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Injectable 'medical' heroin leads to larger reductions in street heroin use than injectable or oral methadone (RIOTT trial)

28 May 2010

Supervised administration of injectable ‘medical’ grade heroin leads to larger reductions in street heroin use in chronic heroin addicts who are failing on treatment, than does either injectable or oral methadone. The findings of the Randomised Injectable Opiate Treatment Trial (RIOTT )  trial are reported in an article in this week’s Lancet, written by Professor John Strang and colleagues from the  National Addiction Centre, Institute of Psychiatry (IoP), King’s College London (KCL).

At least 5–10% of heroin addicts fail to benefit from established conventional treatments but whether they are untreatable or just difficult to treat is unknown. A scientific evidence base is emerging to support the effectiveness of maintenance treatment with directly supervised medicinal heroin (diamorphine or diacetylmorphine) as a second-line treatment for chronic heroin addiction.

This randomised controlled trial looked at chronic heroin addicts who were receiving conventional oral treatment but continued to inject street heroin regularly. Patients were assigned to receive supervised injectable methadone, supervised injectable heroin, or optimised oral methadone. Treatment was provided for 26 weeks in three National Health Service (NHS) supervised injecting clinics in England (London, Brighton, Darlington). During weeks 14–26 50% or more tested negative for street heroin on weekly random urine analysis.

The researchers found that at 26 weeks, 80% of patients remained in assigned treatment - 81% on supervised injectable methadone, 88% on supervised injectable heroin and 69% on optimised oral methadone. Proportions of patients achieving 50% or more negative samples for street heroin were highest in the injectable heroin group (66%) followed by injectable methadone (30%) and oral methadone (19%).  The measure of measurable improvement, the pre-selected primary outcome, was that through Months 4-6, at least 50% of randomly collected urines tested negative for street heroin (from weekly random urine analysis).  The authors report on 'abstinence from street heroin' also, and a similar greater benefit of the supervised heroin treatment was seen, compared with the other two treatments.

The authors say: 'We have shown that treatment with supervised injectable heroin leads to significantly lower use of street heroin than does supervised injectable methadone or optimised oral methadone. Furthermore, this difference was evident within the first 6 weeks of treatment.'

They conclude: 'Rolling out the prescription of injectable heroin and methadone to clients who do not respond to other forms of treatment’, is detailed in the UK Government’s 2008 Drug Strategy, subject to the results from this trial. In the past 15 years, six randomised trials have all reported benefits from treatment with injectable heroin compared with oral methadone. Supervised injectable heroin should now be provided, with close monitoring, for carefully selected chronic heroin addicts in the UK.'

Professor Strang said: 'Our scientific understanding about how to treat people with severe heroin addiction has taken an important step forward.  The RIOTT study shows that previously unresponsive patients can achieve major reductions in their use of street heroin and, impressively, these outcomes were seen within 6 weeks. Our work offers government robust evidence to support the expansion of this treatment, so that more patients can benefit.'

The National Addiction Centre is jointly run by the IoP KCL and South London and Maudsley NHS Foundation Trust (SLaM). Both are part of King's Health Partners, an Academic Health Sciences Centre (AHSC) for London, bringing together clinical and research expertise across both physical and mental health. For more information, visit   

The article ‘Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial’ can be found here, along with a podcast featuring Professor Strang discussing the trial. Professor Strang can be seen also on the new SLaM website talking about RIOTT:

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