Accentuate the Positive: Vouchers Help Drug Abusers Stay in Treatment

Whether it's a pay raise for exceptional job performance or boosting a child's allowance for helping out more around the house, we respond to positive reinforcement. Psychological research shows that positive reinforcement can also be highly effective in drug abuse treatment.

Findings

One of the problems in treating people who abuse drugs is getting them to stay in treatment long enough to work towards recovery. For example, up to 80 percent of cocaine abusers drop out of traditional treatment programs. But psychologist Stephen T. Higgins, Ph.D. and colleagues at the University of Vermont have shown that positive reinforcement - in the form of vouchers - is a more effective way to help drug abusers stay in treatment and work towards their recovery.

Voucher programs are a type of reinforcement known as Contingency Management (CM). CM treatments are based on the behavioral principle that if a behavior is reinforced or rewarded, it is more likely to occur in the future. In a voucher-based system to treat cocaine abuse, patients leave urine specimens multiple times each week and receive vouchers for each specimen that tests negative for drugs. These vouchers can be exchanged for retail items and services such as restaurant gift certificates, clothing, movie theater tickets and electronic items. The vouchers increase in value the longer the person stays off drugs. No money is ever given to patients. The voucher program also includes intensive counseling to improve work skills and social relationships that reinforce healthy choices.

Since the early 1990's, Dr. Higgins research has shown over and over that vouchers are highly effective in reducing substance use and retaining patients in treatment programs. A 2003 research review examining the effectiveness of voucher-based interventions for cocaine abuse found that in 15 of the 16 studies examined, significant increases in cocaine abstinence were observed. Much of Higgins' research involved substance abusers in his mostly rural state of Vermont. Research by Kenneth Silverman, Ph.D., of Johns Hopkins University and colleagues shows that a voucher-based program also works for inner-city cocaine abusers. Additional research by psychologist Nancy Petry, Ph.D., and others at the University of Connecticut has found that a lower-cost reward system using prizes also works in retention and treatment of drug abusers and may be attractive to community-based treatment programs that cannot afford using the vouchers.

Significance

The economic cost to U.S. society of drug abuse is estimated at nearly 100 billion dollars, according to the National Institute on Drug Abuse. Use of drugs like cocaine is associated with serious social and health problems, including crime and the spread of infectious diseases. Contingency management treatments that use vouchers or prizes are helping people with substance abuse disorders stay in treatment, giving them a better chance of full recovery. CM treatments work across a broad array of substance use populations, including some of the most difficult to treat like pregnant women and those with serious mental illnesses. Although a voucher system may cost more to operate than other treatment alternatives, their effectiveness may save society money in the long run through reduced medical and criminal justice costs.

Practical Application

The New York City Health and Hospitals Corporation, which operates one of the city's largest drug and alcohol treatment programs, recently implemented an incentive program as an outgrowth of Dr. Higgins work in five major clinics involving more than 1,000 patients. A follow-up study by clinicians and researchers from The Rockefeller University, done in collaboration with the Johns Hopkins School of Medicine, looked at the reactions of patients, staff, and administrators to the adoption of this contingency management approach in their treatment setting and found the following:

  • The patients were excited about the CM program from the start. They began to show increases in self-esteem, improvements in appearance and self-care, and a more goal-oriented perspective. There were a number of stories concerning the initiation of a family reconciliation process that took place when patients shared their prizes with estranged relatives.

  • Some counselors believed that the patients had begun to take on a greater sense of responsibility for their recovery; they went from "You are forcing me" to "I choose".

  • The process of receiving a reinforcement or prize was quite powerful, and the staff reported a number of instances in which patients burst into tears when they were acknowledged in a positive way.

  • The counseling staff was initially quite resistant. However, when they saw both the enthusiastic response and the positive changes in their patients, they typically embraced the approach in a dynamic and creative way. Over time, they became more comfortable with the use of reinforcements and some changed their initially negative perspective to one that was more positive. Instead of seeing reinforcements as a form of "bribery", they began to understand that they were effective tools for behavior change.

In another successful application of contingency management, Dr. Silverman and colleagues at Johns Hopkins University took the voucher research one step further by forming a non-profit data processing company in 2000 to employ and treat drug addicts. The company, Hopkins Data Services, employs men and woman who abused cocaine and gives them regular salaries (instead of vouchers) for their scientific research data entry work as long as they stay off drugs. The company's goal is to maintain a self-sustaining business that continues to employ the former addicts and pay for their drug treatment and monitoring. The company has more than a dozen clients so far.

Cited Research

Higgins S. T., Delaney D. D., Budney A. J., Bickel W. K., Hughes J. R., et al. 1991. A behavioral approach to achieving initial cocaine abstinence. American Journal of Psychiatry, Vol. 148(9), pp. 1218-24.

Higgins S. T., Budney A. J., Bickel W. K., Hughes J. R., Foerg F., Badger G. 1993. Achieving cocaine abstinence with a behavioral approach. American Journal of Psychiatry, Vol. 150(5), pp.763-9.

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, Vol. 51(7), pp. 568-76.

Higgins S. T., Wong C. J., Badger G. J., Ogden D. E., Dantona R. L. 2000. Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up. Journal of Consulting and Clinical Psychology, Vol. 68(1), pp. 64-72.

Higgins, S. T., Heil, S. H., Plebani Lussier, J. (2003). Clinical implications of reinforcement as a Determinant of substance use disorders. Annual Review of Psychology, Vol. 55.

Kellogg, S. H., Burns, M., Coleman, P., Stitzer, M., Wale, J. B., & Kreek, M. J. (2005). Something of value: The introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service. Journal of Substance Abuse Treatment, Vol. 28, pp. 57-65.

Petry, N. M. (2002). Contingency management in addiction treatment. Psychiatric Times, Vol. XIX, No. 2.

Petry, N. M. (2002). Low-cost contingency management for treating cocaine- and opioid-abusing methadone patients. Journal of Consulting and Clinical Psychology, Vol. 70(2), pp. 398-404.

Silverman K., Higgins S. T., Brooner R. K., Montoya I. D., Cone E. J., et al. 1996. Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy, Archives of General Psychiatry. Vol. 53(5), pp. 409-15.

Silverman K., Wong C. J., Higgins S. T., Brooner R. K., Montoya I. D., et al. 1996. Increasing opiate abstinence through voucher-based reinforcement therapy, Drug Alcohol Depend. Vol. 41(2), pp. 157-65.


American Psychological Association, December 10, 2003