This report describes the intake characteristics of 82 clients presenting for assessment at the Royal Free Drug Service between 21.9.1999 to 6.3.2000. The purpose being to illustrate and explore the nature of client problems being dealt with by the service. It is assumed that this random client sample is representative of all individuals presenting for help from the service.

Two instruments were used for the assessments:

• The Christo Inventory for Substance-misuse Services (CISS; Christo, 1998; Christo, Spurrell & Alcorn, 2000) was used to measure levels of client dysfunction within 10 different areas of life.
• The Christo Inventory of Drugs (CID; Christo & Franey, 1995, 1996) was used to measure type, frequency, method and cost of drug use.

• n indicates the number of data points incorporated in each variable description, some assessments were incomplete.
• m indicates a mean value, all averages in this report are means.
• sd indicates a standard deviation, thus giving an idea of the spread of scores about the mean.
• range indicates the total range of scores achieved.
• p indicates the level of significance of a statistical test, the smaller the better.

Gender: (n = 82)

The gender distribution among clients was 65% male, 35% female. Gender was unrelated to dysfunction or drug use as measured by the CISS or CID respectively.

Age: (n = 75)

The average age was 32.7 (sd = 7.4, range = 18 to 59). Age was unrelated to levels of dysfunction or drug use as measured by the CISS or CID respectively.

Levels of client dysfunction: (n = 81)

The clients’ average CISS score was 10.3 (sd = 3.2, range = 2 to 17).

Each of the CISS’s 10 items is scored on a 3 point scale of 0 = no problem, 1 = moderate problem, 2 = severe problem; thus yielding a total score range of 0 to 20. A total score of 20 indicating severe problems in all areas.

Items are listed below in order of decreasing average item scores. Higher scores illustrate the areas of greatest need:

• 1.74 - Drug / alcohol use
• 1.62 - Support problems
• 1.57 - Occupational problems
• 1.22 - Psychological problems
• 0.99 - Social functioning problems
• 0.75 - Criminality problems
• 0.74 - Sexual / injecting risk problems
• 0.70 - Health problems
• 0.53 - Working relationship problems
• 0.46 - Compliance problems

Drugs of choice: (n = 82)

The table below lists the percentage of clients reporting a drug type as their drug of choice. Drugs are listed in order of popularity. The majority (71%) of clients preferentially used opiates. However, their secondary preferences revealed a more even distribution of drug types. The last column indicates the age at first use and as expected, alcohol is generally the first mind altering drug experienced by the majority of clients.

Current average age of clients m = 32.7 years

Drug use events: (n = 65)

On average, the presenting clients used drugs or alcohol on 125.4 occasions in the month prior to the assessment (sd = 82.8, range 0 to 338).

Polydrug use: (n = 44)

New clients were asked to self-report if they had used a range of drugs in the past week, and without notice they were also asked to provide a urine sample at the end of the assessment interview. The sample was analysed with an instant urine testing dipstick and the remainder was sent to the Royal Free Hospital's chemical pathology department for further analysis.

Only 44 of the 82 presenting clients had complete results for all three methods of ascertaining drug use, the remaining assessments were not used in the subsequent analysis.

• 64% of clients’ urine samples were positive for 3 or more drug types as measured by dipstick.
• 52% of clients’ urine samples were positive for 3 or more drug types as measured by the chemical pathology department.

The above table indicates that clients are generally truthful in their self-reported drug use. Heroin, alcohol and methadone are the most popular drugs in that order. Cannabis, cocaine (mostly crack) and benzodiazepines are about fourth equal with about 40% of clients using them. Amphetamines and ecstacy do not feature highly in this clinical population of London drug users.

Finance and crime: (n = 65)

• On average, the presenting clients spent a total of £1,492.80 on drugs, alcohol and cigarettes in the past month (sd = 1423.9, range 0 to £7,140.00).
• On average, the presenting clients spent £1,224.51 on illicit drugs in the past month (sd = 1423.9, range 0 to £5,400.00).
• On average, the presenting clients spent £151.91 on alcohol and cigarettes in the past month (sd = 162.3, range 0 to £910.00).

The above sums are excessive, particularly since only 14% of the clients reported no occupational problems and 70% were totally unemployed. In the absence of a legitimate income, many drug users fund their habits by shoplifting at a cost ratio of 1:3 (Healey et al., 1998). This means that as many as 70% of our prospective clients may cost society £4,478 per month in order to fund their drug use.

It is highly likely that criminal involvement problems are under reported at assessment were 43% of clients report no criminal involvement and only 19% report regular criminal involvement. Despite under reporting, these intake figures are far in excess of criminal involvement reported by established clients of the Royal Free Drug Service (were 65% of clients report no criminal involvement and only 6% report regular criminal involvement).

It is evident that subsequent engagement with the service is likely to protect the local community from a great financial burden.

Injecting: (n = 64)

Among the presenting clients, 42% had injected during the past month. The average number of times they injected in that month was 80.5 times (sd = 57.5, range = 4 to 240). The average CISS score (m = 11.0, sd = 2.5) of injectors was higher than the rest (m = 8.8, sd = 3.2), and this difference was statistically significant (t [62] = -3.0, p = .004).

Individual CISS items were analysed for differences in order to see what factors contributed to the elevated dysfunction of the injecting clients. As expected the injecting clients scored higher on sexual / injecting risk problems (Mann-Whitney U [62] = 141.5, p < .001), however they also scored higher on:

• Social functioning problems (Mann-Whitney U [62] = 310.5, p = .005)
• Support problems (Mann-Whitney U [62] = 365.5, p = .02)

Injectors scored no differently than the rest on the number of times they used drugs in the past month or the amount of money they spent on drugs / alcohol.

Alcohol use: (n = 66)

Over the month prior to the intake assessment, 30% of clients were drinking over the suggested limits (60 units per month for women and 90 units per month for men). The average monthly amount drank by these individuals was 390.6 units (sd = 297.5, range = 91-990). That is 91 units per week (sd = 69.4, range = 21.2-231).

The average CISS score (m = 10.8, sd = 2.6) of problem drinkers was a little higher than that of the rest (m = 9.3, sd = 3.1), and this difference failed to reach statistical significance (t [64] = -1.8, p = .08). However as expected from a previous CISS item analysis Christo et al. (2000), the heavy drinkers scored higher on psychological problems (Mann-Whitney U [64] = 297.5, p < .05), there were no other differences between individual CISS item scores.

Heavy drinkers scored no differently than the rest on the amount of money they spent on drugs / alcohol in the past month. However, the number of times they used drugs / alcohol in the past month (m = 106.0, sd = 73.3) were fewer than the rest (m = 172.4, sd = 87.6) and the difference was statistically significant (t [63] = -3.1, p = .003).

Dual Diagnosis Clients: (n = 81)

Among the presenting clients 17% had concurrent input from the psychiatric department at the hospital and their average CISS score was 13.5 (sd = 2.2), 83% did not have any psychiatric input and their average CISS score was 9.6 (sd = 3.0). CISS scores of dual diagnosis clients were significantly higher than the rest (t [78] = 4.6, p < .001).

Individual CISS items were analysed for differences in order to see what factors contributed to the elevated dysfunction levels of the dual diagnosis clients. As expected the dual diagnosis clients scored higher on psychological problems (Mann-Whitney U [79] = 133.0, p < .001), however they also scored higher on:

• Health problems (Mann-Whitney U [78] = 280.0, p = .01)
• Criminality problems (Mann-Whitney U [78] = 313.0, p = .04)
• Compliance problems (Mann-Whitney U [78] = 212.5, p < .001)
• Working relationship problems (Mann-Whitney U [78] = 167.0, p < .001)

These findings clearly illustrate the increased levels of stress that staff are likely to endure when working with this sub-group of clients.

Individuals with a dual diagnosis scored no differently than the rest on the number of times they used drugs in the past month or the amount of money they spent on drugs / alcohol.

Christo, G. (1995) Understanding the processes of relapse and recovery: a longitudinal study of drug users in abstinence oriented treatment. Ph.D. thesis, King’s College, London.

Christo, G. and Franey, C. (1995) Drug users’ spiritual beliefs, locus of control and the disease concept in relation to Narcotics Anonymous attendance and six-month outcomes. Drug and Alcohol Dependence. 38, 51-56.

Christo, G. and Franey, C. (1996) Addicts’ drug related dreams: their frequency and relationship to six-month outcomes. Substance use and Misuse, 31, 1-15.

Christo, G. (1998) Outcomes of residential care placements for people with drug and alcohol problems. The Centre for Research on Drugs and Health Behaviour.

Christo, G., Spurrell, S. and Alcorn, R. (2000) Validation of the Christo Inventory for Substance-misuse Services (CISS): a simple outcome evaluation tool. Drug and Alcohol Dependence, May issue.

Healey, A., Knapp, M., Austin, J., et al. (1998) Economic burden of drug dependency. Social costs incurred by clients at intake to the National Treatment Outcome Research Study. British Journal of Psychiatry, 173, 160-165.

 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.