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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 health problem. This study assessed the effectiveness of a voucher-based reinforcement contingency in producing sustained cocaine abstinence.

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

Results
Patients receiving vouchers for cocaine-free urine samples achieved significantly more weeks of cocaine abstinence (P=.007) and significantly longer durations of sustained cocaine abstinence (P=.001) than controls. Nine patients (47%) receiving vouchers for cocaine-free urine samples achieved between 7 and 12 weeks of sustained cocaine abstinence; only one control patient (6%) achieved more than 2 weeks of sustained abstinence. Among patients receiving vouchers for cocaine-free urine samples, those who achieved sustained abstinence (5 weeks) had significantly lower concentrations of benzoylecgonine in baseline urine samples than those who did not achieve sustained abstinence (P.01). Patients receiving voucher reinforcement rated the overall treatment quality significantly higher than controls (P=.002).

Conclusion
Voucher-based reinforcement contingencies can produce sustained cocaine 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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