The Voucher Program
The voucher program is a contingency-management procedure that systematically reinforces treatment retention and cocaine abstinence, the primary targets of CRA + Vouchers. Points are awarded for cocaine-negative urine test results, and the number of points is increased for each consecutive negative urine sample (exhibit 5). Failure to submit a scheduled specimen is treated as a cocaine positive. This procedure not only provides a reward for each cocaine-negative test but provides a greater incentive for patients who maintain long periods of continuous abstinence. Stable patients are better able to systematically work on the lifestyle changes targeted in the counseling sessions.
This system also recognizes that slips (use of cocaine) are highly probable during treatment. To discourage slips, the value of the voucher reverts to its initial value whenever cocaine use occurs. However, patients can regain the higher voucher values by providing five consecutive cocaine-negative specimens. Points already in the patients' accounts can never be lost.
Money is not provided directly to patients. Instead, vouchers are used to purchase retail items in the community by a staff member. Items obtained using the vouchers are quite diverse and have included ski-lift passes, fishing licenses, gift certificates to local restaurants, camera equipment, bicycle equipment, and continuing education materials.
Therapists retain veto power over all purchases. Purchases are only approved if, in the therapists' opinion, they are in concert with individual treatment goals related to increasing drug-free prosocial activities.
Regular objective monitoring of cocaine and other drug use via urinalysis testing is an essential part of implementing CRA + Vouchers.
- Objective monitoring is necessary for fair and effective implementation of the incentive program and other behavioral contracts used in this treatment. Such contracts are only effective if they are administered consistently and precisely. Reliance on self-reports would not be adequate for those purposes.
- By the time illicit drug abusers enroll in treatment, family, friends, employers, and others have often lost confidence in their veracity. Lying almost has to be part and parcel of regular involvement in illegal activities. Objective monitoring provides an effective means for patients to reduce suspicion and rebuild respect among their significant others.
Objective monitoring keeps all interested parties, especially therapists, regularly apprised of the ups and downs in patients' efforts to resolve their drug abuse problem. Timely and objective evidence of patient progress is necessary for developing and revising treatment plans.
Urine specimens should be collected from all patients under staff observation according to a set schedule (e.g., Monday, Wednesday, and Friday during weeks 1 - 12 and Monday and Thursday during weeks 13 - 24.) All specimens should be screened for benzoylecgonine. Each week, one randomly selected specimen is screened for the presence of other abused drugs. Breath alcohol levels can also be assessed at the time urine specimens are collected. Patients and therapists should be informed of the urinalysis results as soon as possible after specimens are submitted.
The schedule is designed to optimize the probability of detection of cocaine use. Frequent testing allows detection of almost any use of cocaine. However, it may also result in multiple positive tests from a single cocaine use episode. This possibility cannot be avoided. Inform patients about this possibility at the start of treatment. Providing information about multiple positives in the beginning of treatment will greatly reduce controversy over the results or the fairness of the voucher system.
Staff members who collect urine specimens need at least bachelors degrees and should have received special instruction for several weeks by a trained staff person in the collection and analysis of urine. Adequate precautions must be taken to ensure against submission of bogus specimens. Some clinics have a same-sex staff member observe specimen collection; others monitor the temperature of the specimen. A written copy of the rationale and procedures for specimen collection should be provided to all patients before they enter the urinalysis component of the program.
After patients have read these materials, the staff member should ask if they have any questions and whether they understand these rules. Taking time at the outset to discuss the rationale and procedures for collecting specimens and referring to them while collecting the first specimen can prevent later confusion and problems. Patients who have any difficulty with these procedures should be asked to discuss their problem with the appropriate treatment staff.
Monitoring of cocaine use for clinical purposes can be accomplished by testing for the presence of the cocaine metabolite, benzoylecgonine, in urine. As a general rule of thumb, benzoylecgonine can be detected for up to 2 days following use of a psychoactive dose of cocaine. Longer intervals, up to almost 2 weeks, can result from use of high doses of cocaine. Because most specimens collected from patients enrolled in drug treatment are expected to be negative, immunoassays are recommended for screening out negative samples (e.g., Braithwaite et al. 1995).
Because of cost and other factors, positive specimens are not regularly confirmed. Immunoassays for benzoylecgonine like the Enzyme Multiplied Immunoassay Technique (EMIT) are very specific; that is, there is little reaction with other compounds that might produce a positive result. Also, in the majority of cases, patients confirm the screens through self-reported cocaine use.
If your clinic policy is to regularly confirm positive specimens, experts recommend high performance liquid chromatography (HPLC) for clinical purposes and gas chromatography mass spectrometry (GCMS) for forensic purposes (e.g., Braithwaite et al. 1995).
Presenting the Results
Ideally, urine specimens should be tested immediately after collection while the patients wait. If you have a drug-testing system in your agency, and all testing is done by trained assistants, turnaround time can be very rapid (2 - 5 minutes). If your agency does not have laboratory capability, the results should be presented to patients as soon as possible.
To be consistent with the CRA + Vouchers model, staff should adhere to the following protocol when informing patients of their urinalysis results.
- Engage in pleasant conversation with patients while waiting for the results of the urinalysis.
- If the specimen is negative for cocaine use (clean), give the patients a voucher. Provide positive feedback to the patients and engage in positive interaction for a few minutes.
" Good job, Jim. You're doing great. That's three in a row. How's work going ? Great, keep it up. What do you have planned this weekend?"
- If the specimen is positive for cocaine use (dirty), ask patients about the amount of cocaine used and on what day. Record this information. Tell patients to speak to their therapist and immediately terminate the conversation. This is very important. Do not engage in pleasant conversation. Do not ask about what happened. Do not give therapeutic advice. Merely refer patients to their therapist.
- Inform the therapist of the urinalysis result as soon as possible.