Measures This document is a treatment manual. The curriculum was developed for cocaine abusers.

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1 1. Subject Area: Community Reinforcement Approaches Manual Two of Therapy Manuals for Drug Addiction. A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction Budney, A.J. and Higgins, S. T. Both individual and group interventions are involved in the curriculum. This document is a treatment manual. The curriculum was developed for cocaine abusers. No. Iowa s cocaine population is not at the level of other states, but might have some application for methamphetamine-using clients. Budney, A., & Higgins, ST. (1994). A community reinforcement plus vouchers approach: treating cocaine addiction (NIDA Publication No ed.). Rockville, Maryland: National Institute on Drug Abuse. Abstract/Results/Notes: This NIDA curriculum is a psychosocial treatment that follows the Community Reinforcement Approach (CRA) introduced by Myers and Smith in Early CRA development included: a prescription for disulfiram; reciprocity marriage counseling; job club support; social skills training; social and recreational advice; and help with controlling urges to drink. The NIDA curriculum integrates the Community Reinforcement Approach and includes a voucher program for creating an abstinence contract, urinalysis monitoring, and contingency rewards based on clean UAs. It is designed as a 24-week program. Randomized controlled trials by Silverman and Higgins provide support that vouchers increased cocaine and other drug abstinence. Current clinical literature supports the component interventions for improved social support, social skills, employment training, risk management and family involvement regardless of the use of a voucher/reward contingency for remaining clean and sober. The curriculum can be adapted to shorter periods of treatment time.

2 2. Subject Area: Community Reinforcement Approaches The Community Reinforcement Approach Sisson and Azrin Both individual and group interventions are involved in this approach. N/A N/A No. Iowa s cocaine population is not at the level of other states, but might have some application for methamphetamine-using clients. Sisson, R. W., & Azrin, N. H. (1989). The community reinforcement approach (Chapter 16). R. Hester, & W. Miller Handbook of Alcoholism Treatment Approaches. New York: Pergamon Press. Abstract/Results/Notes: Chapter Sixteen in this handbook examines early Community Reinforcement Approach development by Azrin and Hunt (1973) with alcoholic populations. The chapter provides a good review of the basic components of CRA.

3 3. Subject Area: Community Reinforcement Approaches A Community Reinforcement Approach to Addiction Treatment Individualized or Group Outcome/s Subjects Info Meyers and Miller Both individual and group Multiple Multiple subject interventions are involved measures for samples. in the approach. different types of studies. Randomized Controlled No. There is a review of RCT studies included. Generalizable to Iowa? The voucher-based systems that provide contingency management through rewards and sanctions for negative UAs are not used in Iowa. Meyers, R. J., & Miller, W. R. (2001). A community reinforcement approach to addiction treatment (International Research Monographs in the Addictions. UK: Cambridge University Press. Abstract/Results/Notes: This text provided extensive information regarding the comparisons of Community Reinforcement Approaches (CRA) with other traditional treatment approaches. Chapter 5 described trials that supported CRA use with drug abusers. The science quality for the alcohol research in Chapter 5 was weak. Careful examination of the tables indicated that the abstinence rates are not that much better over time. Much of the resistance for CRA approaches is connected to the cost of vouchers or rewards for negative UAs or for positive behavior changes. There is science available by Nancy Petry that argues the point about cost, suggesting that the cost benefits will become clear over the long-term. More time is needed for data collection and science to be able to show the value. This book would be a good resource for anyone trying to ascertain what would be involved in developing a CRA intervention.

4 4. Subject Area: Community Reinforcement Approaches Increasing opiate abstinence through voucher-based reinforcement therapy Individualized or Group Outcome/s Subjects Info Silverman, Wong, Not specifically outlined Higgins, et. Al. in the article. Effectiveness of voucherbased abstinence reinforcement. N=13 Small Sample of heroin users in a methadone clinic. Randomized Controlled No. Generalizable to Iowa? Voucher programs are not currently used in Iowa. Silverman, K., Wong, C. J., Higgins, S. T., & et al. (1996). Increasing opiate abstinence through voucher-based reinforcement therapy. Drug and Alcohol Dependence, 41, Abstract/Results/Notes: This was a small sample study that examined the effectiveness of voucher-based abstinence reinforcement in reducing opiate use by patients receiving methadone maintenance treatment. Using within-subject reversal design, subjects were given vouchers for negative screens for opiate use and later in treatment were assessed for opiate use with the vouchers removed from the method. The percentage of positive screens for opiates decreased significantly when the voucher program was in place and increased when the voucher program was discontinued.

5 5. Subject Area: Community Reinforcement Approaches Achieving Cocaine Abstinence with a Behavioral Approach Individualized or Group Outcome/s Higgins, Budney, Bickel, Not clear from the article. Retention Hughes, et al. and days of continuous abstinence. Subjects Info N=38 cocaine dependent adults. Randomized Controlled Yes. Generalizable to Iowa? Voucher programs are not currently used in Iowa. Higgins, S. T., Budney, A. J., Bickel, W. K., & et al. (1993). Achieving cocaine abstinence witha behavioral approach. American Journal of Psychiatry, 150, Abstract/Results/Notes: Fifty-eight percent (58%) of those receiving the behavioral Community Reinforcement Approach (CRA) plus incentive program finished 24 weeks of treatment vs. 11% of those receiving standard drug abuse counseling. Sixty-eight percent (68%) vs. 11% achieved 8 weeks of continuous cocaine abstinence. 42% vs. 5% achieved 16 weeks of continuous cocaine abstinence. The behavioral treatment (CRA) is well received by cocaine users as is the use of incentives. Cost of the incentives ($12.00/per day per client for the first twelve weeks) and cost of the monitoring with drug screens and UAs.

6 6. Subject Area: Community Reinforcement Approaches Low-Cost Contingency Management for Treating Cocaine- and Opioid-Abusing Methadone Patients Petry and Martin N/A Continuous abstinence. Yes. N=42 adults at a community-based methadone treatment center. Promising results, but Iowa does not use any voucher systems at this time and has a small cocaine- and opioid- abusing population. Petry, N., & Martin, B. (2002). Low-cost contingency management for treating cocaine-and opioid-abusing methadone patients. Journal of Consulting and Clinical Psychology, 70, Abstract/Results/Notes: Subjects were randomly assigned to twelve weeks of standard treatment (control) or standard treatment plus contingency management (CM) procedures. Clients in both groups participated in a random drug screen plan. The plan was to offer low-cost prizes/rewards for positive behaviors. Prices ranged from $1 to $100 for negative drug tests for cocaine and opioids. Patients in the standard plus CM assignment achieved longer continuous abstinence lengths, and the effects were maintained through a 6-month follow-up. Petry s research was an effort to support behavioral interventions like CRA and posit that less expensive and manageable contingency management used as reinforcers are possible in community-based treatment settings.

7 7. Subject Area: Community Reinforcement Approaches Fishbowls and Candy Bars: Using Low-Cost Incentives to Increase Treatment Retention Petry and Bohn N/A N/A N/A No. Voucher programs are not currently used in Iowa. Petry, N., & Bohn, M. J. (2003). Fishbowls and candy bars: using low-cost incentives to increase treatment retention. Science and Practice Perspectives, 2, Abstract/Results/Notes: A preliminary and yet interesting discussion of research demonstration in support of contingency management incentives and the particular uses and benefits perceived in clinical settings. The article addressed the issues of cost effectiveness arguing that retention in treatment and increasing the time before return to using may provide considerable cost effectiveness over the long term. The article was a call for more carefully monitored research.

8 8. Subject Area: Community Reinforcement Approaches A systematic review of the effectiveness of the community reinforcement approach in alcohol, cocaine, and opioid addiction. Roozen, Boulogne,van Tulder, et al N/A Retention and abstinence. Multiple subjects. Yes. A review of 11 studies. Voucher programs are not currently used in Iowa. Roozen, H. G., Boulogne, J. J., van Tulder, M. W., van den Brink, W., De Jong, C. A., & Kerkhof, A. J. (2004). A systematic review of the effectiveness of the community reinforcement approach in alcohol, cocaine and opioid addiction. [Review] [70 refs]. Drug & Alcohol Dependence, 74(1), Abstract/Results/Notes: The article is a review of eleven high-quality randomized controlled trial studies focusing on substance abuse. The objective was to compare the effectiveness of CRA compared to usual care and CRA versus CRA with contingency management. There is considerable evidence that CRA is more effective than treatment as usual when related to number of drinking days and less clear evidence regarding continuous abstinence. Moderate evidence is available that CRA with disulfiram is more effective related to number of drinking days and no difference for continuous abstinence. CRA s with incentives are more effective for opioid detox programs, and limited evidence to support that CRA is more effective in methadone maintenance programs. Abstinencecontingent incentives are more effective than non-contingent incentives in treatments aimed at cocaine abstinence.