VOUCHERS HELP DRUG USERS OVERCOME THEIR ADDICTIONS

Studies: Rewards Enhance Treatment

PHILADELPHIA -- It's a proposition as old as parenthood: Do this
thing you don't want to do -- "please?" -- and you'll get something
nice for your trouble.

Now, the idea that we can influence adult behavior by offering
meaningful incentives -- gift cards, bus tokens, CD players and rent
subsidies -- is slowly catching on in drug and alcohol treatment.

More than 60 studies in the United States and in Europe show that
rewarding substance abusers for staying clean helps keep them
enrolled in the crucial early weeks of outpatient rehab, when dropout
rates can hit 40% or more.

It's also helped double abstinence rates later on to about 60%.

"Many of us recognize this as one of the most important and effective
tools we have," said Charles R. Schuster, director of the National
Institute on Drug Abuse under Presidents Ronald Reagan and George
Bush, now head of addictions research at Wayne State University
School of Medicine.

"But we've done a lousy job of selling it," he added.

Costs of goods weighed

"Contingency management," as this system is called, is all about
stimulating the brain's natural reward centers with something other
than drugs or alcohol.

And while offering goods and services to addicts can get expensive,
think of it this way: Untreated addiction costs this country $400
billion a year, more than heart disease, diabetes and cancer combined.

Consider, too, that two centuries of collective knowledge and
treatment history have brought us no closer to a cure for addiction.
Only a small percentage of addicts ever achieve complete and
sustained recovery.

Scientists began looking at the reinforcing effects of drugs in
laboratory animals as early as the 1940s. In the 1960s, studies
showed that normal monkeys offered intravenous cocaine anytime they
pressed a lever quickly began acting like drug-crazed humans. The
animals pressed and pressed and would have overdosed or starved to
death had they not been forced to stop.

Research waned as interest in new medications and talk therapies for
addiction emerged.

Then, in the 1980s, Stephen T. Higgins, a behavioral psychologist,
began looking for a way to keep cocaine addicts -- a particularly
tough group -- in rehab long enough for the inherent rewards of being
drug-free to kick in.

He knew he couldn't use cash. "For many cocaine users, that's a cue
for drug use," he said.

Higgins settled on vouchers to augment standard treatment.

That can include time in a residential facility, an intensive
outpatient program, Alcoholics Anonymous-style group therapy,
individual counseling and medication, followed by years in AA support
groups. With some variation, this has been the model for treating
addiction for decades.

Values of vouchers increase

Higgins' idea was simple. If addicts in treatment produce a drug-free
urine specimen, they get vouchers ultimately redeemable for things
like camera equipment, passes to local gyms, McDonald's gift
certificates and fishing licenses.

The vouchers start small -- $2.50 -- and build up over the 12-week
program, for a possible total of $1,000.

But produce one dirty sample and you're back to square one.

A lot of these decisions to use drugs are spontaneous, said Higgins,
professor of psychiatry at the University of Vermont. "All we wanted
to do was give them reason to pause." His studies found that with
vouchers, retention rates in his rehab programs increased fivefold, to 50%.

James R. McKay, an addictions expert at the University of
Pennsylvania, is wrapping up a five-year, 170-patient voucher study
funded by a $2.5-million federal grant. Cocaine addicts with alcohol
and other problems earned up to $1,150 in vouchers redeemable for
rent and utility subsidies or gift cards from stores like Target and Wal-Mart.

McKay's results, now being analyzed, show vouchers having a modest,
not huge, effect in keeping addicts in outpatient treatment and
reducing cocaine use. But he's intrigued.

"I think this taps into some sense of achievement, giving people
clearly measurable goals: Clean urine equals progress," he said.

Even so, the idea may be a tough sell on a large scale.

Incentives cost money and treatment programs are notoriously underfunded.

The AA 12-step philosophy is deeply entrenched. The idea of rewarding
people to stay off drugs offends those who think abstinence should be
its own reward, said Tyrone Thomas, a drug counselor who works with McKay.

"They say, 'You're paying people to stay clean,' which isn't
necessarily accurate, but that's the perception," he said.