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Supervised administration of injectable ‘medical’ grade heroin (diamorphine) leads to larger reductions in street heroin use in chronic heroin addicts who are failing in conventional treatment, than does either supervised injectable methadone or optimised oral methadone. The findings of the Randomised Injectable Opiate Treatment Trial (RIOTT) trial are reported in an article in the Lancet, written by Professor John Strang and colleagues from the  National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience (IoPPN) at King’s.

At least 5–10 per cent 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 and Darlington).

Lower use of street heroin

The researchers found that at 26 weeks, 80 per cent of patients remained in assigned treatment - 88 per cent on supervised injectable heroin, 81 per cent on supervised injectable methadone and 69 per cent on optimised oral methadone. Proportions of patients achieving 50 per cent or more negative samples for street heroin were highest in the injectable heroin group (66 per cent) followed by injectable methadone (30 per cent) and oral methadone (19 per cent). The measure of measurable improvement, the pre-selected primary outcome, was that, through months 4-6, at least 50 per cent 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 six 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 six weeks. Our work offers government robust evidence to support the expansion of this treatment, so that more patients can benefit.'

Click here to watch Professor Strang discussing the RIOTT study.



  • Strang J, Groshkova T, Uchtenhagen A, van den Brink W, Haasen C, Schechter M T, Lintzeris N, Bell J, Pirona A, Oviedo-Joekes E, Simon R & Metrebian N. Heroin on trial: Systematic review and meta-analysis of randomised trials of diamorphine prescribing as treatment for refractory heroin addiction. The British Journal of Psychiatry 2015: 207, 5-14.
  • Metrebian, N Groshkova, T, Hellier J, Charles V, Martin A, Forzisi L, Lintzeris N, Zador D, Williams H, Carnwath T, Mayet S and Strang J. Drug Use, health and social outcomes of hard to treat heroin addicts receiving supervised injectable opiate treatment: secondary outcomes from the Randomised Injectable Opioid Treatment Trial (RIOTT). Addiction 2014; 10.1111/add.12748
  • Byford S, Barrett B, Metrebian N, Groshkova T, Cary M, Charles V, Lintzeris N, Strang J. Correspondence. The British Journal of Psychiatry 2014; 204,3, p241-242
  • Strang J, Groshkova T and Metrebian N. New Heroin-Assisted Treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond. EMCDDA Insight series 11
  • Groshkova, T; Metrebian, N; Hallam, C; Charles, V; Martin, A, Forzisi, L; Lintzeris, N and Strang J. Treatment expectations and satisfaction of treatment-refractory opioid-dependent patients in RIOTT, the Randomised Injectable Opiate Treatment Trial, the UK’s first supervised injectable maintenance clinics. Drug and Alcohol Review 2013; 32, 566-573
  • Byford S, Barrett B, Metrebian N, Groshkova T, Cary M, Charles V, Lintzeris N and Strang J. Cost-effectiveness of injectable opioid treatment v. oral methadone for chronic heroin addiction. The British Journal of Psychiatry 2013; 203:341-349.
  • Strang J, Metrebian N, Lintzeris N, et al (2010) 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. Lancet 375: 1885-95
  • Miller P, Forzisi L, Lintzeris N, Zador D, Metrebian N, Strang J. (2009) Groin Injecting in Injectable Opioid Treatment Service Users in South London Addiction Research and Theory2009; 17(4):381-389..
  • Zador D, Lintzeris N, van der Waal R, Miller P, Metrebian N, Strang J. (2008) The fine line between harm reduction and harm production – development of a clinical policy on femoral (groin) injecting European Addiction Research Journal; 14; 213-218
  • Lintzeris N, Strang J, Metrebian N, Byford S, Hallam C, Lee S and RIOTT Group. (2006) Methodology for the Randomised Injecting Opioid Treatment Trial (RIOTT): evaluating injectable methadone and heroin treatment versus optimised oral methadone treatment in the UK. Harm Reduction Journal 2006, 3:28
For further details, please contact Dr Nicola Metrebian
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