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Abstract Whilst unsupervised injectable methadone and diamorphine treatment has been part of the British treatment system for decades, the numbers receiving injectable opioid treatment (IOT) has been steadily diminishing in recent years. In contrast, there has been a recent expansion of supervised injectable diamorphine programs under trial conditions in a number of European and North American cities, although the evidence regarding the safety, efficacy and cost effectiveness of this treatment approach remains equivocal. Recent British clinical guidance indicates that IOT should be a second-line treatment for those patients in high-quality oral methadone treatment who continue to regularly inject heroin, and that treatment be initiated in newly-developed supervised injecting clinics. The Randomised Injectable Opioid Treatment Trial (RIOTT) is a multisite, prospective open-label randomised controlled trial (RCT) examining the role of treatment with injected opioids (methadone and heroin) for the management of heroin dependence in patients not responding to conventional substitution treatment. Specifically, the study examines whether efforts should be made to optimise methadone treatment for such patients (e.g. regular attendance, supervised dosing, high oral doses, access to psychosocial services), or whether such patients should be treated with injected methadone or heroin. Eligible patients (in oral substitution treatment and injecting illicit heroin on a regular basis) are randomised to one of three conditions: (1) optimized oral methadone treatment (Control group); (2) injected methadone treatment; or (3) injected heroin treatment (with access to oral methadone doses). Subjects are followed up for 6-months, with between-group comparisons on an intention-to-treat basis across a range of outcome measures. The primary outcome is the proportion of patients who discontinue regular illicit heroin use (operationalised as providing >50% urine drug screens negative for markers of illicit heroin in months 4 to 6). Secondary outcomes include measures of other drug use, injecting practices, health and psychosocial functioning, criminal activity, patient satisfaction and incremental cost effectiveness. The study aims to recruit 150 subjects, with 50 patients per group, and is to be conducted in supervised injecting clinics across England.

Introduction and Aims: Opioid substitution treatment (OST) reduces drug-related harms in custody and after release. However, OST providers in prisons have reported that some patients prefer to cease treatment prior to release, placing them at risk of fatal overdose. We aimed to examine reasons for seeking OST in custody, and intentions regarding continuation or cessation of treatment prior to and following release.Design and Methods: This qualitative study employed semi-structured interviews with opioid-dependent people currently incarcerated in New South Wales, Australia.Results: Of 46 participants, 27 were currently in OST. Reported benefits of OST included withdrawal management and avoidance of high-risk injecting. Over a third of participants in OST stated their intention to withdraw from OST prior to release. Reasons included concerns that attending community OST clinics could lead to drug use or offending, family opposition, inconvenience of clinic attendance, stigma and a perception that prison provided an opportunity to withdraw from OST more easily than in the community. Nineteen participants had already ceased OST in custody or had declined it, citing preferences to 'be clean' and the long-term nature of OST.Discussion and Conclusions: Balancing the preference of many patients to cease OST prior to release against patient safety post-release is a substantial challenge for opioid treatment providers in correctional settings. These findings indicate the need for research on how best to attract and retain opioid-dependent prisoners in treatment and the need to provide other interventions for prisoners uninterested in post-release OST, such as take-home naloxone. [Larney S, Zador D, Sindicich N, Dolan K. A qualitative study of reasons for seeking and ceasing opioid substitution treatment in prisons in New South Wales, Australia. Drug Alcohol Rev 2017;36:305-310]. [ABSTRACT FROM AUTHOR]