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 do either injectable or oral methadone. The findings of the RIOTT* trial are reported in an Article in this week's Lancet, written by Professor John Strang, National Addiction Centre**, Institute of Psychiatry, King's College London, UK, and colleagues.
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. However, 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.
In this randomised controlled trial, chronic heroin addicts who were receiving conventional oral treatment (≥26 weeks), but continued to inject street heroin regularly (≥50% days in preceding 13 weeks) were enrolled. Patients were assigned to receive supervised injectable methadone*** (42 patients), supervised injectable heroin (43), or optimised oral methadone (42). Treatment was provided for 26 weeks in three National Health Service (NHS) supervised injecting clinics in England (London, Brighton, Darlington). Primary outcome was 50% or more negative specimens for street heroin on weekly random urine analysis during weeks 14-26.
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 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 adds****: "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."
In an accompanying Comment, Dr Thomas Kerr, Julio S G Montaner, Evan Wood, all of the Urban Health Research Initiative, at British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, and University of British Columbia, Vancouver, BC, Canada, say: "History tells us that availability of heroin prescription can be dictated more by special interests and politics than evidence." They detail various scenarios in Australia, Switzerland and other countries where heroin trials have been halted or existing heroin support programmes have been placed under threat.
They conclude: "This state of affairs is sad because other medical specialties commonly embrace second-line therapies, even if only for a selected group who fail first-line treatments. In the era of evidence-based decision making, moving forward will probably need those embroiled in this debate to cast aside the stigma associated with heroin prescription, and recognise that the drug was once a pharmaceutical product with physiological and chemical properties similar to other opioids that are in common clinical use. The existing interference and non-evidence-based opposition from politicians and care providers, who refuse to acknowledge the limitations of methadone maintenance and the superiority of prescribed heroin in selected populations, is arguably unethical. Denying effective second-line therapy to those in need ultimately serves to condemn many users of illicit heroin to the all too common outcomes of untreated heroin addiction, including HIV infection or death from overdose."
For Professor John Strang, Head, National Addiction Centre, Institute of Psychiatry, King's College London, UK, contact Louise Pratt T) +44 (0) 20 7848 5378 / +44 (0) 7966 265084 E) louise.a.pratt@kcl.ac.uk; or Dan Charlton or Lorcan O'Neill, South London and Maudsley NHS Foundation Trust, UK. T) +44 (0) 20 3228 2830 E) dan.charlton@slam.nhs.uk / lorcan.oneill@slam.nhs.uk
Dr Thomas Kerr, Urban Health Research Initiative, at British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, and University of British Columbia, Vancouver, BC, Canada. T) +1-604-314-7817 E) uhri@cfenet.ubc.ca
For full Article and Comment see: http://press.thelancet.com/riott.pdf
Notes to editors: *RIOTT: Randomised Injectable Opiate Treatment Trial
** The National Addictions Centre is jointly run by the Institute of Psychiatry, King's College London and South London and Maudsley NHS Foundation Trust. 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 www.kingshealthpartners.org
***For details of the three treatment strategies, see panel page 1886 of full Article
****quote direct from Professor Strang and cannot be found in text of Article
Background: Supervised injecting clinics were established in England under the UK Government's Updated Drug Strategy (2002) which stated that "The administration of prescribed heroin for those with a clinical need will take place in safe, medically-supervised areas with clean needles. Strict and verifiable measures will be in place to ensure there is no risk of seepage into the wider community." A small number of similar clinics already operate in Switzerland, Netherlands, Germany, and Canada. Doctors in the UK have always been able to prescribe pharmaceutical heroin (diamorphine) in general medical practice (e.g. relief of severe pain, or other emergency care) and also in addiction treatment (although, since the late 1960s, the authority to prescribe pharmaceutical heroin for addiction treatment has been restricted to doctors with a special licence to prescribe - usually doctors specialising in the addictions treatment field).
Journal
The Lancet