RIOTT: 2 years on

1. Dr Nicola Metrebian, Dr Teodora Groshkova, Dr Nicholas Lintzeris, Dr James Bell, Dr Deborah Zador, Dr Tom Carnwath, Dr Soraya Mayet, Dr Hugh Williams, Mr Rob van der Waal & Prof John Strang Introduction The authors recently completed the RandomisedInjectable Opiate Treatment Trial (RIOTT ) examining the effectiveness of supervised injectable heroin (SIH) and supervised injectable methadone (SIM) versus optimised oral methadone (OOM) treatment for chronic heroin addicts failing in conventional drug treatment. One hundred and twenty-seven patients were randomly allocated to receive either SIM, SIH or OOM within new European style supervised injecting clinics and followed-up for 6 months. Findings show that, within 6 months, SIH treatment reduces street heroin use in these “hard-to-treat” heroin addicts (Strang, Metrebian & Lintzeris et al 2010). We now need to know the long-term trajectory of patients receiving this treatment in order to identify the longer term effectiveness and ultimate role of SIH within the UK. Previous trials of heroin treatment with extended follow-up conducted in Europe (Rehm et al 2001; Verthein et al 2008; Blanken et al 2009)) have found heroin treatment can be provided effectively on a long term basis. RIOTT trial patients have continued to receive SIH, if clinically appropriate, beyond the 6 month trial period. We have 2 year follow-up data on all of the 43 patients originally assigned to SIH. • Method • Trial patients continued to receive SIH if clinically appropriate in new supervised injecting clinics in south London, Darlington and Brighton. Patients were followed-up at baseline, six, and 24 months. We report on the 43 originally assigned to SIH. • Treatment outcomes measured included : retention in SIH, movement onto to oral substitute treatment (OST), frequency of injecting SIH and illicit heroin use (self report & urine drug screening). • Findings • Two year outcomes for those originally assigned to SIH: • 25 (58%) were still receiving SIH • 13 (30%) had switched to receive oral substitution treatment (OST) (methadone (11), buprenorphine (1) and sustained-release oral morphine (1)) • two had completed opiate detoxification (no longer receiving treatment) • two dead • one did not start SIH treatment. • Of the 25 still receiving SIH at 2 years: • 11 were receiving SIH injections twice a day • 14, were receiving SIH injections once a day • At 2 years, there was an increase in the numbers abstinent from street-heroin (defined as no self-reported street-heroin use in the 30 days prior to 2 years interview) : • Those receiving SIH injections twice a day (data available for 9/11) from zero at baseline, 56% at 6 months to 100% at 2 years. • Those receiving SIH injections one a day (data available for 8/14), from zero at baseline, to 75% at 6 months and 100% at 2 years. Clinical analysis results broadly accord with these data. • Of the 13 who had transferred to OST and were receiving it at 2 years: • nine had transferred voluntarily • four their transfer was compulsory. RIOTT: 2 years on Conclusions SIH treatment can be provided effectively on a long-term basis, confirming the results of previous extended follow-up studies. Moreover, at 2 years there was a movement away from injecting twice-daily to once-daily and towards abstinence. However, rather disturbingly, progression to OST was often associated with an increased use of street heroin for both those transferring voluntarily and those transferred compulsory. This needs further investigation. References Strang J, Metrebian N, Lintzeris N, Potts L, Carnwath T, Mayet S, et al Heroin on trial: the RIOTT randomised trial of supervised injectable heroin and injectable methadone as treatment for chronic heroin addicts persistently failing in orthodox treatment. Lancet, 2010, 375: 1885-1895. Rehm J, Gschwend P, Steffen T, Gutzwiller F, Dobler-Mikola A and Uchtenhagen A. Feasibility, safety and efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study. Lancet 2001, 358; 1417-1420. Verthein U, Bonorden-Kleij K, Degkwitz P et al Long-term effects of heroin-assisted treatment in Germany. Addiction 2008; 103: 960-6. Blanken P, Hendriks V, van Ree JM, van den Brink W. Outcome of long-term heroin-assisted treatment offered to chronic, treatment-resistant heroin addicts in the Netherlands. Addiction 2009; 105, 300-308. • Findings cont: • All interviewed (n=4 voluntary, 1 compulsory) reported increased street-heroin use at the 2 year follow-up, compared with their achievements at the 6 month follow-up point: • OST voluntary group being zero at baseline, 25% at 6 months and 0 % at 2 years • OST compulsory group being zero at baseline, 6 months and 2 years. • Serious Adverse Events • During the 18 months after the 6 month trial period (we have already reported on SAEs during this trial period), there were 7 SAEs. • Three likely to be related to SIH • 1 x seizure • 2 x overdoses post SIH injection • Four not related to SIH • 1 x cardiac arrhythmia • 1 x respiratory depression some time post SIH • 1 x pneumothorax following RTA • 1 x pneumonia • Incidence rate for SIH related SAEs was 1 in 8000 SIH injections.