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) was not designed to be conducted in a group.

Community Reinforcement + Vouchers Approach (CRA + Vouchers) has not been tested for use in a group setting.

Recommended intensity: Depending on where they are in treatment, clients are seen for therapy between 2 (or more) times a week and once a month and provide urine samples between 3 times a week and once a month.

Recommended duration: Therapy session duration depends on the client’s needs and the nature of the goals for the particular session. Generally, sessions are 60 minutes. The recommended treatment duration is 24 weeks of treatment and 24 weeks of aftercare. During weeks 1-12 of treatment, clients are asked to visit the clinic to provide urine samples for drug screens three times per week and have individual therapy sessions at least two times a week. During weeks 12-24, the intensity of treatment is decreased to urine toxicology testing twice a week and therapy sessions once a week. After the 24-weeks of treatment, a 24-week period of “aftercare” is recommended, involving at least one check-in session a month, a brief therapy session and a urine toxicology test.

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

Description: 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.

Community Reinforcement + Vouchers Approach (CRA + Vouchers) is typically conducted in a(n): Outpatient Clinic.

Community Reinforcement + Vouchers Approach (CRA + Vouchers) was not designed with a Parent Component.

Community Reinforcement + Vouchers Approach (CRA + Vouchers) was not designed with a Child Component.

Community Reinforcement + Vouchers Approach (CRA + Vouchers) was not developed for children with developmental delays.

Community Reinforcement + Vouchers Approach (CRA + Vouchers) has not been tested for children with developmental delays.

Community Reinforcement + Vouchers Approach (CRA + Vouchers) was not designed for specific racial/ethnic/cultural groups.

Community Reinforcement + Vouchers Approach (CRA + Vouchers) was not tested in specific racial/ethnic/cultural groups.

There is a manual that describes how to implement this program.

There is not training available for Community Reinforcement + Vouchers Approach (CRA + Vouchers).

The typical resources for implementing Community Reinforcement + Vouchers Approach (CRA + Vouchers) are: Staffing needs: two therapists, one program manager, one data manager, one research assistant, one secretary, one post-doctoral fellow and 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.

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

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.

Contact name: Stephen T. Higgins, Ph.D.