Community Reinforcement + Vouchers Approach (CRA + Vouchers) - Detailed Report

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.
• Failure to submit a scheduled specimen is treated as a cocaine positive test.
• This procedure not only provides a reward for each cocaine-negative test but also provides a greater incentive for patients who maintain long periods of continuous abstinence.
• 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' individual accounts can never be lost.
• Money is not provided directly to patients. Instead, a staff member uses vouchers to purchase retail items in the community. Purchases are only approved if, in the therapists' opinion, they are in concert with individual treatment goals related to increasing drug-free pro-social activities.

Counseling Component

• The treatment plan should target areas for change that are directly related to cocaine use, are likely to decrease cocaine use, or will reduce the probability of relapse.
• CRA + Vouchers requires both therapists and patients to adopt an active, can-do, make-it-happen attitude throughout treatment.
• Therapists do whatever it takes to help patients make lifestyle changes. This includes taking patients to appointments or job interviews, initiating recreational activities with them, scheduling sessions at different times to accomplish specific goals, having patients make phone calls while in the office, assisting them with appointments, and searching newspapers for job possibilities or recreational events.

(Essential Components for CRA + Vouchers program were obtained from the National Institute on Drug Abuse website.)

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 Psychiatry, 148(9), 1218-1224.

Non-randomized trial (N=28) comparing CRA + Vouchers to a 12-step drug- counseling program. CRA + Vouchers had better retention rate and increased length of abstinence over the 12-week follow-up period.

Higgins, S.T., Budney, A.J., Bickel, W.K., Hughes, J.R., Foerg, F., and Badger, G. (1993). Achieving cocaine abstinence with a behavioral approach. American Journal Psychiatry, 150(5), 763-769.

Randomized trial (N=38) comparing CRA + Vouchers to a 12-step drug-counseling program. CRA + Vouchers had better retention rate and increased length of abstinence over the 24-week follow-up period.

Higgins, S.T., Budney, A.J., Bickel, W.K., Badger, G.J., Foerg, F.E., & Ogden, D. (1995). Outpatient behavioral treatment for cocaine dependence: One-year outcome. Experimental and Clinical Psychopharmacology, 3, 205 -212.

This article describes outcomes observed, during the year after treatment entry, from two controlled trials in which cocaine-dependent outpatients were randomly assigned to either a multi-component behavioral treatment CRA + Vouchers or to one of two control treatments (drug abuse counseling or CRA only). All treatment groups improved significantly compared to intake, and those changes were maintained through the follow-up period. When efficacy differences were observed during treatment and follow-up, they supported CRA + Vouchers over the control treatments.

Higgins, S.T., Budney, A.J., Bickel, W.K., Foerg, F.E., Donham, R., & Badger, G.J. (1994). Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry, 51(7), 568 - 576.

Forty cocaine-dependent adults were randomly assigned to CRA + Vouchers or CRA only. Subjects in the CRA + Vouchers group received vouchers exchangeable for retail items contingent on submitting cocaine-free urine specimens during weeks 1 through 12 of treatment, while the group without incentives received no vouchers during that period. The two groups were treated the same during weeks 13 through 24. RESULTS: The CRA + Vouchers group was more likely to complete the 24 week treatment program than the CRA only group (75% vs. 40%; p = .03). The average durations of continuous cocaine abstinence documented via urinalysis were 9.7 to 13.7 weeks in the CRA + Vouchers group vs. 4.5 to 7.5 weeks in the CRA only group (p = .03).

Higgins, S.T., Alessi, S.M., & Dantona, R.L. (2002). Voucher-based incentives: A substance abuse treatment innovation. Addictive Behaviors, 27, 887-910.

Budney, A. & Higgins, S.T. (1994). A community reinforcement plus vouchers approach: Treating cocaine addiction (NIDA Publication No. 98-4309 ed.). Rockville, Maryland: National Institute on Drug Abuse.

Lussier, J.P., Heil, S. H., Mongeon, J. A., Badger, J.G. & Higgins, S.T. (2006). A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction, 101, 192-203.