National Institute on Drug Abuse
Behavioral Therapies Development Program - Effective Drug Abuse Treatment Approaches
Community Reinforcement Approach (CRA) plus Vouchers
Community Reinforcement Approach (CRA) plus Vouchers (Higgins et al., 1993) is an intensive outpatient therapy for treatment of cocaine dependence. The treatment is 24 weeks in duration and involves once-to-twice weekly individual counseling sessions and twice-to-thrice weekly urinalysis monitoring. Counseling sessions focus on five general issues: (a) improving family relations, (b) providing skills training to minimize drug use, (c) providing vocational counseling, (d) assisting with developing new recreational activities and social networks, and (e) clinic-monitored disulfiram therapy for those who abuse cocaine and alcohol. To improve treatment retention and increase initial abstinence, CRA is combined with an incentive program wherein patients earn vouchers exchangeable for retail items contingent on cocaine-negative urinalysis results during the initial 12 weeks of treatment.
Higgins and colleagues, from the University of Vermont, demonstrated the efficacy of this treatment in several randomized clinical trials. In one trial, 38 cocaine-dependent adults were randomized to CRA plus vouchers or drug abuse counseling based on a disease-model approach to cocaine dependence (Higgins et al., 1993). In another trial, 40 cocaine-dependent adults were randomized to receive 24 weeks of CRA plus vouchers or CRA only.
Approximately 75% of those who received CRA plus vouchers were retained for the recommended course of 24 weeks of outpatient treatment compared to less than half of those who received drug abuse counseling or CRA alone. Similarly, greater than 50% of patients who received CRA plus vouchers were documented to have achieved at least two or more months of continuous cocaine abstinence compared to a quarter or fewer of those assigned to CRA alone or drug abuse counseling. When followed-up one-year after treatment entry, all treatment groups improved significantly compared to intake status. However, the groups treated with CRA plus vouchers showed greater improvements in measures related to cocaine use than groups treated with the two comparison treatments (Higgins et al., 1995). Dr. Higgins reports high retention rates and noteworthy rates of continuous abstinence for an outpatient treatment. This approach appears to facilitate patients' engagement in outpatient treatment and systematically aids them in gaining substantial periods of cocaine abstinence. This CRA plus vouchers approach shows great promise for effectively treating cocaine dependence in outpatient settings.
Bickel et al., (1997), also at the University of Vermont, extended the CRA plus vouchers approach to outpatient detoxification of opiate-dependent adults. Patients undergoing an extended opiate detoxification with buprenorphine were randomized to (a) CRA with vouchers for providing opioid-free urine samples and engaging in verifiable therapeutic activities or to (b) standard drug counseling. Fifty-three percent of the patients receiving behavioral treatment completed treatment, versus 20% receiving standard treatment. The percentage of patients achieving 4, 8, 12, and 16 weeks of continuous opioid abstinence were 68, 47, 26 and 11 for the behavioral group and 55, 15, 5, and 0 for the standard group, respectively. Behavioral treatment improved outcomes during outpatient heroin detoxification.
Silverman and colleagues (Silverman et al., 1996) of the NIDA Addiction Research Center in Baltimore extended the voucher-incentive program to inner-city methadone maintenance patients who exhibited high rates of intravenous cocaine abuse. Thirty-seven patients were randomly assigned to receive 12 weeks of vouchers contingent on cocaine abstinence or the same amount of vouchers independent of their recent drug use. The group that received vouchers contingent on cocaine abstinence achieved an average of 5 weeks of continuous cocaine abstinence versus less than 1 week in the comparison group. This study systematically replicated the results that Dr. Higgins obtained with cocaine abusers in a rural setting and extended them to an inner-city population of intravenous cocaine abusers.
Higgins, S.T., Delaney, D.D., Budney, A.J., Bickel, W.K., Hughes, J.R., Foerg, F., & Fenwick, J.W. (1991). A behavioral approach to achieving initial cocaine abstinence. American Journal of Psychiatry, 148 (9), 1218-1224.
Higgins, S.T., Budney, A.J., Bickel, W.K., Hughes, J.R., Foerg, F., & Badger, G. (1993) Achieving cocaine abstinence with a behavioral approach. American Journal of Psychiatry, 150, 763-769.
Higgins, S.T., Budney, A.J., Bickel, W.K., Foerg, F., Donham, R. & Badger, G. (1994). Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry, 51, 568-576.
Higgins, S.T., Budney, A.J., Bickel, H.K., Badger, G., Foerg, F. & Ogden, D. (1995) Outpatient behavioral treatment for cocaine dependence: one-year outcome. Experimental & Clinical Psychopharmacology, 3 (2), 205-212.
Silverman, K., Higgins, S.T., Brooner, R.K., Montoya, I.D., Cone, E.J., Schuster, C.R., & Preston, K.L. (1996). Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry, 53, 409-415.
Bickel, H.K., Amass, L., Higgins, S., Badger, G. & Esch, R. (W97). Effects of adding behavioral treatment to opioid detoxification with buprenorphine. Journal of Counseling and Clinical Psychology, 65 (5), 803-810.
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