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Principles for the Provision of Opioid Dependence Treatment By Manitoba Pharmacists. Updated December 2014
- Karin Wilkinson
- 3 years ago
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1 Principles for the Provision of Opioid Dependence Treatment By Manitoba Pharmacists
2 ACKNOWLEDGEMENTS The College of Pharmacists of Manitoba would like to thank the following organizations and individuals for their help and expertise in updating the Principles for the Provision of Methadone by Manitoba Pharmacists guidelines document: Alberta College of Pharmacists College of Pharmacists of British Columbia Ms. Nicole Nakatsu, B.Sc.(Pharm.) Mr. Mike Sloan, B.Sc.(Pharm.) The College would also like to take a moment to recognize Dr. Lindy Lee, MD, College of Physicians and Surgeons of Manitoba for her many years of tireless dedication and compassion for patients struggling with opioid addiction. Dr. Lee worked closely with the College of Pharmacists of Manitoba to help educate pharmacists and improve patient safety. Dr. Lee passed away in November
3 TABLE OF CONTENTS PART ONE... 6 Summary of Methadone for Harm Reduction and Pain... 6 (1) Common Concentration... 6 (2) Common Care Plan... 6 (3) Knowledgeable... 6 (4) References... 7 (5) Deliveries... 7 (6) Witnessed Ingestion... 7 (7) Delegation... 7 (8) Policy and Procedures Manual... 7 (9) Labelling... 8 (10) Private Area... 8 (11) Equipment... 8 (12) Tamper Proof Seals... 8 (13) Carries... 8 PART TWO... 9 Introduction to Opioid Dependence Treatment and Methadone... 9 Introduction... 9 Harm Reduction Philosophy... 9 Overview of MMT... 9 Criterion for admission to MMT program Overview of Methadone for Analgesia Pharmacology of Methadone Adverse Effects Drug interactions Drugs with additive effects Opioid antagonists and partial agonists QTc Interval Prolongation Table 1: Drug Interactions with Methadone PART THREE...14 Methadone Overview Methadone Dosing Early Stabilization Phase (0 2 Weeks): Late Stabilization Phase (2 6 Weeks): Maintenance Phase (6 Weeks +): Extended Methadone Maintenance Urine Drug Screens Tapering off Methadone Split Dosing Pregnancy Breast Feeding Incarceration Treatment of Acute Pain Overdose
4 Diversion Chronic Viral Infections and MMT Recommended Readings PART FOUR...19 Implementing Opioid Dependence Treatment in Pharmacy Practice Methadone Including Methadone Maintenance Treatment (MMT) in your Pharmacy Practice Community considerations and workflow Policy and Procedure Manual Education and Training Pharmacist - Practitioner Communication Methadone Exemption for Prescribers M3P Prescription Program Faxing M3P Prescriptions New Patient on Opioid Dependence Treatment Methadone Dispensing Dispensing Methadose Diluting Methadose Table 2: Methadone stability in various diluents for carries i Storage Pharmacy Storage and Security Labelling of Prescription Bottles Methadone Inventory Records Billing MY, MZ, and Interaction Codes Caution Witnessed Ingestion Positive Identification Daily Witnessed Ingestion Intoxicated Patients Refusing methadone administration Documentation Guest Drinkers Take Home Doses (Carries) Storage of Carries Documentation for non-childproof caps Warning Labels Destruction of Empty Methadone Bottles Vacation Supply Counselling Replacement Doses Vomited Doses Missed doses MMT in hospital Continuation of Care Temporary Exemptions for Physicians Provision of methadone within the hospital Initiating MMT in hospital Buprenorphine/Naloxone (Suboxone ) Education Suboxone Exemptions for Practitioners Dispensing Buprenorphine/Naloxone
5 Witnessing Suboxone Dosing REFERENCES...35 PART FIVE...36 Appendices Appendix A Manitoba Health, Healthy Living and Seniors: Methadone Reimbursement Procedure and Questions and Answers Appendix B Sample Pharmacist Patient Agreement Appendix C Sample Emergency M3P Documentation Appendix D Sample Ingestion and Carrier Log Appendix E Suboxone (Buprenorphine / Naloxone) Important Practice Notes Appendix F Methadone Compounding Issues Appendix G Sample Compounding Log
6 PART ONE Summary of Methadone for Harm Reduction and Pain (1) Common Concentration a. Harm Reduction: Methadose (methadone HCl) is a commercially available oral liquid concentrate indicated for substitution treatment in opioid drug dependence in adults by Health Canada. It comes in a concentration of 10 mg/ml. The following products are to be used when patients are being treated for opioid dependency: Methadose 10mg/ml oral liquid DIN Methadose Sugar Free 10mg/ml oral liquid DIN This change took effect as of October 16, The use of compounded methadone stock solution will be discontinued on the effective date of the next Manitoba Health Formulary Bulletin update in mid-january This transition period of approximately three months will allow for part fills of existing prescriptions to be filled using the old pseudopin of compounded methadone stock solution. Please see Appendix A for the information sent to pharmacists from Manitoba Health, Healthy Living and Seniors regarding the changes in methadone reimbursement procedure. If dispensing the dye-free, sugar-free, unflavoured Methadose, the methadone dose must be diluted with a suitable crystalline diluent in a sufficient quantity (qs) to 60 to 100mL final volume for witnessed dose ingestion by the pharmacist. If dispensing the red, cherry-flavoured Methadose, the dose may be ingested without dilution for witnessed dosing by the pharmacist. However, the cherry-flavoured formulation may be diluted if deemed necessary by the pharmacist or prescriber. b. Analgesia: Metadol is a commercially available product indicated for pain management by Health Canada. The same transition period as stated above for methadone for harm reduction will occur for methadone for analgesia. Please see Appendix A for the information sent to pharmacists from Manitoba Health, Healthy Living and Seniors regarding the changes in methadone reimbursement procedure for Metadol and Methadose for pain management. (2) Common Care Plan a. Harm Reduction: For harm reduction, the methadone prescriber, patient and pharmacist will enter into a common written care plan with the rights, obligations, conditions and consequences agreed upon. (3) Knowledgeable Pharmacists must be knowledgeable in all aspects of methadone use when involved in care with methadone. Section 18 of the Pharmaceutical Regulation states that a member may only engage in the aspects of pharmacy practice that he or she has the requisite knowledge, skill and judgment to provide or perform and that are appropriate to his or her area of practice. a. Harm Reduction: For harm reduction, the expectation is that the pharmacist will be knowledgeable in the use of methadone for opioid dependence treatment. The expectation is that there will be at least one pharmacist at each pharmacy with specialized training in harm 6
7 reduction and if that is not possible (i.e. first 6 months), in the interim there will be a trained pharmacist functioning as a mentor at another location. The pharmacist with specialized training at a pharmacy is responsible for training all pharmacists who will be dispensing methadone. For further information on available training programs, please see page 20. b. Analgesia: Where methadone is used for pain, the expectation is that the pharmacist will be knowledgeable in the use of methadone for analgesia. Specialized training should be considered for use of methadone in pain in a similar manner to methadone used for harm reduction. (4) References Pharmacists must have onsite or readily available references and treatment guidelines when involved in harm reduction care and/or care with methadone for pain (e.g. College of Physicians and Surgeons of Manitoba Recommended Practices Manitoba Methadone and Buprenorphine Maintenance document, Center for Addictions and Mental Health Methadone Maintenance: A Pharmacist s Guide to Treatment, etc.) a. Harm Reduction: Minimum requirements onsite include the CPhM and CPSM guidelines and/or standards and a reference similar to that offered by CAMH; b. Analgesia: Minimum requirements onsite include the CPhM and CPSM guidelines and/or standards and a reference similar to that offered by CPSO. (5) Deliveries a. Harm Reduction: Deliveries (by persons other than a pharmacist) are not acceptable; with the understanding that there may be exceptions as determined in consultation with the methadone prescriber and the agreement of the sponsoring harm reduction program. The witnessing of ingestion cannot be delegated by a pharmacist and therefore delivery and witnessing needs to be done by a pharmacist (with the exception of deferring to a methadone prescriber at an established harm reduction program or another pharmacist). If in the professional judgement of the pharmacist and prescriber that delivery is necessary, individual case review, justification and documentation is required. b. Analgesia: Deliveries may be undertaken with the same precautions afforded narcotics of a similar nature and can be accepted by an agent (if appropriate). (6) Witnessed Ingestion a. Harm Reduction: When methadone is used for harm reduction, witnessed doses (non-carries) must be observed, logged with date and time in a patient specific, patient identified and confidential manner. b. Analgesia: Not applicable. (7) Delegation a. Harm Reduction: The act of witnessing the ingestion of methadone for methadone maintenance treatment (MMT) cannot be delegated by a pharmacist, with the exception of deferring to a methadone prescriber at an established harm reduction program or another pharmacist. b. Analgesia: Not applicable. (8) Policy and Procedures Manual A site specific Policy and Procedures Manual should be readily available onsite when methadone is dispensed for harm reduction and/or management of pain. 7
8 (9) Labelling All patient labels will be compliant with the provisions of The Pharmaceutical Act and Regulations; a. Harm Reduction: For methadone maintenance therapy, the label needs to indicate the date of ingestion and the total dosage (mg) in the bottle with a notation that the dosage was made up to a set volume (if applicable). Methadone doses that have been pre-measured into individual patient dose bottles/containers must be clearly labelled with the patient name, dosage, and initials of the pharmacist who checked the measured doses. b. Pain: Labelling needs to be completed as per a regular prescription. (10) Private Area a. Harm Reduction: For harm reduction, a confidential area in the pharmacy for counselling and observation of ingestion is required. b. Pain: An area suitable for confidential counselling is required by the CPhM Standards and Practice Direction in all pharmacies for all prescription and non-prescription medication. (11) Equipment It is recommended that all devices used for methadone preparation be used only for methadone. (12) Tamper Proof Seals It is strongly recommended that each individual methadone dose delivered offsite (i.e. to an institution) be sealed with a tamper-proof seal. (13) Carries It is recommended that bottles/containers for carries are returned to the pharmacy and accounted for prior to issuing further carries to prevent diversion. These bottles are not to be reused but disposed of in an appropriate manner. 8
9 PART TWO Introduction to Opioid Dependence Treatment and Methadone Introduction These guidelines provide an overview of the pharmacist s role in opioid dependence treatment in Manitoba. Two of the available medications available for opioid dependence treatment include methadone (brand name: Methadose ) and buprenorphine/naloxone in a 4:1 ratio (brand name: Suboxone ). Methadone and buprenorphine-naloxone can bring normal functioning back to an individual since they are opioids that cause little to no euphoric effects. Additionally, these medications have a long half-life to enable suppression of the withdrawal symptoms and cravings of opioid addiction that often contribute to relapse. The choice of therapy between these two options will depend on a number of factors including (but not limited to): The degree of opioid dependence and tolerance experienced by the patient, An evaluation of the patient s risk of harm from the chosen therapy including the risk of non-compliance, The patient s concomitant health conditions and comorbidities, The potential for significant drug interactions with other concomitant therapies, The patient s ability to access the specialized services and expertise of an opioid dependence program, The patient s response to therapy, The patient s ability to afford the chosen therapy, and The patient s lifestyle and social history. i These guidelines will focus more closely on methadone maintenance treatment (MMT), but more information on buprenorphine/naloxone can be found on page 33. There are an increasing number of methadone patients as well as methadone dispensing pharmacies in Manitoba. MMT in Manitoba began in 1970 with the treatment of one heroin addict. ii In 2007, the number of patients receiving MMT in Manitoba was nearly 500 iii. Now, it is estimated that there are approximately 1,200 methadone patients in Manitoba in iv The provision of methadone in practice can be both rewarding and challenging. These guidelines are intended to provide a standard framework for successfully integrating this important program into practice. Harm Reduction Philosophy The Manitoba methadone maintenance treatment program is based on a harm reduction philosophy. Harm reduction attempts to decrease the harmful consequences of illicit drug use to the individual, family, community and society. The goals of the program are to reduce illicit opioid use, needle sharing, criminal activity and mortality associated with addiction. The intent of a methadone maintenance program is that the patient should function like they are in abstinence while on the program. Methadone is an important therapeutic tool in the treatment of opioid addiction. It has been shown to be more effective than placebo in decreasing illicit opioid use and imprisonment. Many people stabilized on methadone can return to work or school and become contributing members of society. A portion of these patients may eventually be tapered off the program. Overview of MMT Until 2007, methadone was the only substance approved in Canada for the long term (>180 days) treatment of opioid dependence. Buprenorphine, a partial µ-opioid receptor agonist, can also be used in the treatment of opioid addiction. Pharmacists are expected to be knowledgeable about either product prior to dispensing. More information on buprenorphine/naloxone can be found on page 33. 9
10 Methadone is an oral substitute for heroin and other opioid narcotics. It prevents withdrawal symptoms and reduces cravings. Oral methadone does not induce euphoria in stabilized patients and it blocks the euphoric response to other opioids. Methadone s long half life allows it to be dosed once daily for MMT. Since methadone is dispensed from a licensed pharmacy, it is from a safe source and of known dose and purity. Methadone is also affordable. It is covered by most third party payers, including Manitoba Pharmacare and the Non-Insured Health Benefits program. While some patients may pay up to several hundred dollars a day for illicit drugs, prescription methadone can cost significantly less. There are many benefits to MMT, however some people feel it is inconvenient to have to drink a witnessed dose at the pharmacy on a regular basis. Although this may be cumbersome for some patients, it can help them establish a routine which is considered part of their rehabilitation. Unfortunately, there continues to be much stigma associated with methadone maintenance and many people do not understand how methadone works. Pharmacists can play an important role in educating the general public and other health care professionals on MMT. Criterion for admission to MMT program Prior to admission to an MMT program, patients should be informed of all other treatment options for their opioid dependence so they are able to make an informed decision. Opioid dependence is a psychological disorder that is defined in the DSM IV as a: Maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12 month period: 1. Tolerance, as defined by either of the following: a) The need for markedly increased amounts of the substance to achieve intoxication or the desired effect. b) Markedly diminished effect with continued use of the same amount of the substance. 2. Withdrawal, as manifested by either of the following: a) The opioid withdrawal syndrome. b) The same (or related) opioid is taken to relieve or avoid withdrawal symptoms. 3. The substance is often taken in larger amounts or over a longer period than was intended. 4. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 5. A great deal of time is spent in activities necessary to obtain the substance (e.g. visiting multiple doctors or driving long distances), use the substance (e.g., chain smoking), or recover from its effects. 6. Important social, occupational or recreational activities are given up or reduced because of substance use. 7. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was worsened by alcohol consumption). v It should be noted that tolerance and withdrawal on their own do not constitute opioid dependence. For example, a cancer patient that is on morphine for pain control will likely develop tolerance to morphine and require higher doses. If this patient s morphine is abruptly stopped he/she would experience withdrawal symptoms. Substance dependence requires the behavioral component(s) to be present in order for the diagnosis to be made. 10
11 When considering a patient for MMT, the methadone prescriber will ensure the patient has a significant history of opioid use/abuse. This is usually confirmed with a positive urine drug screen and/or other appropriate collateral information. Typically the patient will have greater than a one year history of opioid use and have failed abstinence treatment or have a small likelihood of benefit from non-methadone treatment. Prior failure on MMT does not preclude someone from restarting the program. The prescriber will discuss the commitment required for the program and the expectations that he/she has of the patient. The patient will be required to make an informed decision in order to participate in the program. It is a good idea to have a 3-way (prescriberpatient-pharmacist) agreement that specifically lays out the expectations each party has of the program. Some pharmacies prefer to use a 2-way agreement (pharmacist-patient). A sample agreement has been provided in the Appendix B. Overview of Methadone for Analgesia Methadone was originally developed in 1941 by IG Farbenindustrie in Germany. It was marketed in the United States by Eli Lilly as an analgesic by the name of Dolophine. While methadone is a very effective analgesic, it is important to note that methadone dosed once daily is non-analgesic in a patient stabilized on MMT. Since the analgesic effects of methadone do not last as long as its suppression of opioid withdrawal, it typically needs to be administered every 8 hours for pain control. Pharmacology of Methadone Methadone is a synthetic opioid that acts as an agonist at the mu-opioid receptor. This action is similar to morphine and heroin, however, it is structurally unrelated. Absorption: Methadone has high oral bioavailability (79% range ) and is quickly absorbed (30 minutes +/-15 minutes). Peak plasma levels of methadone can occur between 1 and 7.5 hours post oral dose (average peak occurs between 2.5 and 4 hours). Distribution: Methadone is lipophilic and highly protein bound. It has a free fraction of 13% however there is significant inter-patient variability. Its volume of distribution is 4L/kg (range 2-13 L/kg). Metabolism: Methadone has a half life of 35 ± 12 hours. Methadone is primarily metabolized by CYP P450 3A4 and to a lesser extent by 1A2, 2B6, 2C8, 2C9, 2C19, and 2D6. It is also a weak inhibitor of 2D6. Methadone s major metabolite is 2-ethylidene-1,5-dimethyl-3,3 diphenylpyrrolidine (EDDP) which is inactive. It has 2 active metabolites that are produced in very small amounts and are not clinically significant. Excretion: Methadone undergoes urinary and fecal excretion. Urinary excretion of methadone increases as the magnitude of the dose increases. Methadone s major metabolite EDDP is also eliminated both in the urine and feces. Methadone s long half life allows it to be dosed once daily for MMT. It should be noted that methadone takes 3 to 7 days to reach steady state; for a methadone naïve adult a daily dose as low as 40 mg can be lethal by day 3. Single doses as low as 30 mg have known to be fatal in children. 11
12 Tolerance to methadone is lost very quickly and after 3 days of missed doses, the patient must not be given their current maintenance dose. True tolerance to methadone is rarely achieved therefore most people can be maintained on the same maintenance dose for years without requiring an increase. Cross tolerance of other opioids to methadone is incomplete and erratic. One cannot accurately predict a patient s methadone maintenance dose based on other opioid use nor should tolerance to methadone be assumed when initiating a new patient on methadone. Adverse Effects Much of methadone s side effect profile is similar to other opioids. Please see the Methadose or Metadol product monograph for more information. Frequently observed but improve with time Frequently observed and persistent Infrequently observed Drowsiness, nausea, weight gain, nervousness, appetite changes Constipation, sweating, sleep disturbances, changes in sexual desire/function, dry mouth Vomiting, dizziness, flushing, unsteadiness, itching, myalgias, arthralgias, abdominal cramping, swelling of the feet and ankles, QTc interval prolongation (usually only occurs at higher doses), dental problems Drug interactions Methadone is primarily metabolized by CYP P450 3A4. (It is also metabolized to a lesser extent by CYP 1A2, 2B6, 2C8, 2C9, 2C19 and 2D6.) It is also a weak inhibitor of 2D6. Most interactions will be a result of induction or inhibition of CYP 3A4. Generally these interactions can be managed by monitoring for signs of toxicity or withdrawal and adjusting the dose accordingly. The sequence of witnessed dosing of the drugs is key to evaluating the significance of the interaction. When a patient is stabilized on a drug that affects liver metabolism and methadone is introduced, the interaction may not be observed unless the drug is discontinued. In a patient on a stable MMT dose, careful consideration and monitoring is required on initiation or discontinuation of a medication known to interact with methadone. Drugs with additive effects Extreme caution should be taken when drugs with additive adverse effects are prescribed, particularly those that can cause central nervous system or respiratory depression. In most methadone related deaths, concurrent use of sedatives such as benzodiazepines and alcohol were found to have contributed to the cause of death. Opioid antagonists and partial agonists Drugs that are opioid antagonists or partial agonists should be avoided in patients stabilized on methadone as they can precipitate withdrawal. Examples of these drugs are buprenorphine, pentazocine, butorphanol, nalbuphine, and naltrexone. QTc Interval Prolongation Methadone at higher doses can prolong the QT interval and concomitant use of other QT interval prolonging agents should be avoided. 12
13 Table 1: Drug Interactions with Methadone Drugs that may increase methadone level Amiodarone Cimetidine Ciprofloxacin Clarithromycin Diazepam Echinacea Erythromycin Ethanol (acute ingestion) Fluconazole Drugs that may decrease methadone levels Abacavir Amprenavir Carbamazepine Cocaine Efavirenz Ethanol (chronic ingestion) Fosamprenavir Lopinavir/ritonavir Nelfinavir Nevirapine Fluvoxamine Grapefruit juice Itraconazole Ketoconazole Nefazodone Paroxetine Sertraline Voriconazole Urinary alkalizers Other P450 inhibitors Phenobarbital Phenytoin Primidone Rifampin Risperidone Ritonavir Saquinavir St. John s wort Urinary acidifiers Other P450 inducers The above table does not include all possible drug interactions. The table is meant as a guide and does not preclude the use of sound clinical judgment. 13
14 PART THREE Methadone Overview Methadone Dosing MMT can be divided into 3 phases: the initial or early stabilization phase, the late stabilization phase and the maintenance phase. The initial stabilization phase has been reported to be the most common phase for death from methadone maintenance treatment. This is generally due to an overestimation of tolerance and an underestimation of methadone accumulation. As mentioned earlier, cross tolerance to methadone from other opioids is incomplete and unpredictable. Dose Equivalency reference tables should not be used to convert opioid intake to methadone for addiction. Early Stabilization Phase (0 2 Weeks): This phase encompasses the first 2 weeks of the program. During this phase patients will be initiated on methadone and gradually titrated upward. The starting dose of methadone is mg/day. The lower end of the dosing range (10-20 mg/day) should be used for those patients at higher risk of toxicity (elderly, on a drug that inhibits methadone metabolism, concomitant use of sedating medications). The methadone dose can be increased by 5-10 mg every 3-4 days as required to suppress opioid cravings and alleviate withdrawal symptoms. It is very important not to increase the dose too quickly as the drug is accumulating for 5 days. The key is to start low and go slow! The pharmacist should ensure that the patient is aware of signs of toxicity and what to do about them. During this period the patient will have all their doses supervised unless the pharmacy or clinic is closed. The pharmacist should be aware that the patient may continue using their drug of choice during this period as methadone will not yet be at a maintenance dose and will wear off before their next dose. Late Stabilization Phase (2 6 Weeks): This phase encompasses weeks two to six of the program. During this phase the patient s dose will be optimized and the use of other opioids should be decreased. Dose adjustments of 5-10 mg every 5 to 7 days are made depending on severity, onset and duration of withdrawal symptoms. Most patients will be on mg of methadone during this phase. The patient will still have all doses supervised (unless pharmacy/clinic closed) during this period. Maintenance Phase (6 Weeks +): This phase encompasses the time period after the initial six weeks. By this time the patient should be on or close to their maintenance dose. The use of other opioids should be largely eliminated and the patient should not be experiencing withdrawal effects for the full 24 hour period. When a patient is receiving their optimal methadone dose they will not have withdrawal symptoms, opioid cravings will be reduced, euphoria from opioid use will be blocked and the patient will not have any psychomotor or intellectual impairment. The usual maintenance for methadone is between mg/day although doses upwards of 200 mg may be required in some patients. Pharmacists should be aware that potential QT interval changes can begin to manifest in doses above 100mg. Professional judgment must be used to evaluate patients who are using other medications that can also prolong the QTc interval. If dose adjustment is required during this phase it is usually between 5-10 mg/day every 5 to 14 days. Dosage adjustment may be required if the patient subjectively complains of withdrawal symptoms, if cravings become intense or if they relapse to opioid use. Patients should be cautioned to avoid driving or operating heavy machinery for several hours after dose increases until their body adjusts to the higher dose. 14
15 Extended Methadone Maintenance This phase is only for long term stable patients. These patients have been socially rehabilitated and the intent of the extended program is to allow for more flexibility. Patients on this program meet the following criteria: A. Two consecutive years of biopsychosocial stability in a methadone maintenance program. Employment or other socially productive activity Absence of criminality Absence of drug and alcohol abuse B. Reliability and honesty in keeping appointments and interactions with clinic staff. C. Ability to safely store medications. These patients are seen less frequently by their methadone prescriber, once every 1 to 3 months. The patients must have a negative urine drug screen on every visit or they will be reverted back to the standard program. The methadone is dispensed every 2 weeks or monthly and a witnessed dose must be taken at the time of dispensing under supervision of a pharmacist. Tablets may be given as an alternative to liquid methadone, and must be indicated by the prescriber. Urine Drug Screens The utility of urine drug screening is twofold. The prescriber will use the test to confirm that the patient is not taking illicit drugs and also to confirm that the patient is taking methadone. If a patient tests positive for illicit substances it may indicate lifestyle instability. Patients will most likely lose carry privileges if they produce a dirty or positive urine sample for street drugs. If your patient has been prescribed narcotics or benzodiazepines from another practitioner offer to call the methadone clinic/prescriber on their behalf so that he/she is not penalized for producing a positive urine sample. To confirm that the patient has been taking methadone, the prescriber will look for a positive methadone result on the drug screen. If the prescriber suspects that the sample has been tampered with and the patient is diverting his/her methadone, then it is prudent to perform additional testing for the methadone metabolite. Tapering off Methadone Occasionally a patient will request or be forced to taper off the methadone program. This can be for a variety of reasons and pharmacists should take this opportunity to discuss the patient s treatment with them. A pharmacist can play an important role in helping patients manage side effects, etc. The pharmacist should counsel the patient on the risk of relapse of opioid use and encourage the patient to have prevention strategies in place. The rate of taper is usually 5-10% of the current dose every one to two weeks. Once the patient reaches 20 mg/day the taper should be slower as withdrawal effects become more pronounced. Many patients can only tolerate decreases of 1 to 2 mg every one to two weeks at this point. Patients should be monitored for signs of withdrawal and the taper should be reversed or held if cravings become too intense. Split Dosing Methadone prescribing may authorize split doses for various reasons. A very small proportion of patients may metabolize methadone rapidly and some patients may be better able to tolerate the side effects of the methadone if their dose is divided. The metabolism of methadone changes in pregnant women and some may require split doses during the latter half of their pregnancy. Authorized split doses for patients who must have every dose witnessed require the patient to attend the pharmacy in the morning for a portion of their dose and again in the evening for the remainder. Pharmacists may not dispense a carry of the remainder of the patient s daily dose unless specifically directed to do so by the prescriber in writing. If a patient requests or appears to require split dosing contact the prescriber for authorization. 15
16 Pregnancy MMT is generally considered the standard of care for pregnant women with an opioid addiction. vi Opioid use disorder is dangerous for the fetus and is associated with increased risk of low birth weight, prematurity, neonatal withdrawal and sudden infant death syndrome. Opioid addiction affects fetal health primarily through effects of variable opioid withdrawal which is associated with fetal compromise and stillbirth. vii Conversely, MMT is associated with increased birth weight, decreased infant mortality and increased gestational age. The goal of MMT is to use the dose of methadone that will keep the patient comfortable and abstinent from illicit opioids. The patient should be maintained on methadone for the duration of her pregnancy and for several months post-partum. As metabolism changes during pregnancy the patient should be monitored for sudden increased requirements of methadone (10-20 mg) or the need to split the dosing. Pharmacists can play an important role in determining when the patient needs a dosing change as they will follow the patient on a daily basis. Adjustment of the dose post-partum will likely be required. Pharmacists can also guide the patient in making health lifestyle changes during this period and recommending additional resources to the patient when appropriate/necessary. Pregnant women should not miss a dose of methadone. The withdrawal symptoms associated with missing a dose may cause fetal distress. If the woman is feeling nauseous recommend that she sip the methadone slowly as this may prevent emesis of the dose. In some situations, it may be advisable to have the women remain in the pharmacy until the dose is absorbed. If emesis occurs during this period, then you can accurately assess what portion of the dose should be replaced. The prescriber should be contacted immediately and a replacement dose ordered. Methadone crosses the placental barrier and, therefore, the newborn should be monitored closely for signs of neonatal abstinence syndrome and treated with medical care. Breast Feeding Methadone is considered compatible with breast feeding according the American Pediatric Society. However, since methadone is present in the breast milk it is important that the patient and their prescriber discuss the risks and benefits of breastfeeding while being maintained on methadone. It is important to note that methadone in the breast milk will not necessarily prevent symptoms of neonatal abstinence syndrome. Incarceration The provision of methadone in correctional facilities provides for continuation of the harm reduction philosophy. An important goal is to prevent transmission of blood borne pathogens such as HIV and HCV. Injection drug use is known to be high among inmate populations and therefore it is believed that MMT can help prevent the spread of HIV and HCV. The National Task Force on HIV, AIDS, and Injection Drug Use recommended the following: Continuation of methadone in patients previously stabilized on methadone prior to incarceration. Make MMT available to those inmates who are in opioid withdrawal. Evaluate the need for MMT prior to release and ensure transfer to an appropriate community program upon release. If your pharmacy is providing methadone to a correctional facility you must ensure that the patients are receiving the correct dose. If the patient has been stabilized on methadone prior to incarceration you must contact the dispensing pharmacy to verify the date, time and dose of the last drink. If a patient has been diverting his/her methadone, giving the usual prescribed dose in the correctional facility can result in sedation or death. Methadone should be dispensed with a tamper proof seal prior to being delivered to the correctional facility. 16
17 Treatment of Acute Pain Methadone is non-analgesic in a person stabilized on MMT. A common misconception among health care professionals is that if a person is on methadone then they do not need to be treated for their pain. Unfortunately, due to the stigma associated with drug addiction many of these patients are managed inappropriately when they present with acute pain. As many of these patients will have a history of drug seeking behavior, the problems in assessing and treating pain in somebody who is methadone maintained are at least threefold: 1. The objective assessment of a subjective phenomenon (pain). 2. The question whether the pain presentation of the patient suffering from opiate dependence is in fact drug seeking or a genuine request for relief of real pain. 3. The appropriate dose of opiate or other analgesics or adjuncts in a methadone maintained patient. The first and second problems are best dealt with by a thorough and objective assessment of the presenting illness and its correlated pain. This is a matter of clinical judgement and includes making one s best estimate as to the appropriate treatment for similar causes of pain in other patients. For mild to moderate pain, recommend the use of NSAIDs and acetaminophen as first line therapy. These should be prescribed in the usual dosages and frequency. For more severe pain, patients should be initiated on opioid analgesics (morphine, oxycodone, hydromorphone, or codeine) in doses similar to those used for other people with similar pain. Monitor the patient s pain level and adjust the dosing accordingly. Patients stabilized on MMT (greater than 3 months) will likely require higher doses (10-50%) and more frequent dosing of short acting opioids. The patient should be maintained on their usual MMT dose while being treated for acute pain. Ideally discussion should occur between any practitioner prescribing a new opioid for these patients and the methadone prescriber. In addition, the pharmacist should consider notifying the methadone prescriber if a patient receives a new prescription for a benzodiazipine or opioid from another practitioner. Pentazocine, nalbuphine, and buprenorphine are partial opiate antagonists and should not be administered to MMT patients as they will cause severe opiate withdrawal. Overdose Methadone overdose is a medical emergency as is any other opioid overdose. Methadone overdose is characterized by extreme sedation, stupor or coma, respiratory depression, bradycardia and hypotension. Naloxone, an opioid antagonist, is used to treat methadone overdose. The difficulty in treating a methadone overdose is the exceptionally long half life of methadone. A naloxone infusion should be considered over repeated bolus dosing. Naloxone should be administered for a minimum of 24 hours (up to several days) followed by at least 12 hours of monitoring after the infusion is stopped. Naloxone competitively inhibits methadone at the opioid receptor thus the infusion is required until sufficient time has passed that the patient s own metabolism has cleared the methadone out of his/her system. Care should be taken to titrate the naloxone slowly so as not to precipitate severe withdrawal in the patient. Diversion Diversion of take home doses of methadone can have fatal consequences if taken by a person naïve to methadone. In most cases, methadone is diverted to friends and family who are experiencing opioid withdrawal but are not on the program, or sold for profit. It is also taken by some people for the psychoactive effects that can occur at doses higher than a person s tolerance. 17
18 Some tactics for preventing/minimizing diversion include: Having the patients return their empty carry bottles to the pharmacy. The bottles should be counted to ensure all the bottles are returned and none have been given away. Requiring the patient to present their remaining take-home doses to the pharmacy at random intervals. Educating the patient on the dangers of taking methadone if you have not developed a tolerance to it. Requiring the patients to present their lock box prior to dispensing take home doses for the first time. Storage in a locked box will prevent accidental ingestion by someone who may think it is simply juice (especially children). Methadone must always be dispensed directly to the person. Friends are not allowed to pick up someone else s methadone. Maintaining a sight line on the patient at all times when they are given their methadone to be ingested. Some patients may try to pocket their dose, or spit it into another container. Chronic Viral Infections and MMT Methadone is important from both an individual and public perspective with respect to HIV/AIDS and hepatitis C. As discussed earlier, methadone is a harm reduction strategy aimed at reducing the spread of diseases (including HIV/AIDS and hepatitis C) through needle sharing and prostitution. For the individual, methadone can help stabilize the patient and thus increase compliance with AIDS medications. Many AIDS medications interact with methadone but these interactions can generally be managed by monitoring for side effects and adjusting the dose accordingly. It is especially important to closely monitor patients when their medication or dose changes or is discontinued. The pharmacist can play an important role in encouraging compliance with these medications on a regular basis. Helping this patient population manage side effects is equally important and can have a huge impact on quality of life. Recommended Readings Pharmacists must have onsite or readily available references and treatment guidelines. Minimum requirements include the College of Pharmacists of Manitoba Principles for the Provision of Opioid Dependence Treatment by Manitoba Pharmacists and the College of Physicians and Surgeons of Manitoba Recommended Practices Manitoba Methadone and Buprenorphine Maintenance document. A list of additional resources can be found on the Centre for Addiction and Mental Health website at Other recommended readings include: Handford C. et al. Buprenorphine/naloxone for Opioid Dependence: Clinical Practice Guideline. Toronto: Centre for Addiction and Mental Health (CAMH), PDF pdf Isaac P. et al. Methadone Maintenance: A Pharmacist s Guide to Treatment, 2nd Edition. Toronto: Centre for Addiction and Mental Health (CAMH),
19 PART FOUR Implementing Opioid Dependence Treatment in Pharmacy Practice Methadone Including Methadone Maintenance Treatment (MMT) in your Pharmacy Practice A patient s success with opioid dependence treatment can be linked to the interactions they have with their health care providers. All members of the health care team should monitor the patients progress and recommend changes to their care as needed. Pharmacists must have a clear understanding of the goals of the program and a willingness to participate fully with other members of the health care team in order to contribute to their patients success. Pharmacists are in a unique position as they will see the patient more than any other member of the treatment team. These daily interactions allow the pharmacist to monitor their patients progress and identify actual and potential drug related problems. Community considerations and workflow By including methadone in your pharmacy practice you are providing an important service to your patients and your community. You might choose to provide methadone to a small number of patients, perhaps beginning with those who are already patients of your pharmacy. A confidential area in the pharmacy for counselling and observation of ingestion is required. If you decide to make methadone a part of your practice, the community may notice the increased visibility of opioid addicts in the area. There are a number of steps you can take to proactively address and alleviate the community s concerns: Establish solid working relationships with the practitioners/clinics who prescribe methadone for your patients. Ensure they realize you will be an active participant in your patient s care, and that you will be communicating frequently with the prescriber if the patient is having difficulty on the program. Consider meeting with the community police office to let them know that you will be involved in the methadone program. Ensure that they realize that there are benefits to the community in helping opioid addicted patients obtain methadone maintenance treatment. Ensure that your patients realize their responsibility to the community. Although their primary concern will be obtaining methadone on a regular basis, they must be informed that the program can only operate effectively if they respect the surrounding businesses and homes as well as other patients. This can be enhanced by ensuring agreements highlight behavior both inside and outside the pharmacy. Ensure that drinking cups used for methadone dispensing do not leave the pharmacy. Monitor the area outside your pharmacy to ensure it is clean and free of drinking cups and methadone carry bottles. If methadone becomes a major focus of your practice, careful planning and diligence will be required to avoid patient line-ups and patient loitering. Line-ups are not acceptable to the surrounding neighborhood and can focus undue attention to the program. Strategies to reduce line-ups of patients outside your pharmacy include: Establish a regular opening time, and stick to it. Do not open the pharmacy a few minutes early because you happen to be in early. If patients begin to arrive early, let them know that they must not loiter in front of the pharmacy before opening. Ensure that your waiting area is large enough to accommodate the number of clients you have. Consider establishing appointments for your patients on methadone. For example, you may want to schedule half of your patients to attend the pharmacy in the morning and the other half to attend in the afternoon. 19
20 Policy and Procedure Manual A site specific Policy and Procedures Manual should be readily available onsite when methadone is dispensed for harm reduction and management of pain. Education and Training Pharmacists must be knowledgeable in all pertinent aspects of methadone use when involved in care with methadone in order to prevent errors and close calls. Section 18 of the Pharmaceutical Regulation states that a member may only engage in the aspects of pharmacy practice that he or she has the requisite knowledge, skill and judgment to provide or perform and that are appropriate to his or her area of practice. At least one pharmacist must be extensively knowledgeable at each pharmacy that provides methadone and the expectation is that one of the opioid dependence treatment courses listed below will be successfully completed within 6 months of initiating care. Successful completion of one of these courses would demonstrate compliance with Section 18 of the Regulation with respect to MMT. An exception to this rule would be for a pharmacy that must provide methadone for continuation of care. In this situation the pharmacy would have a 6 month grace period to allow a pharmacist to take one of the required courses. In the interim any pharmacy dispensing methadone waiting for specialized training must have a trained/knowledgeable pharmacist functioning as a mentor who may be at another pharmacy. Contact CPhM for assistance in finding a mentor. Several specialized training programs are available to pharmacists. The Principles for the Provision of Opioid Dependence Treatment by Manitoba Pharmacists Certificate Program is offered by the CPhM periodically throughout the year and also briefly reviews treatment with buprenorphine/naloxone. This program involves reading the guidelines, Principles for the Provision of Opioid Dependence Treatment by Manitoba Pharmacists, watching (or have previously attended) the University of Manitoba, Office of Continuing Professional Development DVD Methadone An Introduction to Clinical Practice (this resource can be borrowed by contacting the CPhM office), and attending a full day, live workshop. The Centre for Addiction and Mental Health (CAMH) in Toronto and the College of Physicians and Surgeons of B.C. both offer methadone training programs to pharmacists. The CAMH courses are available partially online and in person and more information can be found at Please contact the CPhM office if you are wondering if a similar course would meet the training requirement for providing opioid dependence treatment in your practice. Pharmacists should also be familiar with the College of Physicians and Surgeons of Manitoba Recommended Practices Manitoba Methadone and Buprenorphine Maintenance document. This document is currently being developed. Pharmacist - Practitioner Communication The methadone prescriber/patient/pharmacist will enter into a common care plan with the rights, obligations, conditions and consequences agreed upon. Pharmacists who participate in the methadone maintenance program interact with most of their patients on a daily basis. Even those patients with carry privileges see their dispensing pharmacist more often than any other health professional, including their physician or methadone prescriber. In order to ensure that the prescriber is making therapeutic decisions based on reliable information from and about the patient, you must inform the prescriber if you have concerns about the patient s progress or success with the program. Contacting the prescriber regarding your concerns is essential for patient care. There are several situations that should be reported to the prescriber /clinic. The following are examples of reportable situations: If a patient exhibits unusual behavior If a patient has not picked up their daily dose If a patient refuses all or a portion of their daily dose If a patient appears to be impaired or intoxicated when they arrive at the pharmacy 20
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text:
Connecticut Archives and Libraries
The following archives, libraries, and societies have major collections or services helpful to genealogical researchers.
Connecticut State Library
231 Capitol Avenue
Hartford, CT 06106
Telephone: 860-566-4301
Fax: 860-566-8940
Internet: http://www.cslib.org/
A helpful inventory of this library is Connecticut State Library, Guide to Archives in the Connecticut State Library, Third Edition. (Hartford, Connecticut: Connecticut State Library, 1981; FHL book 974.6 A1 No. 30).
National Archives—Northeast Region (Boston)
380 Trapelo Road
Waltham, MA 02154
Telephone: 617-647-8100
Fax: 617-647-8460
Internet: http://www.archives.gov/northeast/boston/
Connecticut Society of Genealogists, Inc.
P.O. Box 435
2106 Main Street
Glastonbury, CT 06033-0435
Telephone: 860-569-0002
Internet: http://csginc.org/
Connecticut Historical Society
1 Elizabeth Street
Hartford, CT 06105
Telephone: 860-236-5621
Fax: 860-236-2664
Internet: http://www.chs.org/
New England Historic Genealogical Society
101 Newbury Street
Boston, MA 02116-3007
Telephone: 617-536-5740
Fax: 617-536-7307
Internet: http://www.newenglandancestors.org/
Connecticut Ancestry Society
P.O. Box 249
Stamford, CT 06904-0249
Internet: http://www.rootsweb.com/~ctcas/
Overview of Connecticut genealoigcal Resources
A useful guide to the published and original genealogical
records of Connecticut is Connecticut Researcher's Handbook'''''''''by Thomas Jay Kemp (Detroit, MI: Gale, 1981. 755p.). (FHL book 974.6 D23k).
Computer Networks and Bulletin Boards
Computers with modems can be useful tools for obtaining information from selected archives and libraries. In a way, computer networks themselves serve as a library. The Internet, certain computer bulletin boards, and commercial on-line services help family history researchers:
- Locate other researchers
- Post queries
- Send and receive e-mail
- Search large databases
- Search computer libraries
- Join in computer chat and lecture sessions
You can find computerized research tips and information about ancestors from Connecticut in a variety of sources at local, state, national, and international levels. The list of sources is growing rapidly. Most of the information is available at no cost.
Addresses on the Internet change frequently. As of April 1997, the following sites are important gateways linking you to many more network and bulletin board sites:
A cooperative effort by many volunteers to list genealogical databases, libraries, bulletin boards, and other resources available on the Internet for each county, state, and country.
A useful list of sites and resources. Includes a large, regularly-updated research coordination list.
For further details about using computer networks, bulletin boards, and news groups for family history research, see the United States Research Outline (30972), 2nd ed., "Archives and Libraries" section.
The Family History Library and Family History Centers have computers with FamilySearch™. FamilySearch is a collection of computer files containing several million names. FamilySearch is a good place to begin your research. Some of the records come from compiled sources; some have been automated from original sources.

subset: commoncrawl


text:
Over the past several days, severe flooding has occurred in PremNagar as well as other villages along the Karnali River. Over 20 people have died and others are missing as homes collapsed or were swept away in the flood waters. PremNagar School is currently a flood shelter for many families who have fled their homes. The Tikpaur Church is organizing a relief effort to deliver food, water and medicine to the flood victims. Please pray for the hundreds of people effected by these floods. If you would like to contribute to the flood relief effort, you can give online by clicking here. Thank you for supporting the people of Far West Nepal during this difficult time.
|PremNagar School has become a flood shelter


text:
Next year is going to be hard. Really hard. I don't know how Emmi is going to make it without her current teacher. She has had her for the past three school years, and she loves her. When she gets hurt, sometimes her name gets called before "Mommy!" Spring Break has been horrendous, because Emmi has asked for her teacher everyday. And? Apparently, her teacher ranks among the greats such as Santa Claus...
Sunday, March 22, 2009
2 comments:
- Sheri said...
- March 22, 2009 at 7:31 AM
- Linda said...
Yes, not having Lisa Moore as her teacher is going to be tough on Emmi. (Hope I've got her name right: you know how I am with names.) Let's just hope she loves her next teacher as much as she does this one.
- March 22, 2009 at 12:59 PM
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text:
Effect of Grain Size on Sediment Transport Calculationsby Daniel Gessler, Colorado State Univ, Fort Collins, United States,
Chester C. Watson, Colorado State Univ, Fort Collins, United States,
Nolan Raphelt, Colorado State Univ, Fort Collins, United States,
Document Type: Proceeding Paper
Part of: Hydraulic Engineering
The U.S. Army Corps of Engineers is currently developing a `Hydraulic Design Package for Flood Control Channels' (SAM). SAM is capable of computing sediment rating curves and stable channel dimensions. The program requires input regarding channel geometry, discharge, and grain size distribution. The analysis of sediment samples collected in mixed bed streams indicated that the median grain size, D50, varied up to 1.5 orders of magnitude for different samples collected in the same channel. This high degree of variability resulted in the need to ascertain the sensitivity of the SAM program to variations in the input grain size distribution. The analysis was performed on a representative trapezoidal channel, with typical unit discharge for nine different grain size distributions.
Subject Headings: Sediment transport | Grain (material) | Sediment | Water discharge | Sensitivity analysis | Particle size distribution | Fluid flow | Computer software
Services: Buy this book/Buy this article
Return to search


text:
Hello, goeie dag, molo, dumelang, awé, Asalamu Alaikum, sawubona, Shalom
Welcome to Mel's Postbox!
I am Melissa Javan, creator of Mel's Postbox. For those of you who know me, I previously did my blogging at www.melissanel.wordpress.com. Alhoewel ek begin blog het in Engels, skryf ek sedert September 2018 in Afrikaans hier.
THE AIM of my blog is to share inspirational stories of my journey and others who are on a path to live intentionally. I'll share how I realised that in order for me to teach my child she can do anything she dreams of, I too have to try to reach my goals and live my dreams.
One of my goals is to be debt-free, so I intend to learn as much as I can about saving- and investing money. I've started a "Money Mistakes" series where myself and others share bad financial decisions we've made. We're still learning!
I also give lessons relating to Writing Like A Journalist and entrepreneurship. I'm working on my first novel – so look out for lessons relating to it.
I WANT TO help people to create better content for their websites, social media platforms or newsletters. I CAN help you write your good stories.
Married Javan, I am a South African journalist and content producer by profession. I became a journalist, because of my love for storytelling.
So far IT'S BEEN AN INCREDIBLE JOURNEY. I started blogging in 2011 while reporting on the 17th United Nations Framework Convention on Climate Change (COP17) event in Durban. I was working for an independent grassroots newspaper, Cape Flats News then. While on my journey as a blogger, I encouraged some of my female media friends to join me, to give people insight into our careers and thoughts in general.
I stopped blogging after I moved to a new province and job in Port Elizabeth. I started taking blogging seriously in July 2016.
Anyway, I am also the mamma of a two-year-old daughter and stepmom to a beautiful, talented chef, who is in her early 20s. My husband, Leslie, is a music composer. He will definitely share some of his gems on this site!
I speak a little South African – my mother tongue is Afrikaans and I am surrounded daily by friends and colleagues who speak isiXhosa and Setswana.
I HOPE TO inspire you, or make you laugh – while you read about my (and others') journey. Hopefully, by end of 2017, I will be a published author 🙂
Thank you for visiting my site.
Melissa Javan
PS Connect with me via email email@example.com
or Twitter @melissa_nel.


text:
Looking for a way to use up that random pork loin and frozen pesto ice cubes you've had in your freezer? Looking for an excuse to buy a bunch of peaches? No? Just me? Well, this is a pretty tasty complete meal anyhow, and it's a nice opportunity to use the grill outside rather than heating up your whole house with the oven/stove.
(Adapted from Eating Well, July/August 2015 Issue)
Total Time: 35 Mins
Serves: 4 (2 pinwheels, 2 peach wedges each)
Six 12 inch skewers
3/4 cup coarse fresh breadcrumbs
1/2 cup prepared pesto (I used my mustard green pesto I saved in ice cubes)
1 Tb extra virgin olive oil
1 Tb balsamic vinegar
1/4 tsp ground pepper
1/8 tsp salt
1 lb pork tenderloin, trimmed
2 large peaches, quartered
1.) Preheat grill to medium.
2.) Combine breadcrumbs and pesto in a small bowl. (If you use pesto ice cubes, melt them with a quick 30 seconds in your microwave.) Combine oil, vinegar, pepper in another bowl, set aside.
3.) Lay pork on a large cutting board. Hold the knife blade parallel to the board, make a lengthwise cut through the center of the meat, but not all the way through so it stays in one piece. Fold open the meat so it lays flat, cut side up. Cover it with plastic wrap and pound flat with a rolling pin until it's about 1/4 inch thick across. Lay it so one of the length of the original pork loin is in front of you. Spread the breadcrumb mixture over the pork, stopping 1 inch from the opposite long side. Starting at the side closest to you, roll up the pork. Brush top with 1 tablespoon of the oil mixture.
4.) Toss the peaches with the leftover oil mixture.
5.) Slice the pork crosswise into 8 pinwheel slices. Put 2 pinwheels each on 4 of the 6 skewers. Make sure pinwheels are 1 inch apart, threading skewers through the meat to keep the pinwheel shape intact. Be sure to put smaller pinwheels on the same skewers, so the cooking time will be equal.
6.) Slide peaches length-wise on the 2 remaining skewers to ensure skewers go through the skin.
6.) Oil the grill rack by oiling a paper towel and rubbing it over the grill rack. Place all skewers on the grill, flat side down. Grill turning once until the peaches are soft and the pork is 145 degrees. The original recipe says this will be 3-5 minutes for the peaches, 8-10 minutes for the pork, however a few of my larger pork pinwheels took longer, so keep an eye on them.
Nutrition: 389 Cal; 21 g Fat (sat 5 g); 70 mg Chol; 19 g Carbs; 30 g Protein; 3 g Fiber; 435 mg Sodium
Weight Watchers Points: 10


text:
Amana's ACE19V is a high-speed oven that allows you to cook food in quarter-size trays faster than is possible in a conventional oven, using fully-programmable combinations of convection and microwave heat in 11 power levels. This model can hold up to 100 menu options, each of which can have up to four cooking stages. Updating those menu options is made simple with the USB drive that is compatible with standard flash drives.
Product Details
- Part of the Amana Convection Express series
- High-speed combination oven uses convection and microwaves to cook food faster than a conventional oven
- Temperature range of 150 to 475 degrees F can be set in in 5 degree increments
- Able to use 1⁄4-size metal trays, pans, and screens, so no specialty pieces are needed
- Able to store up to 100 menu options
- USB port for easy menu updates with standard flash drives
- Up to four stages of cooking can be used for each menu option, with 11 power levels to choose from
- Operated by touchpad controls that also have braille labels for ADA compliance
- Door opens to 90 degrees for complete access to interior
- Air filter is removable from the front of the unit, and the oven reminds you when filter cleaning is needed
- Backlit LCD display is easy to read
- Includes 1 rack, adjustable to 2 positions so you can find the best position for each recipe
- Stainless steel interior is easy to clean
- Exterior is powder-coat painted for durability
- Units are stackable, so you can maximize the use of the unit's footprint
- 208-240 V/60 Hz/1-ph, 1900W, 5-ft. cord and NEMA 6-30 plug included
- Cavity Dimensions: 13 in. W x 15 in. D x 101⁄2 in. H
- Overall Dimensions: 191⁄4 in. W x 261⁄2 in. D x 181⁄8 in. H
- cETLus, ETL Listed
Amana® Commercial Convection Xpress™ Combination Oven, 1.2 cu. ft. capacity, 2700 watts convection , 1900 watts microwave, 150°F to 475°F (70°C-250°C) temperature range, stackable, programmable timer, 4-stage, 100 memory settings, side hinged door, stainless steel interior, black powder coated exterior, catalytic converter filters grease laden air & vapors-UL-KNLZ certified for ventless operation, 5' cord, NEMA 6-30P, 30 amps, 20 MCA, 208-240v/60/1-ph, 5300 total watts, 3 year limited warranty
*The warranty will not be honored for residential or non-commercial use of any Commercial Equipment.
Important Prop 65 information for California residents.
Amana ACE19V SpecificationsPDF Spec Sheet
|Also Known As
|Menumaster JET19
|Max Pan Size
|Door Type
|Usage Level
|Heavy Duty
|Product Type
|Countertop Cooking Equipment
|Convection Oven


text: Hi Andrew > I am the author of Shipment - https://metacpan.org/module/Shipment - > which was designed to integrate into our current Interchange 5 setup, > but also to be useful outside of that. > > I would love to see it become a part of Interchange 6 if that is > something the community wants. I would also be open to doing a > presentation at the next conference. I don't know about IC6, but I do have a couple of questions about Shipment - How come there's no DHL module? - How easy would it be to plug into a local postal service provider? In Denmark it looks like it's EDI / EDIFACT, and I guess that would be the case in more countries (?)


text:
Will these Preamps work with your Bass? Ask Frankie, our Bass Tech.
Best Bass Gear is proud to be able to offer you a wide array of onboard preamps for your EQ and tone shaping needs. We offer systems custom prewired in house and also wired by the manufacturer with a large selection of control configurations for almost any bass.We stock only the highest quality manufacturers including ACG, Aguilar, Bartolini, Glockenklang, John East, Mike Pope, Nordstrand, and Seymour Duncan.
Lakland LH3 2-Pickup 5-Knob 1-Switch 3-Band Vol P/P A/P - Bl - Treb - Bass - Mid - Coil Sel. Sw$182.403-Band: 2-Pickup, 5-Knob, 1-Switch VPP A/P - Bl - Treb - Bass - Mid - Coil Sel. Switch
Control Configuration Volume Active/Passive Push/Pull Blend Treble Mid Bass Coil Selector Switch(Bridge Pickup) Working in conjunction with Lakland Bass Guitars in Chicago, Hanson...


text:
A teenage boy was involved in a joyride in Lytham where thousands of pounds worth of damage was caused to cars and property.
The 16-year-old Lytham boy was with two other teenagers when his mother's car was taken.
I then got in the car and it hit the Mercedes and the garage
The defendant, whose identity can not be revealed for legal reasons, pleaded guilty to the aggravated taking of his mum's car.
Philip Hall, prosecuting, said the boy's mother's car was taken from her home on July 7 at 7.30pm.
It was driven around Lytham, colliding with a Mercedes, a Range Rover, a Renault Megane and a garage, causing thousands of pounds of damage.
A witness, at one point, saw a teenage boy running alongside the car which had been taken, trying to get in the vehicle.
The prosecutor said the prosecution could not prove who had been driving the car.
Suzanne Mugford, defending, said the defendant, who had no previous convictions, had learning difficulties .
The boy told the judge he was not originally involved in taking the car.
He said he was not in the car at first when it was driven into the car park of a block of flats, where it crashed into the Range Rover and the Megane.
The boy added: "I was trying to stop what was going on.
"I then got in the car and it hit the Mercedes and the garage."
He was sentenced to a six-month referral order, banned from driving for 12 months and ordered to pay £85 costs with £15 victims' surcharge by District Judge Jeff Brailsford, sitting at Blackpool Youth Court.
The boy's mother, who wept throughout the hearing, was told by the judge that he would have to make the order – to pay the financial penalties involved in the case – against her as her son had no income.
The judge added that he hoped the mother would get her son to pay her back in some way.


text:
Our Experience
If you are starting up a new entity or your company is ready for second-stage growth, you don't need to do it alone. Gray, Gray & Gray can provide the support and guidance of professionals with industry-specific experience and knowledge of finance, management and systems, licensing, strategic alliances, mergers & acquisitions, tax, accounting, and real estate. Because of the depth of talent and level of experience within our firm, we are fully prepared to assist you in successfully managing the profitable growth of your business.


text:
Upon completion of this course, participants will be able to: 1) Plan and perform a comprehensive evaluation for a patient with a neuromuscular diagnosis. 2) Apply appropriate standardized tests for patients with neuromuscular disorders. 3) Apply motor learning and motor control principles as they relate to patients with neuromuscular diagnoses. 4) Identify current research trends in neuromuscular rehabilitation. 5) Identify common impairments associated with neuromuscular diagnoses. 6) Develop treatment strategies for improving neurological impairments. 7) Explain functional deficits occurring in the patient with neuromuscular diagnoses. 8) Develop treatment strategies for treating functional deficits and making functional progress. 9) Describe basic principles of orthotic intervention. 10) Describe the basic principles of providing seating and mobility devices. 11) Document functional goals and functional progression in neuromuscular rehabilitation.
Physical and Occupational Therapists and Assistants
Customer Service
Cvent Online Event Registration Software | Copyright © 2000-2018 Cvent, Inc. All rights reserved.


text:
Family Law | Business Law | Personal Injury
The attorneys at Lancaster and St. Louis are different than most attorneys — and we like it that way. Since our founding, we have been striving to provide a fresh approach to legal representation in Cabarrus County and the surrounding areas.
What does a fresh approach to legal representation mean? We implement practices that put clients at ease. We tailor our legal services to meet our clients' individualized needs. Whether through flexible scheduling or direct access and communication with our attorneys, we are focused on providing the superior support and service our clients deserve.
A Comprehensive Family Law Practice
We represent clients in a wide range of family law matters, including divorce, custody and visitation, separation agreements, child support, equitable division of property, prenuptial agreements and post-decree modifications. Additionally, our firm can represent clients seeking stepparent or agency adoption. Visit our family law overview for a more comprehensive listing of our family law services.
Serving Individuals And Local Business Owners
We are also pleased to assist clients in business law and personal injury matters. We work diligently to provide each of our clients with quality legal representation and superior service. You will have a strong advocate on your side at Lancaster and St. Louis.
Discuss Your Case With Experienced Attorneys
With an office in Concord, North Carolina, we serve clients throughout Cabarrus County, the Charlotte metro area and the surrounding areas. To schedule a consultation with one of our lawyers at Lancaster and St. Louis, call 704-743-4204 or contact us by email.