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Criminal Justice Referral and Incentives in
Outpatient Substance Abuse Treatment
Anthony
1
DeFulio ,
2
Nuzzo ,
Paul
& Maxine
1
Stitzer
1 – Johns Hopkins University School of Medicine; 2 – University of Kentucky College of Medicine
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)
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
METHODS
Four 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.
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.
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).
SUMMARY
 Criminal justice referral was associated with better
Table 1. Retention, participation and stimulant use outcomes.
substance abuse treatment outcomes compared to nonVariable
Condition Effects
Statistical Results
CJ referred.
CJ Incent
CJ UC
NCJ Incent
NCJ UC
Main Effect Main Effect CJ
Interaction
(N = 68)
(N = 70)
(N =141)
(N = 136)
Incentives
Referral

Impact
of
abstinence
incentives
was
larger
and
more
Retention and Participation
% retained to
consistent in the non-CJ subgroup
56
44
45
31
P=0.003
P=0.025
P=0.001
week 12
 Best outcomes were seen in those exposed to both
Mean weeks
18.2
16.1
16.6
14.1
P=0.005
P=0.045
P=0.007
retained
positive
(abstinence
incentive)
and
negative
(avoidance
Mean # Urines
13.7
11.4
12.6
9.1
P<0.001
P=0.032
P=0.419
Submitted
of CJ sanctions) interventions
a
b
a,b
a
a
a
b
a,b
Stimulant Drug Use
Stim 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 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.
Table 2. Distribution of stimulant
use outcomes.
# Neg UA’s
CJ Incent
N = 68
CJ UC
N= 70
NCJ Incent
N = 141
NCJ UC
N = 136
0-4
22
30
32
45
5-19
52
57
41
47
20-24
27
13
27
8
CONCLUSION
Abstinence 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.
REFERENCE
Petry NM, Peirce JM, Stitzer ML, et al. Effect of prizebased 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.
SUPPORTED BY: U10DA13034 from the National Institute on Drug Abuse Clinical Trials Network. The authors declare no conflict of interest.