CBT: Cognitive Behavioural Therapy; CCPSAs: Counselling Centres for Psychotropic Substance Abusers; CISS: Christo Inventory for Substance-Misuse Services; HA: Hospital Authority; NDH: North District Hospital; NTEC: New Territories East Cluster; PWH: Prince of Wales Hospital; SACs: Substance Abuse Clinics

Drug misuse is associated with a variety of somatic and psychiatric disorders, some of which are associated with certain types of drugs. For example, bladder effects [1], cognitive dysfunction [2], dissociative symptoms [2] and depression [2] have been found in chronic ketamine abusers, whereas psychotic symptoms have been reported among methamphetamine and cocaine abusers [3], and heroin abusers are often diagnosed with antisocial and borderline personality disorder [4]. Drug misuse is associated with criminality, with 72-80% of individuals improperly using drugs in Hong Kong being convicted of criminal offences in the past decade [5]. In view of the wide range of medical, personal and social issues found in substance abusers, it is important that they be provided with appropriate treatments.

The Hospital Authority (HA) of the Hong Kong SAR runs seven outpatient Substance Abuse Clinics (SACs) under the auspices of psychiatric services. The SACs accept referrals from counselling centres for psychotropic substance abusers (CCPSAs), voluntary agencies and other health care providers, and they also deal directly with substance users seeking help. SACs offer pharmacological treatments, counselling by social workers and other forms of services, such as pastoral and occupational counselling.

To monitor the quality of the treatments offered by the SACs, it was necessary to devise a uniform outcome measure. Monitoring and outcome evaluation can help to determine which service areas are appropriate and where improvements are needed.

The Christo Inventory for Substance-Misuse Services (CISS) [6] is a brief, simple outcome evaluation tool for drug and alcohol services. The CISS assesses the severity of different aspects of substance misusers’ condition and covers 10 areas, ranging from social functioning to working relationships in the past month. It can be completed from case notes without interviewing the clients. The CISS has four items on skills development (social functioning, occupation, criminal activity and working relationships), four items on physical and mental health (general health, high-risk behaviour [risky sexual behaviour and/ or the use of injectable substances], psychological status and drug/ alcohol use), and two on structured support, that is, ongoing support and treatment adherence. Items are rated on a three-point Likert scale, where 0=‘stable’, 1=‘may not be stable’ and 2=‘unstable’. The CISS is widely used in the United Kingdom [7,8], in outpatient services [9], methadone and opiate maintenance treatments [10] and drug intervention programmes [11], to assess the problem severity of drug abusers and to appraise the effectiveness of their treatment.

The objective of the present study was to examine the outcome of patients attending the two SACs operating in the New Territories East Cluster (NTEC) of Hong Kong.

Subjects

The two SACs in the NTEC are located at the Prince of Wales Hospital (PWH) and the North District Hospital (NDH). Two half-time psychiatrists, one half-time psychiatric nurse and a number of parttime social workers work in both SACs. The mainstays of treatment are pharmacological treatment and counselling by social workers. Such treatment programmes as occupational counselling and recreational services are currently unavailable. The major targets of these two SACs are psychotropic substance abusers. The medical record of consecutive patients attended the two aforementioned SACs from October 2009 to May 2010 were reviewed for age, sex, marital status, education and occupation, substance abuse history, and CISS score at intake and at 6 months follow up [12].

The current project was in compliance with the Helsinki Declaration and it has been approved by Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (Reference number: CRE-2009.129). Written informed consent is not required in this retrospective study, and the collection of patient’s information is a part of the routine clinical care.

Statistical analysis

Statistical analyses were performed using the SPSS, Version 17.0 (SPSS, Chicago, USA). Descriptive data are presented herein as means or proportions, as appropriate. Statistical differences were established by a two-tailed paired-sample t-test for normally distributed, continuous data, with the level of significance set at 0.05 (two-sided).

Characteristics of the sample

Subjects’ socio-demographic characteristics are shown in Tables 1-3. Their mean age was 34.85 ± 10.23; 62 (61.6%) were men; and 22.2% were primarily methyl amphetamine abusers, 21.2% mainly abused cough mixtures and 17.2% were heroin abusers. The most commonly diagnosed co-existing psychiatric disorder was drug-induced psychosis (46.5%), and 66% of the sample had a criminal record. The majority of subjects were referred by other HA facilities or by general practitioners (77%); thus, they had been under treatment and had been relatively stable at intake to the SACs.

Table 1: Demographic characteristics of the study sample (N = 99)

Table 2: Frequency of primary and secondary drugs in the sample (N = 99)

Table 3: Co-existing psychiatric disorders in the sample (N = 99)

Analysis of total CISS score

The CISS total scores were 5.9 ± 2.6 and 4.4 ± 2.3 at the first assessment and six-month follow-up, respectively, thus exhibiting a 25% reduction over time (t=6.345, p<0.001). Of the 99 patients, 64.6% showed an improvement from the initial assessment to the six-month follow-up, whereas 35.4% either deteriorated (10.1%) or showed no change (25.3%) in their CISS total scores.

Analysis of individual CISS items

The results were mixed regarding the individual CISS items. Subjects displayed different degrees of improvement in different areas, with the exception of ongoing support and treatment adherence (Figure 1). Significant differences were found in the areas of psychological status (t=0.5202, p<0.001), drug/alcohol use (t=4.589, p<0.001), general health (t=4.500, p<0.001), degree of criminal activity (t=2.803, p=0.006) and high-risk behaviour (t=2.755, p=0.007) between the initial assessment and the six-month follow-up (Table 4).

Table 4: Patients’ changes in CISS score at initial assessment and six-month follow- up (N = 99)

Figure 1: Changes in individual CISS items between initial assessment and six-month follow-up

The mean value of the CISS at the first assessment in this study was 5.48 ± 2.20, which is considerably lower than the 8.1% reported by Best et al. [11]. The discrepancy can be explained by the different study populations and sampling methods, as the sample in Best et al. was recruited from the criminal justice system.

Treatment outcomes

The significantly reduced total CISS score indicated overall improvement. Subjects’ psychological status, drug/alcohol use, general health, degree of criminal activity and high-risk behaviour all improved significantly, which suggests that the current SAC services are effective in promoting better psychological and physical health and lessening involvement in criminal behaviour. These health-related categories are interrelated: as expected, drug/alcohol use was significantly associated with psychological and general health and high-risk behaviour. Psychological status was also a significant correlate of general health and drug/alcohol use. Targeting drug/alcohol use can thus indirectly lead to better overall health.

In contrast to the aforementioned improvements, ongoing support deteriorated over the six-month period. Ongoing support refers to participation in non-medical treatments, mainly counselling. It seems that patients rely exclusively on drug treatment and ignore counselling. The majority of patients may lack sufficient understanding of the rationale for continuing psychological support. Continuing care requires long-term commitment, as its benefits are not realised immediately. Patients appear to place undue emphasis on medication and overlook the importance of the interrelated precipitating and perpetuating factors that lead to drug abuse and its harmful consequences. It is therefore important that this patient group be educated about the rationale for non-medical treatment modalities and that the value of these modalities be emphasised.

Poor adherence to drug counselling services is associated with a higher risk of relapse because patients are more vulnerable to interpersonal, occupational or spiritual difficulties when they lack counselling [13]. Peer influence [14], living with other drug/alcohol users [14] and high-risk behaviour [15] are significantly associated with poor engagement in continuous care. It may well be that patients consider themselves to be well-adjusted and are relatively satisfied with their lifestyle; thus, they are unlikely to accept referrals to other support services such as those provided by Non-Governmental Organisations (NGOs).

The modest improvement in occupation and working relationships is possibly attributable to the lack of occupational counselling offered at the PWH and NDH. The effectiveness of such counselling [16] and Cognitive Behavioural Therapy (CBT) [17] has been clearly documented with regard to substance abusers’ employment status. One-to-one CBT is reported to be effective in achieving abstinence from drugs and alcohol [18]. Due to the limited resources available to the SACs, it is recommended that group CBT be offered, as it is clinically effective but significantly cheaper than individual CBT.

Self-help groups not only provide strong social support to patients, but also structured daily living [19], which, in turn, can improve social functioning and vocational status. Similarly, structured behavioural and social-skills training are also promising avenues for the improvement of psychosocial functioning [20,21], employment [20] and concentration [22]. In short, self-help groups and skills training would be very desirable additions to the services currently available at the SACs as an integral part of the management of patients with substance abuse accompanied by a psychiatric disorder. The current drug/alcohol services provided by the HA through SACs in the NTEC are generally adequate, although they require further strengthening in specific areas.

The present study has methodological limitations. First, the present study examined the effectiveness of the 6-month treatment offered by the SACs in one of the seven service clusters in Hong Kong; future study should warrant a longitudinal design to investigate whether existing service has an impact on the relapse rate in service recipients in all service clusters. Secondly, CISS is a rater-administered scale, although it has not been translated and validated in Chinese population yet, raters in this study who are fluent in English are capable to use this scale to assess patient’s condition. Validation study in the Chinese version of this scale should be conducted in the future.

The authors declare that they have no competing interests.

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