookbook" solution, but rather as a tool to enhance effective decision-making in the provision of individualized client care. In addition, the guideline provides an overview of the appropriate structures and supports necessary for the provision of best possible care.
  • This guideline document is meant to be used as a guideline for nurses. As such, it complements – but does not replace or supersede – the existing policies and procedures of any agency.
  • This guideline contains recommendations for Registered Nurses, Registered Practical Nurses and Advanced Practices Nurses on best nursing practices in the area of supporting clients on methadone maintenance treatment (MMT). It is intended for nurses who are not necessarily experts in this practice area, and who work in a variety of practice settings (i.e., addictions, corrections, mental health, emergency, maternal child, community health, etc.) across the continuum of care. It is acknowledged that individual competencies vary between nurses and across categories of nursing professionals. Individual competencies are based on knowledge, skills, attitudes, critical analysis and decision-making, which are enhanced over time by experience and education.
  • It is expected that individual nurses will perform only those aspects of assessment and intervention for which they have received appropriate education and have acquired the necessary skill sets. It is also expected that they will seek appropriate consultation in instances where the client's care needs surpass their ability to act independently.

Implementation of the Guideline

Description of Implementation Strategy

Best practice guidelines can only be successfully implemented if there are adequate planning, resources, organizational and administrative support as well as appropriate facilitation. In this light, Registered Nurses' Association of Ontario (RNAO), through a panel of nurses, researchers and administrators has developed the Toolkit: Implementation of Clinical Practice Guidelines based on available evidence, theoretical perspectives and consensus. The Toolkit is recommended for guiding the implementation of any clinical practice guideline in a healthcare organization.

The Toolkit provides step-by-step directions to individuals and groups involved in planning, coordinating and facilitating the guideline implementation. Specifically, the Toolkit addresses the following key steps in implementing a guideline:

  1. Selecting your clinical practice guideline.
  2. Identifying, analyzing and engaging your stakeholders.
  3. Assessing your environmental readiness.
  4. Deciding on your implementation strategies.
  5. Evaluating your success.
  6. What about your resources?

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is a key resource for managing this process.

Implementing guidelines in practice that result in successful practice changes and positive clinical impact is a complex undertaking. The Toolkit is one key resource for managing this process. The Toolkit can be downloaded from the RNAO Web site External Web Site Policy.

Evaluation and Monitoring

Organizations implementing the recommendations in this nursing best practice guideline are advised to consider how the implementation and its impact will be monitored and evaluated. A table found in the original guideline document, based on the framework outlined in the RNAO Toolkit: Implementation of Clinical Practice Guidelines (2002), illustrates some suggested indicators for monitoring and evaluation.

Implementation Tools
Chart Documentation/Checklists/Forms
Foreign Language Translations
Mobile Device Resources
Resources
Staff Training/Competency Material
Tool Kits
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Registered Nurses' Association of Ontario (RNAO). Supporting clients on methadone maintenance treatment. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2009 Jul. 113 p. [147 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Jul 1
Guideline Developer(s)
Registered Nurses' Association of Ontario - Professional Association
Source(s) of Funding

Funding was provided by the Ontario Ministry of Health and Long-Term Care.

Guideline Committee

Guideline Development Panel

Composition of Group That Authored the Guideline

Development Panel Members

Margaret Dykeman, RN, NP, PhD
Team Leader
Professor
Faculty of Nursing, University of New Brunswick
Fredericton, New Brunswick

Katie Bowler
Nursing Student
Daphne Cockwell School of Nursing
Ryerson University
Toronto, Ontario

Carol Edwards, RN, MN, CPMHNC, CARN
Advanced Practice Nurse, Addictions Program
Centre for Addiction and Mental Health
Toronto, Ontario

Jan Holland, RN
Regional Methadone Coordinator, Acting/Senior
Project Manager Methadone/Harm Reduction
Correctional Services Canada
Ottawa, Ontario

Sheleza Latif, RN, BScN
Correctional Staff Nurse
Toronto East Detention Centre
Toronto, Ontario

Somina Lee
Methadone Case Manager
Nipissing Detoxification and
Substance Abuse Programs
North Bay, Ontario

Carol Lynch, RN(EC), BNSc
Primary Health Care Nurse Practitioner
Kingston Community Health Centre: Street Health
Kingston, Ontario

Angela McNabb, RN, BScN, MN, CPMHN(c)
Outreach Consultant, Mental Health
and Correctional Services
College of Nurses of Ontario
Toronto, Ontario

Josephine Muxlow, RN, MScN
Clinical Nurse Specialist, Adult Mental Health
Prevention & Promotion Programs and Nursing
Leadership
First Nations and Inuit Health,
Atlantic Region
Halifax, Nova Scotia

Janice Price, RN, BScN
Public Health Nurse
Sexual Health Clinic/Outreach Nursing
Sudbury and District Health Unit
Sudbury, Ontario

Abby Smith, RN(EC), BScN, PHCNP
Nurse Practitioner
Out 'n About Clinic
St. Catharines, Ontario

Victoria (Vicki) Smye, RN, MHSc, PhD
Assistant Professor
School of Nursing, University of British Columbia
Vancouver, British Columbia

Melanie Stansfield, RN(EC), FNP(BC), MScN
Nurse Practitioner
Newport Centre, Niagara Health System
Port Colborne, Ontario

Sue Starling, RN, BScN, MSc, PhD(student)
Assistant Professor
School of Nursing, McMaster University
Hamilton, Ontario

Jenny Oey Chung, RN, MN
Program Manager
International Affairs and Nursing Best
Practice Guidelines Programs
Registered Nurses' Association of Ontario
Toronto, Ontario

Frederick Go, RN, MN
Program Manager
International Affairs and Nursing Best
Practice Guidelines Programs
Registered Nurses' Association of Ontario
Toronto, Ontario

Pamela VanBelle, RN, MN
Program Manager
International Affairs and Nursing Best
Practice Guidelines Programs
Registered Nurses' Association of Ontario
Toronto, Ontario

Glynis Vales, B.A. (Honours)
Program Assistant
International Affairs and Nursing Best
Practice Guidelines Programs
Registered Nurses' Association of Ontario
Toronto, Ontario

Financial Disclosures/Conflicts of Interest

Declarations of interest and confidentiality were made by all members of the guideline development panel. Further details are available from the Registered Nurses' Association of Ontario.

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in English and Spanish in Portable Document Format (PDF) from the Registered Nurses' Association of Ontario (RNAO) Web site External Web Site Policy.

Print copies: Available from Registered Nurses' Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3

Availability of Companion Documents

The following are available:

  • Toolkit: implementation of clinical practice guidelines. Toronto (ON): Registered Nurses' Association of Ontario (RNAO); 2002 Mar. 91 p. Available in Portable Document Format (PDF) from the RNAO Web site External Web Site Policy. See the related QualityTool summary on the Health Care Innovations Exchange Web site External Web Site Policy.
  • e-learning: Addictions. Toronto (ON): Registered Nurses' Association of Ontario (RNAO). Available from the RNAO Web site External Web Site Policy.

Print copies: Available from the Registered Nurses' Association of Ontario (RNAO), Nursing Best Practice Guidelines Project, 158 Pearl Street, Toronto, Ontario M5H 1L3.

A methadone learning tool calendar and other resources are available in the original guideline document External Web Site Policy.

Mobile versions of RNAO guidelines are available from the RNAO Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This summary was completed by ECRI Institute on June 16, 2010. The information was verified by the guideline developer on September 16, 2010.

Copyright Statement

With the exception of those portions of this document for which a specific prohibition or limitation against copying appears, the balance of this document may be produced, reproduced, and published in its entirety only, in any form, including in electronic form, for educational or non-commercial purposes, without requiring the consent or permission of the Registered Nurses' Association of Ontario, provided that an appropriate credit or citation appears in the copied work as follows:

Registered Nurses' Association of Ontario 2009. Supporting clients on methadone maintenance treatment. Toronto, Canada: Registered Nurses' Association of Ontario.

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