Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

652 V. TREATMENTS FOR ADDICTIONSVoucher-Based Contingency ManagementPerhaps the most exciting findings pertaining to the effectiveness of psychosocialtreatments for cocaine dependence have been reports by Higgins and colleagues(Higgins et al., 1991, 1994; Higgins, Wong, Badger, Haug-Ogden, &Dantona, 2000) of the effectiveness of a program incorporating positive incentivesfor abstinence, reciprocal relationship counseling, and disulfiram into acommunity reinforcement approach (CRA; Azrin, 1976). The Higgins strategyhas four organizing features, which are grounded in principles of behavioralpharmacology: (1) Drug use and abstinence must be swiftly and accuratelydetected; (2) abstinence is positively reinforced; (3) drug use results in loss ofreinforcement; and (4) emphasis is on the development of competing reinforcersto drug use (Higgins, Budney, Bickel, & Hughes, 1993).In this program, urine specimens are required three times weekly. Abstinence,assessed through drug-free urine screens, is reinforced through a vouchersystem in which patients receive points redeemable for items consistent with adrug-free lifestyle, such as movie tickets, sporting goods, and the like, butpatients never receive money directly. To encourage longer periods of consecutiveabstinence, the value of the points earned by the patients increases witheach successive clean urine specimen, and the value of the points is reset backto its original level when the patient produces a drug-positive urine screen ordoes not provide a urine specimen.In a series of well-controlled clinical trials, Higgins and colleagues havedemonstrated (1) high acceptance, retention, and rates of abstinence forpatients receiving this approach (i.e., 85% completing a 12-week course oftreatment, and 65% achieving 6 or more weeks of abstinence) relative to standardsubstance abuse counseling; (2) rates of abstinence that do not declinesubstantially when less valuable incentives are substituted for the voucher system;(3) the value of the voucher system itself (as opposed to other programelements) in producing good outcomes by comparing the behavioral systemwith and without the vouchers; and (4) the durable effects of the voucher system(Higgins et al., 1993, 2000; Higgins & Silverman, 1999). Higgins’s initialwork with voucher-based contingency management has now been widely replicatedin other settings and samples: homeless substance abusers (Milby et al.,2000), pregnant substance users (Svikis, Haug, & Stitzer, 1997), drug users in atherapeutic workplace (Silverman et al., 2002), alcohol-dependent individuals(Petry, Martin, Cooney, & Kranzler, 2000), and cocaine-dependent individualswithin methadone maintenance treatment programs (Silverman et al., 1998).In regard to matching, there is some evidence that individuals with antisocialpersonality disorder may respond comparatively well to contingency managementapproaches (Messina, Farabee, & Rawson, 2003), and that raising thelevel of reinforcement may improve response among individuals who do notrespond initially to lower levels of reinforcement (Silverman, 1999).