Criminal Justice Referral and Incentives in Outpatient Substance Abuse Treatment

Anthony DeFulio1, Paul Nuzzo2, & Maxine Stitzer1

1 – Johns Hopkins University School of Medicine; 2 – University of Kentucky College of Medicine

AIMS To examine the influence of criminal justice referral status on treatment outcome To examine the interaction between criminal justice status and response to the abstinence incentive intervention

METHODSFour study subgroups were identified for comparison:

• Incentives with criminal justice referral (Incentives-CJ; N = 68), • Incentives without criminal justice referral (Incentives-No CJ;

N = 141), •Usual Care with criminal justice referral (UC-CJ; N = 70), •Usual Care without criminal justice referral (UC-No CJ; N =

136). Criminal justice referral was defined as a positive response to the question “Did you come to this treatment program because a judge or probation/parole officer told you to go to treatment?” Data was analyzed for main effects of criminal justice referral status, main effects of the incentive intervention and the criminal justice X incentives interaction. Variables examined included retention (Cox survival) and mean weeks retained (two-factor ANOVA), proportion of stimulant negative urine samples submitted over time (GEE) and longest number of consecutive stimulant negative urine samples (two factor ANOVA) Tukey’s post-hoc tests were conducted between incentive and no incentive conditions within each criminal justice referral subgroup irrespective of whether the interaction term was significant.

RESULTS Those referred from criminal justice had better outcomes than non CJ-referred on retention and drug use measures. Percent retained at end of 12 weeks was 50% for CJ-referred vs 38% for non CJ-referred. Number of negative urines submitted was 11.3 vs 9.5 (p = .021). A significant interaction of criminal justice referral and incentives was seen only on treatment retention (survival analysis χ2=13.39, p<.001, HR=.80). Significant effects of the abstinence incentive, when apparent, were confined to the non CJ-referred group (Table 1; Figure 2). For example, number of negative urines submitted was 11.2 vs 7.8 for incentive and usual care, respectively in non CJ-referred (p =.001). Comparable outcomes in CJ-referred were 12.5 vs 10.3 (NS).

CONCLUSIONAbstinence incentives should be offered as a first priority to substance users entering treatment without criminal justice referral but should be considered for use with all stimulant users independent of criminal justice status.

SUPPORTED BY: U10DA13034 from the National Institute on Drug Abuse Clinical Trials Network. The authors declare no conflict of interest.

BACKGROUND Stimulant users who sought treatment in community psychosocial outpatient treatment programs (N = 415) participated in a 12- week randomized controlled trial (CTN-0006; n = 415) of a prize-based abstinence incentive intervention About 30% had been referred to treatment from the criminal justice system Primary study outcomes documenting improved retention in the full sample abstinence incentive group were published previously (Petry et al., 2005)

SUMMARY Criminal justice referral was associated with better substance abuse treatment outcomes compared to non-CJ referred. Impact of abstinence incentives was larger and more consistent in the non-CJ subgroup Best outcomes were seen in those exposed to both positive (abstinence incentive) and negative (avoidance of CJ sanctions) interventions

REFERENCEPetry NM, Peirce JM, Stitzer ML, et al. Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: a national drug abuse treatment clinical trials network study. Archives of General Psychiatry. 2005;62(10):1148-56.

Variable Condition Effects Statistical Results

CJ Incent(N = 68)

CJ UC(N = 70)

NCJ Incent(N =141)

NCJ UC(N = 136)

Main Effect Incentives

Main Effect CJ Referral Interaction

Retention and Participation% retained to week 12 56a 44 45b 31a,b P=0.003 P=0.025 P=0.001

Mean weeks retained 18.2a 16.1 16.6 14.1a P=0.005 P=0.045 P=0.007

Mean # Urines Submitted 13.7a 11.4 12.6b 9.1a,b P<0.001 P=0.032 P=0.419

Stimulant Drug UseStim Negative Urines (Mean #) 12.5a 10.3 11.3b 7.8a,b P=0.001 P=0.021 P=0.455

Longest Consec Neg Samples 11.1a 8.4 10.3b 6.7a,b P<0.001 P=0.127 P=0.541

GEE Analysis

Stim Neg (%) miss /miss 87 86 77 76 P=0.509 P=0.004 P=0.670

Stim neg (%) miss/pos 52a 43 47b 32a,b P=0.001 P=0.017 P=0.394

Table 1 : Retention, Participation, and Stimulant Use Outcomes**Shared superscripts indicate a significant between group difference in Tukey’s Post Hoc test (P<0.01 in

all cases).

# Neg UA’s CJ Incent N = 68

CJ UCN= 70

NCJ IncentN = 141

NCJ UCN = 136

0-4 22 30 32 45

5-19 52 57 41 47

20-24 27 13 27 8

Figure 1. Percent of participants retained in the study.

Figure 2. Stimulant urinalysis results.

Figure Notes: Figure 1 shows retention as a function of urine samples collected twice weekly during the 12-week intervention. For figure 2, missing samples were treated as positive.

Table 1. Retention, participation and stimulant use outcomes.

Table 2. Distribution of stimulant use outcomes.

Table Notes: For Table 1, Shared superscripts indicate a significant between group difference in Tukey’s Post Hoc test (P<0.01 in all cases). For Table 2, participants within each condition are categorized according to the total number of stimulant negative urines submitted in 12 weeks.