STAYING CLEAN HAS NEW REWARDS

Vouchers For Addicts

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 and bus tokens, CD players and rent
subsidies - is slowly catching on in drug and alcohol treatment. More
than 60 studies here and in Europe show that rewarding substance
abusers for staying clean helps keep them enrolled in the critical
early weeks of outpatient rehab, when dropout rates can hit 40 percent
or more.

It has also helped double abstinence rates later on to about 60
percent.

"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 H.W.
Bush, now head of addictions research at the Wayne State University
School of Medicine in Detroit.

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

"Contingency management," as the 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.

"In a field that frequently struggles to find effective treatments, I
think [vouchers] are an attractive and effective option," said Kenneth
Silverman, who is experimenting with contingency management at the
Johns Hopkins University School of Medicine in Baltimore.

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 who were offered intravenous cocaine any time 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 and Philadelphia native, began looking for a
new 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
treatment 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-type
support groups. With some variation, this has been the model for
treating addiction for decades.

Higgins' idea was quite 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. All we
wanted to do was give them reason to pause," said Higgins, professor
of psychiatry at the University of Vermont. His studies found that
with vouchers, retention rates in his rehab programs increased by five
times, to 50 percent.

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,
but not huge, effect in keeping addicts in outpatient treatment and in
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. And, said
Tyrone Thomas, a drug counselor who works with McKay, the idea of
rewarding people to stay off drugs offends those who think abstinence
should be its own reward.

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

Thomas also noted that some clients and counselors think "these
research projects aren't always great, every single time," and resist
the idea of trying new approaches.

Nonetheless, the reward theory has excited a cadre of addiction
researchers who think it should - and soon will - become part of the
standard treatment regimen for people addicted to booze or drugs,
gambling or food. It also has reminded those in the trenches that
there's always room for innovation.

"The more I think about it, the more I think we should be like Toyota,
with their system of continuous quality improvement," said Richard M.
Pine, president of Livengrin Foundation Inc., one of Pennsylvania's
first private nonprofit alcohol rehab centers.

"Rather than congratulating ourselves for doing a good job and taking
care of a lot of people, we should always think of how to do it
better," he said.

As Livengrin, in Bensalem, turns 40 this year, its original mission -
to help alcoholics - has broadened to include other addicts. Today the
facility offers detox, residential and outpatient programs, individual
therapy, and 12-step support groups.

Vouchers aren't used, although William J. Lorman, Livengrin's chief
clinical officer, said he was interested in exploring the idea.
Nonfinancial incentives, such as TV privileges, might be more
feasible, he said.

Vouchers helped Odis Rivers get through rehab six years
ago.

Rivers, 55, became a heroin addict after his 1970 discharge from the
Army and was in and out of rehab before landing in a Wayne State
rehab. Clean urine samples allowed him to collect $1,800 worth of
vouchers, which he used to buy a nephew's 1987 Oldsmobile.

While he doesn't credit vouchers for "curing" him, he considers them a
valuable part of his recovery. "It was the vouchers, the medication,
the classes and stuff that all really helped me," he said.

Voucher proponents agree that incentives alone aren't the answer. But
Stephen J. Gumbley, whose goal at the Addiction Technology Transfer
Center of New England at Brown University is to translate research
into practice, thinks they're worth trying.

"I think people are finally getting the idea that science can help us
get the results we want," he said.