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.)

Community Reinforcement + Vouchers Approach (CRA + Vouchers) is rated a "2 - Supported by Research Evidence" on the Scientific Rating Scale based on the published, peer-reviewed research available. The practice must have at least one rigorous randomized controlled trial with a sustained effect of at least 6 months. For more information on the rating of a "2 - Supported by Research Evidence," please see the Scientific Rating Scale.

Higgins, S. T., Delaney, D. D., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F., et al. (1991). A behavioral approach to achieving initial cocaine abstinence. The American Journal of Psychiatry, 148(9), 1218-1224.

Type of Study: Unmatched comparison group
Number of participants: 28
Population:

Age Range: CRA+V: 29.0 years; 12-Step: 30.5 year, on average
Race/Ethnicity: Not given
Status (e.g., foster care, CW): Individuals entering an outpatient clinic for cocaine dependence.

Location/Institution: Not given.
Summary: (To include comparison groups, outcomes, measures, notable limitations) This study compared participants treated with a Community Reinforcement + Vouchers Approach (CRA+V) enabling them earn money to purchase desired items, with those treated using a traditional 12-step approach. Drug use was monitored with urinalysis and breath alcohol screening 4 times per week during treatment. Patients in the CRA+V condition maintained abstinence from cocaine longer than those in the 12-step condition. However, there was a significantly higher rate of marijuana use in the behavioral group. Groups did not differ in rates of other drug use during the study period. The CRA+V group also had a greater rate of retention than the 12-step group. This study is limited by a small sample size and lack of randomization to groups.
Length of post-intervention follow-up: None

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

Type of Study: Randomized controlled trial
Number of participants: 38
Population:

Age Range: CRA+V: 28.5, Counseling: 30.1 on average
Race/Ethnicity: 89% White, 11% Other
Status (e.g., foster care, CW): Cocaine-dependent individuals recruited through the media and local healthcare professionals.

Location/Institution: Not given
Summary: (To include comparison groups, outcomes, measures, notable limitations) Participants were randomly assigned to receive either the Community Reinforcement + Vouchers Approach (CRA+V) or counseling. The counseling condition combined initial individual counseling with later 12-step group attendance. Drug use was checked using urinalysis. A significantly greater number of the CRA+V group completed 24 weeks of treatment (58% versus 11%) and a greater proportion had maintained sobriety at 8 at 16 weeks. The authors note that this sample did not contain crack cocaine users. The sample was also primarily Caucasian and results may not generalize to other populations.
Length of post-intervention follow-up: None

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, 568-576.

Type of Study: Randomized controlled trial
Number of participants: 40
Population:

Age Range: CRA+V: 31.8; No-Voucher: 30.9 years on average
Race/Ethnicity: CRA+V: 90% White, 10% Other; No-Voucher: 80% White, 20% Other
Status (e.g., foster care, CW): Cocaine dependent adults recruited through the media and local professionals.

Location/Institution: Not given
Summary: (To include comparison groups, outcomes, measures, notable limitations) Participants were randomly assigned to receive the Community Reinforcement + Vouchers Approach (CRA+V) with vouchers equivalent to specified amounts of money contingent on negative urine tests. Voucher amounts increased over time as periods of abstinence increased. The No-Voucher group also received the CRA procedure, but were only informed of the outcome of their uninalysis. At 24 weeks, end of treatment assessments were proformed. The CRA+V group maintained sobriety significantly longer than the no-voucher group, with 30% of patients reaching 20 weeks versus 5% for the no-voucher group. More patients in the voucher group also completed the full 24 weeks of treatment (75% versus 40%). Finally, at the end of treatment the voucher group had significantly better scores on the Drug scale of the Addiction Severity Index (ASI) and also showed improvement on the ASI Psychiatric Scale. This study is limited by lack of a no-treatment or standard treatment control group.
Length of post-intervention follow-up: None.

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(2), 205-212.

Type of Study: Randomized controlled trial
Number of participants: 78
Population:

Age Range: 30.3 on average, across samples
Race/Ethnicity: Trial 1: 100% Caucasian; Trial 2: Voucher group, 90% Caucasian, No-Voucher group 80% Caucasian
Status (e.g., foster care, CW): Cocaine-dependent individuals recruited through the media and local healthcare professionals.

Location/Institution: Not given
Summary: (To include comparison groups, outcomes, measures, notable limitations) Note: This follow-up uses the samples from Higgins et al., 1993 and Higgins, Budney, Bickel, Foerg, et al, 1994. Two randomized controlled trials were conducted comparing the Community Reinforcement + Vouchers Approach (CRA+V) procedure to other treatments. In Trial 1 the CRA+V was compared to a standard 12-step approach. In Trial 2, the CRA+V was compared to CRA without vouchers. Follow-up assessments were taken at 9 months and 1 year after treatment. Assessments included urinalysis, self-reported abstinence, aftercare participation and scores on the Addiction Severity Index (ASI), a structured interview looking at alcohol use, drug use, employment, family-social issues, legal issues, and medical/psychiatric issues. Looking at Trial 1ignificantly more participants in the voucher condition were abstaining from cocaine at 6, 9 and 12 months than in the 12-step counseling condition and they were more likely to enter aftercare. There were no differences between groups in scores on the ASI. For Trial 2, both the CRA+Vand non-voucher CRA groups showed equivalent rates of abstinence at 6, 9, and 12 months and comparable ASI scores. However, more patients in the voucher group enrolled in aftercare.
Length of post-intervention follow-up: 1 year

Bickel, W. K., Marsch, L. A., Buchhalter, A. R., & Badger, G. J. (2008). Computerized behavior therapy for opioid-dependent outpatients: A randomized controlled trial. Experimental and Clinical Psychopharmacology, 16(2), 132-143.

Type of Study: Randomized controlled trial
Number of participants: 135
Population:

Age Range: Standard, 30.1; Therapist, 26.1; Computer, 29.7 on average
Race/Ethnicity: Standard, 98% Caucasian; Therapist, 98% Caucasian; Computer,93% Caucasian.
Status (e.g., foster care, CW): Opioid-dependent adults recruited through the media, physicians, and drug and alcohol clinics.

Location/Institution: Not given
Summary: (To include comparison groups, outcomes, measures, notable limitations) Participants were randomly assigned to a Community Reinforcement + Vouchers Approach (CRA+V) program or to a program containing the same essential elements but delivered via self-directed computer modules. A third group was randomly assigned to receive standard methadone treatment and counseling. Outcome measures included drug abstinence, defined as three consecutive negative urine samples per week, treatment retention, Addiction Severity Index (ASI) score, score on the Helping Alliance Questionnaire-Patient Version (HAQ-P), which measures the degree of helping relationship between therapist and patient. The regular and computer-assisted CRA+V conditions showed comparable rates of continuous abstinence (7.98 and 7.78 weeks on average, respectively) and significantly higher rates than the standard methadone treatment (4.69 weeks on average). All groups showed similar rates of treatment retention and similar ASI and HAQ-P scores.
Length of post-intervention follow-up: None

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.

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

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.