(phone 01203 553845, e-mail: P.Wells@covcdt.demon.co.uk, web site: http://www.covdrug.org.uk/home.htm)

Outcome monitoring has been a theme in both (excellent) editions of FINDINGS, still it needs examining in more detail in the context of services without the luxury of the support of professional researchers.

A few years ago, increased referrals to our community drug team led us to seek a formalised initial assessment tool which could later be used to gauge improvement. We looked at three in detail: EuropASI, the Maudsley Addiction Profile (MAP) and the Christo Inventory for Substance-misuse Services (CISS).

EuropASI is a European adaptation of a US original. Completing this highly formalised questionnaire can take about 45 minutes, but it is very comprehensive and provides scores for several problem areas. The information summary is clear and priorities for action are easily identified. MAP is also multi-dimensional. It takes less time but is harder for a drug worker to interpret than EuropASI.

Over the five years we looked at these tools our client numbers doubled; new referrals last year were up by 43%. Staff increases have not kept pace with increased workload. Also we are an open access service offering a range of responses and operating a three-day local standard for seeing new referrals. Hence the need for an efficient means to codify and standardise our assessment data. In such a setting we found that the comprehensiveness of these tools was also their weakness: they take too long, their structure prevents clients unfolding how they see their problems at their own pace, and they can seem intrusive for an initial contact.

In response we started using CISS in September 1999. CISS is a simple, one page questionnaire which can deliver a single score. By February 2000 over 230 forms had been completed at initial assessment. It proved easy to administer and there has been a high degree of consistency between workers completing forms for the same client. The ease with which it can be built into client practice means CISS is now used as part of our quarterly reviews. Completed forms are held centrally so that at follow up workers are not tempted to allocate an improved score.

Unlike other tools, CISS does not require the client's presence. Most street agencies and community drug teams only know a client has been 'discharged' when they lose contact. They do not have the resources to follow them up, and for many it would not be appropriate to do so. Despite this, CISS allows initial assessment, review and discharge scores to be collected.

I can understand that purists will find fault with the simplicity of the CISS, but this is its attraction for hard pressed staff. Outcome monitoring is essential, but until services have their own researchers or statistical support, the more complex measurement tools will fail to deliver what is urgently needed - a quick and easy method to indicate the level of problem identified and any subsequent changes. In the end what is important is to be able to demonstrate that there has been improvement since first contact. Now that the CISS has been validated, any agency looking for an effective and efficient means of codifying client information should consider adopting it.

A chart showing the CISS score profile generated by the Coventry Community Drug Team (N=267) as compared to the Royal Free Drug Service, London (N=243).Coventry CDT works in police arrest suites, GP surgeries and a primary healthcare service for the homeless in addition to offering a drop in / referral service at the centre. The range of clients therefore is varied and this is reflected in the profile. The Royal Free sample generally score a little lower, probably because they consist only of current clients and do not contain any new referrals.

It is gratifying that Paul Wells has clearly identified the purpose and function of the CISS – a tool for those of us who work in busy services with no researchers and limited admin support, where overworked staff have no time for forms, or already have tried and tested qualitative assessment interviews. It is for clients who may be uncooperative and stressful to work with, have reading difficulties, fail to turn up for assessments, discharge themselves without discharge interviews, or have their own
agendas of things they want to tell you about.

FINDINGS was the first magazine to feature the CISS back in June '99. Since then the CISS validation study has passed peer review and will shortly be published in the international journal Drug and Alcohol Dependence.1 It has also been featured in Addiction Today and Druglink. The CISS has rapidly grown in popularity; I have had about 200 requests for copies from across the UK.

The "purists" Paul refers to may be reassured that the pedigree of the CISS is more than adequate. Its author has worked in this field for 15 years and holds a doctorate in substance misuse treatment outcomes research and another in clinical practice. The validation study basically showed that the CISS is comprehensive, accurately measures what it is supposed to measure, and that different workers rating the same client will produce similar results – essential features of a useful instrument.2

My compliments to Paul Wells and everyone at the Coventry Community Drug team. If any other services want to try the CISS, I will happily send them a copy with comparison scores.

George Christo, Royal Free Drug Service, 457 Finchley Road, London NW3 6HN, phone 020 7431 1731, e-mail DrGeorgeChristo@tiscali.co.uk

1. "Validation of the Christo inventory for substance-misuse services (CISS): a simple outcome evaluation tool." (2000). Drug and Alcohol Dependence, 59, 189-197.

2. The CISS's alpha internal consistency was 0.74; test-retest reliability 0.82; inter-rater reliability 0.82 and 0.91; discriminant validity 88% at a cutoff score of 6. Convergent validity is demonstrated by correlations of 0.43 to 0.99 with the Opiate Treatment Index and measures of trait-anxiety, unpleasant life events, poor quality of life and low-self esteem.
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To appear in Drug and Alcohol FINDINGS (2000) issue 3.

Mike Ashton, editor DRUG & ALCOHOL FINDINGS

10 Mannock Road, London N22 6AA, England.
Tel +44 181 888 6277
Fax +44 181 888 6277
E-mail Findings@mashton.cix.co.uk
A collaboration between leading UK national drug and alcohol agencies ALCOHOL CONCERN - NATIONAL ADDICTION CENTRE - STANDING CONFERENCE ON DRUG ABUSE "Linking drug and alcohol research to practice, practice to research."

 Links within CISS site 

CISS home page and index.

CISS form

CISS general overview. Unedited version of an explanatory article about CISS which appeared in Addiction Today Magazine (Nov/Dec, 1999)

CISS comparison scores for harm minimisation oriented methadone prescribing outpatient services

CISS comparison scores for an outpatient alcohol service (item score comparisons with drug users)  

CISS comparison scores and cutoffs for abstinence oriented services

CISS technical information (reliability, validity, correlations with other scales)  

CISS detailed information. Validation of the Christo Inventory for Substance-misuse Services (CISS): a simple outcome evaluation tool (from Drug and Alcohol Dependence, 2000).

ã 1998 George Christo PhD, PsychD.