The DEAL (Diamorphine Effect Assessment Level) tool to support induction onto injectable diamorphine treatment.

Background: Injectable diamorphine (ID) remains an unusual treatment option for opioid dependence. Despite an evidence base and growing utilisation among many EU states, following on from the RIOT Trial, there have been few services created in the UK. At present in the UK there is one service only, run by Cranstoun in Sandwell. 
Inducting people who are often on other forms of OST and injecting drugs onto ID is a complex and potentially risky procedure. It needs to balance engagement through rapid dose optimisation with the risks of inducing toxicity. A new tool the Diamorphine Effect Assessor Level (DEAL) was developed in partnership with clinical staff, advocacy groups and patients, to support an ID trial offered by a community drug service. This abstract describes the creation of the DEAL tool, its utility, acceptability by staff and patients as well its formal evaluation. based on data from 12 clients receiving ID across an 18-month period.
 
Method: Mixed methods were used including quantitative data analyses to assess inter-rater reliability (between clinicians and clinicians and patients), clinical utility and patient acceptability in supporting dose titration through standardised clinical observations using the DEAL tool.  
 
Results: Preliminary results show that the DEAL tool has high acceptability among both clinicians and patients. Combining basic observations with a 7-item scale describing subjective and objective pre and post injection (at 3,8 and 15 mins) assessment of opioid intoxication, data analysis to be conducted over the summer of 2024 is expected to show that DEAL scores can usefully support the safe induction of patient onto diamorphine though the communication of a simple numerical score between members of the clinical team including the responsible remote prescriber. The DEAL tool can inform ID dose titration and clinical intervention response over the first 4-8 weeks of titration treatment and support the detection of potentially undeclared other substance use after stabilisation through the recording of atypical scores after a period of consistent results and can infirm harm reduction interventions and adjustments in dose.
 
Conclusion: The DEAL is an easy use, acceptable clinical tool that can be used in a wide range of settings to detect risk, inform feedback and manage clinical risk. It may have utility with drug consumption rooms (DCRs) and could usefully support the roll out ID services elsewhere.