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Community Reinforcement + Vouchers Approach (CRA + Vouchers)

Scientific Rating:
2
Supported by Research Evidence
See scale of 1-5
Child Welfare Relevance Level:
Medium

See descriptions of 3 levels

Brief Description

The information in this program outline is provided by the program representative and edited by the CEBC staff. The Community Reinforcement + Vouchers Approach (CRA + Vouchers) program has been rated by the CEBC in the area of: Substance Abuse Treatment (Adult).

  • Types of Maltreatment: Does not target any specific kind of maltreatment
  • Target Population: Adults age 18 or older with a diagnosis of cocaine abuse or dependence.

CRA + Vouchers has two main components. The Community Reinforcement Approach (CRA) component is an intensive psychosocial therapy emphasizing changes in substance use; vocation; social and recreational practices; and coping skills. The Voucher Approach is a contingency- management intervention where clients earn material incentives for remaining in treatment and sustaining cocaine abstinence verified by urine toxicology testing.

Essential Components

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.

Child Component

Community Reinforcement + Vouchers Approach (CRA + Vouchers) was not designed with a child component.

Parent / Caregiver Component

Community Reinforcement + Vouchers Approach (CRA + Vouchers) was not designed with a parent/caregiver component.

Group Format

Community Reinforcement + Vouchers Approach (CRA + Vouchers) was not designed to be conducted in a group setting, and has not been tested for use in a group setting.

Delivery Setting

This program is typically conducted in a(n):

  • Outpatient Clinic

Homework

Community Reinforcement + Vouchers Approach (CRA + Vouchers) includes a homework component:

A primary goal of the program is behavior and lifestyle change. This is an intensive treatment in which patients need to be extremely active participants. During treatment planning and throughout individual sessions, the therapist and client create between-session goals. The goals are in the areas of developing new and healthier social networks, recreational activities, family relationships, and vocational direction. The first order of business of each session is review of the patient's follow-through on their daily and weekly goals.

Languages

Community Reinforcement + Vouchers Approach (CRA + Vouchers) does not have materials available in a language other than English.

Resources Needed to Run Program

The typical resources for implementing the program are:

Staffing needs:

  • two therapists
  • one program manager
  • one data manager
  • one research assistant
  • one secretary
  • one post-doctoral fellow
  • one supervisory psychologist

Space/room requirements: sufficient to accommodate each of the staff members and to provide sufficient privacy for the patients. It is also necessary to have onsite biochemical verification in order to immediately detect cocaine use.

Minimum Provider Qualifications

Therapists need a Master's degree and supervision by a licensed Ph.D.-level Psychologist. Research assistants need to have a Bachelor's degree.

Education and Training Resources

There is a manual that describes how to implement this program; but there is not training available for this program.

Implementation Information

Since Community Reinforcement + Vouchers Approach (CRA + Vouchers) is highly rated on the Scientific Rating Scale, information was requested from the program representative on available pre-implementation assessments, implementation tools, and/or fidelity measures.

Show implementation information...

Pre-Implementation Assessments

There are no pre-implementation assessments to measure organizational or individual provider readiness.

Implementation Tools — for the program (e.g., implementation guides or manuals)

A therapist manual published by NIDA can be found at: www.nida.nih.gov/TXManuals/CRA/CRA1.html.

Fidelity Measures

There are no fidelity measures available for this program.

Relevant Published, Peer-Reviewed Research

This program 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. Please see the Scientific Rating Scale for more information.

Child Welfare Outcome: Child/Family Well-Being

Show relevant research...

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 — 29.0 years; 12-Step: 30.5 year, on average
  • Race/Ethnicity — Not Specified
  • Gender — Not Specified
  • Status — Individuals entering an outpatient clinic for cocaine dependence.

Location / Institution: Not Specified

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 — 28.5, Counseling: 30.1 on average
  • Race/Ethnicity — 89% White, 11% Other
  • Gender — Not Specified
  • Status — Cocaine-dependent individuals recruited through the media and local healthcare professionals.

Location / Institution: Not Specified

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 — 31.8; No-Voucher: 30.9 years on average
  • Race/Ethnicity — 90% White, 10% Other; No-Voucher: 80% White, 20% Other
  • Gender — Not Specified
  • Status — Cocaine dependent adults recruited through the media and local professionals.

Location / Institution: Not Specified

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
  • Gender — Not Specified
  • Status — Cocaine-dependent individuals recruited through the media and local healthcare professionals.

Location / Institution: Not Specified

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.
  • Gender — Not Specified
  • Status — Opioid-dependent adults recruited through the media, physicians, and drug and alcohol clinics.

Location / Institution: Not Specified

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.

Secades-Villa, R., Garcia-Rodriguez, O., Garcia-Fernandez, G., Sanchez-Hervas, E., Fernandez-Hermida, J. R., & Higgins, S. T. (2011). Community Reinforcement Approach Plus Vouchers among cocaine-dependent outpatients: Twelve-month outcomes. Psychology of Addictive Behaviors, 25(1), 174-179.

Type of Study: Randomized controlled trial
Number of Participants: 64

Population:

  • Age range — Mean age 28 years
  • Race/Ethnicity — Hispanic
  • Gender — 87% Male and 13% Female
  • Status — Participants were enrolled in an outpatient treatment program for cocaine dependence.

Location / Institution: Spain

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The study evaluated the effectiveness of the Community Reinforcement plus Vouchers Approach (CRA+Vouchers) in a sample of individuals with cocaine dependence. Participants were randomly assigned to a CRA+Vouchers treatment group or standard care. Participants were assessed at intake and 12 months after treatment began using the Addiction Severity Index (ASI), Symptom Checklist-90-Revised (SCL-90-R), Michigan Alcohol Screening Test (MAST), Beck Depression Inventory (BDI), and regular urinalysis. Results indicated that the CRA+Vouchers treatment group completed a greater amount of treatment than the comparison group, demonstrated a higher rate of abstinence, and greater improvements in psychosocial functioning. Limitations included the lack of post-intervention follow-up.

Length of post-intervention follow-up: None.

Garcia-Fernandez, G., Secades-Villa, R., Garcia-Rodriguez, G., Alvarez-Lopez, H., Fernandez-Hermida, J. R., Fernandez-Artamendi, S., & Higgins, S.T. (2011). Long-term benefits of adding incentives to the Community Reinforcement Approach for cocaine dependence. European Addiction Research, 17(3), 139-145.

Type of Study: Randomized controlled trial
Number of Participants: 58

Population:

  • Age range — Not specified, minimum age 20 years
  • Race/Ethnicity — Not Specified
  • Gender — Not Specified
  • Status — Participants were enrolled in an outpatient treatment program for cocaine dependence.

Location / Institution: Spain

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The study evaluated the effectiveness of the Community Reinforcement Plus Vouchers Approach (CRA+Vouchers) in a sample of individuals with cocaine dependence. Participants were randomly assigned to either a CRA+Vouchers group or a Community Reinforcement Approach (CRA) without vouchers group to evaluate retention, abstinence, and psychological outcomes. Treatment duration was 1 year with a 6-month follow-up. Results indicated that significant improvements in psychosocial functioning occurred in both treatment groups, but when differences were observed, they supported CRA+Vouchers over CRA without vouchers.

Length of post-intervention follow-up: 6 months.

Garcia-Rodriguez, O., Secades-Villa, R., Higgins, S. T., Fernandez-Hermida, J. R., Carballo, J. L., Perez, J. M. E., & Al-halabi Diaz, S. (2009). Effects of a voucher-based intervention on abstinence and retention in an outpatient treatment for cocaine addiction: A randomized controlled trial. Experimental and Clinical Psychopharmacology, 17(3), 131-138.

Type of Study: Randomized controlled trial
Number of Participants: 96

Population:

  • Age range — Mean age 29 years
  • Race/Ethnicity — Not Specified
  • Gender — 87% Male and 13% Female
  • Status — Participants were enrolled in two outpatient treatment programs for cocaine dependence.

Location / Institution: Spain

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The study evaluated the effectiveness of the Community Reinforcement Plus Vouchers Approach (CRA+Vouchers) in a sample of individuals with cocaine dependence. Participants were randomly assigned to one of three treatment conditions: standard outpatient treatment, CRA+Vouchers with low monetary vouchers, or CRA+Vouchers with high monetary vouchers. Participants were assessed at intake and 6-month follow-up using the Michigan Alcoholism Screening Test, Beck Depression Inventory (BDI), and the European version of the Addiction Severity Index (ASI), as well as regular urinalysis. Results indicated that the CRA+Vouchers groups obtained better results than the standard program. The high monetary voucher group obtained the highest retention rate and lowest cocaine traces at follow-up. Overall, the study showed that treating cocaine addiction by combining CRA+Vouchers was more effective than standard treatment in community outpatient programs in Spain. Study limitations include the lack of post-treatment follow-up.

Length of post-intervention follow-up: None.

References

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.

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.

Contact Information

Name: Stephen T. Higgins, PhD
Website: www.drugabuse.gov/TXManuals/CRA/CRA1.html
Email:
Phone: (802) 656-9615
Fax: (802) 847-4891

Date Reviewed: June 2011 (originally reviewed in August 2006)