Sustained Cocaine Abstinence in Methadone Maintenance Patients Through Voucher-Based Reinforcement Therapy

doi:10.1001/archpsyc.1996.01830050045007

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Vol. 53 No. 5, May 1996

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Sustained Cocaine Abstinence in Methadone Maintenance Patients Through Voucher-Based Reinforcement Therapy

Kenneth Silverman, PhD; Stephen T. Higgins, PhD; Robert K. Brooner, PhD; Ivan D. Montoya, MD; Edward J. Cone, PhD; Charles R. Schuster, PhD; Kenzie L. Preston, PhD

Arch Gen Psychiatry. 1996;53(5):409-415.

Abstract

Background
Chronic cocaine abuse remains a serious and costly public healthproblem. This study assessed the effectiveness of a voucher-basedreinforcement contingency in producing sustained cocaine abstinence.

Methods
A randomized controlled trial compared voucherbased reinforcementof cocaine abstinence to noncontingent voucher presentation.Patients were selected from 52 consecutively admitted injectingheroin abusers in a methadone maintenance treatment program.Patients with heavy cocaine use during baseline period (N=37)participated. Except where otherwise indicated, the term cocaineabuse is used in this article in a generic sense and not accordingto the DSM-III-R definition. Patients exposed to abstinencereinforcement received a voucher for each cocaine-free urinesample (ie, negative for benzoylecgonine) provided three timesper week throughout a 12-week period; the vouchers had monetaryvalues that increased as the number of consecutive cocaine-freeurine samples increased. Control patients received noncontingentvouchers that were matched in pattern and amount to the vouchersreceived by patients in the abstinence reinforcement group.

Results
Patients receiving vouchers for cocaine-free urine samples achievedsignificantly more weeks of cocaine abstinence (P=.007) andsignificantly longer durations of sustained cocaine abstinence(P=.001) than controls. Nine patients (47%) receiving vouchersfor cocaine-free urine samples achieved between 7 and 12 weeksof sustained cocaine abstinence; only one control patient (6%)achieved more than 2 weeks of sustained abstinence. Among patientsreceiving vouchers for cocaine-free urine samples, those whoachieved sustained abstinence ( $≥$ 5 weeks) had significantly lowerconcentrations of benzoylecgonine in baseline urine samplesthan those who did not achieve sustained abstinence (P $≤$ .01).Patients receiving voucher reinforcement rated the overall treatmentquality significantly higher than controls (P=.002).

Conclusion
Voucher-based reinforcement contingencies can produce sustainedcocaine abstinence in injecting polydrug abusers.

Author Affiliations

From the Addiction Research Center, Intramural Research Program of the National Institute on Drug Abuse, Baltimore, Md (Drs Silverman, Montoya, Cone, Schuster, and Preston); The Johns Hopkins University School of Medicine, Baltimore (Drs Silverman, Brooner, and Preston); and University of Vermont College of Medicine, Burlington (Dr Higgins). Dr Montoya is now affiliated with L/niversitv of Antioquia, Medellin, Colombia. Dr Schuster is now affiliated with Wayne State University, Detroit, Mich.

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