Community Reinforcement Approach Plus Vouchers (Alcohol, Cocaine, Opioids)
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Community Reinforcement Approach (CRA) Plus Vouchers is an intensive 24-week outpatient
therapy for treating people addicted to cocaine and alcohol. It uses a range of recreational, familial,
social, and vocational reinforcers, along with material incentives, to make a non-drug-using lifestyle
more rewarding than substance use. The treatment goals are twofold:
To maintain abstinence long enough for patients to learn new life skills to help sustain it; and To
reduce alcohol consumption for patients whose drinking is associated with cocaine use
Patients attend one or two individual counseling sessions each week, where they focus on improving
family relations, learn a variety of skills to minimize drug use, receive vocational counseling, and
develop new recreational activities and social networks. Those who also abuse alcohol receive clinic-
monitored disulfiram (Antabuse) therapy. Patients submit urine samples two or three times each week
and receive vouchers for cocaine-negative samples. As in VBR, the value of the vouchers increases
with consecutive clean samples, and the vouchers may be exchanged for retail goods that are
consistent with a drug-free lifestyle. Studies in both urban and rural areas have found that this
approach facilitates patients’ engagement in treatment and successfully aids them in gaining
substantial periods of cocaine abstinence.
A computer-based version of CRA Plus Vouchers called the Therapeutic Education System (TES)
was found to be nearly as effective as treatment administered by a t herapist in promoting abstinence
from opioids and cocaine among opioid-dependent individuals in outpatient treatment. A version of
CRA for adolescents addresses problem-solving, coping, and communication skills and encourages
active participation in positive social and recreational activities.