Results of the Randomised Injectable Opioid Treatment Trial (RIOTT)
The most chronic heroin addicts in the UK can be treated successfully using a radical new treatment model, researchers at King’s Health Partners Academic Health Sciences Centre (AHSC) have found.
Participants in the trial - the first of its kind in the UK - were among the 5% of heroin users for whom treatment, rehabilitation and even prison have had little effect, often over many years of addiction. For these people, daily use of ’street heroin’ has been the norm, even while in conventional treatment.
The headline results from RIOTT are made public today (15 September 2009) at a conference at the Royal College of Physicians organised by the charity Action on Addiction.
RIOTT is the first randomised controlled trial in the UK to compare injectable opiate treatment (injectable methadone and injectable heroin) delivered in new medically supervised injecting clinics to optimised (high quality) oral methadone for severely entrenched and ‘hard to treat’ heroin addicts.
The RIOTT trial has been coordinated by the National Addiction Centre which was developed by the Institute of Psychiatry, Kings College London, and South London and Maudsley NHS Foundation Trust (SLaM). The research was funded by the Big Lottery through the charity Action on Addiction in partnership with the National Treatment Agency who have funded the supervised injecting clinics on behalf of the Government.
The RIOTT trial took chronic heroin addicts who, despite active treatment, were still continuing to inject heroin most virtually daily. These entrenched heroin addicts were then randomised to treatment with either supervised injectable heroin, supervised injectable methadone or optimised oral methadone.
Three supervised injecting clinics have been established in England in recent years and these are the sites for the trial , - in London (SLaM - established October 2005), Darlington (began September 2006) and Brighton (began September 07).
About the trial
This treatment was for a select group of heroin addicts
- entrenched heroin addicts who have repeatedly been found to fail to benefit from existing treatments
- existing clients who despite receiving oral methadone maintenance treatment were continuing to inject street heroin almost every day.
These supervised injecting clinics provide intensive treatment
- providing a prescription of injectable heroin and injectable methadone injected under strict medical supervision
- with a high level of psychological and social support to address health and life issues
- the trial compares injectable heroin and injectable methadone delivered in supervised injecting clinics with high quality conventional treatment (oral methadone)
Key findings
This trial shows that it is possible to engage and retain in treatment some of the most entrenched hard-to-treat heroin addicts for whom previous treatment, rehabilitation and prison appear to have had little beneficial impact. These are existing clients who despite receiving oral methadone maintenance treatment were continuing to inject street heroin almost every day:
- All groups achieved good retention
- Better retention in the injectable heroin group (88%) compared to 81% in the injectable methadone group and 69% in the oral methadone group
The trial has achieved very positive results in terms of the primary outcome measure - reduced use or abstinence from ’street’ heroin. There was a reduction in street heroin use amongst all 3 treatment groups at six months. The most pronounced reduction was seen in the injectable heroin group:
- Three quarters responded well by substantial reduction in the use of ’street’ heroin.
- Of these, three quarters (or around 60% of the total group) remained largely abstinent allowing for no more than two lapses in drug testing during a three month period.
- A quarter of those who reduced (almost 20% of the total group) were totally abstinent from street heroin. This is remarkable in a group for whom daily illicit use while in treatment was the norm.
For the injectable methadone and oral methadone groups, the achievements were much more modest. About a third were no longer using street heroin regularly, although very few of these were totally abstinent from street heroin.
There was an almost immediate benefit just 6 weeks into treatment and this benefit was maintained throughout the six-month period of study for each patient
The degree of effect of the treatment was greatest in the injectable heroin group, followed by injectable methadone and optimised oral methadone.
Optimised oral methadone showed greater success than predicted, perhaps due to the high intensity of engagement provided by regular attendance and psychosocial support. At the same time the injectable methadone group performed less well than predicted, though still with a positive effect.
The amount of money spent on street drugs reduced in all treatment groups.
The biggest reduction was seen in the heroin group.
- Clients were spending an average of just over £300 a week on drugs before entering RIOTT treatment (despite already being in active treatment) and this reduced to an average of just under £50 a week at 6 months.:
- This was as a result of (a) substantial numbers who became ‘crime-abstinent’, and also (b) substantial reduction in the extent of criminal activity of those who were still criminally involved.
- The total spending for the whole heroin group (approximately 40 people) translates as reducing from nearly £14,000 spent a week prior to entering RIOTT which then reduced to under £2,000 at 6 months.
Across the board there was a dramatic reduction in self-reported crime:
- Prior to entering RIOTT treatment over half of the clients in each treatment group were committing crime and were commiting a mean number of between 20-40 crimes in the past 30 days.
- At six months, the proportion committing crimes in each group more than halved and the mean number of crimes committed in the past 30 days reduced to between 4 -13 - less than a third of previous levels.
- The actual number of crimes committed drastically reduced by two thirds in each group. For example, those in the heroin group were committing a total of 1731 crimes in the 30 days prior to entering RIOTT treatment and after 6 months, this fell to 547 crimes (a reduction of 1,184 crimes per month).
Prior to entering RIOTT treatment, around three quarters of each group were using crack. It has been thought that crack use might increase amongst clients receiving injectable opiate treatment. wever, this was not the case and at 6 months the proportion using crack had reduced across all treatment groups as had the amount used.
These clients were existing service users and already receiving oral methadone treatment prior to entering RIOTT. Their levels of street heroin and crack use, money spent on drugs and criminal activity were occurring whilst receiving conventional treatment. It is all the more remarkable that such benefits have been made with the RIOTT treatment but in particular with injectable heroin.
There were improvement in physical, mental health and social functioning across all treatment groups over the 6 month period.
The cost of producing positive results in this ‘difficult to treat’ group is around £15k per patient per year. These are the most severe 5% of the heroin using population, many of whom are typically committing a high level of crime to fund their addiction. By comparison the typical cost of prison is £44k a year per person, not to mention many other costs to society.
