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Community Reinforcement Approach (CRA) with vouchers

Substance Use Disorders: Treatment for Adults
Benefit-cost methods last updated December 2023.  Literature review updated May 2014.
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This intervention combines the Community Reinforcement Approach with contingency management. The Community Reinforcement Approach to therapy is relatively intensive and consists of four main topics: (1) minimizing contact with known antecedents to substance use and recognizing consequences of use, (2) counseling to find alternative activities, (3) employment counseling (if needed), and (4) reciprocal relationship counseling if partner was not involved in substance use. Counseling generally occurs twice a week for the first three months and once a week for the next three months. The contingency management portion of the intervention rewards clients with vouchers if they have negative urinalysis exams. These vouchers can be exchanged for prizes that range in value.
For an overview of WSIPP's Benefit-Cost Model, please see this guide. The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2022). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $2,364 Benefits minus costs $9,393
Participants $3,046 Benefit to cost ratio $7.62
Others $1,187 Chance the program will produce
Indirect $4,214 benefits greater than the costs 60%
Total benefits $10,812
Net program cost ($1,418)
Benefits minus cost $9,393

^^WSIPP does not include this outcome when conducting benefit-cost analysis for this program.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases. See Estimating Program Effects Using Effect Sizes for additional information.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Adjusted effect sizes(ES) and standard errors(SE) used in the benefit - cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
30 1 19 0.002 0.472 30 n/a n/a n/a 0.002 0.996
30 8 248 -0.580 0.129 30 0.000 0.187 33 -0.580 0.001
30 1 19 -0.641 0.470 30 n/a n/a n/a -0.641 0.173
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Affected outcome: Resulting benefits:1 Benefits accrue to:
Taxpayers Participants Others2 Indirect3 Total
Illicit drug use disorder Criminal justice system $5 $0 $14 $2 $21
Labor market earnings associated with illicit drug abuse or dependence $955 $2,249 $0 $0 $3,203
Health care associated with illicit drug abuse or dependence $1,142 $177 $1,173 $571 $3,063
Mortality associated with illicit drugs $263 $620 $0 $4,350 $5,234
Program cost Adjustment for deadweight cost of program $0 $0 $0 ($709) ($709)
Totals $2,364 $3,046 $1,187 $4,214 $10,812
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Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $2,602 2013 Present value of net program costs (in 2022 dollars) ($1,418)
Comparison costs $1,432 2013 Cost range (+ or -) 20%
The cost of treatment is the weighted average cost for studies included in the analysis. We calculate this average cost using Washington's Medicaid hourly reimbursement rates for individual or group outpatient therapy times the weighted average of total hours of outpatient individual or group therapy across the studies. Treatment group costs also include the cost of the vouchers. These costs are estimated from the studies included in the analysis. We used the average voucher received when available and the maximum possible voucher when an average was not reported. Comparison group costs are computed in a similar manner based on treatment received in the studies (individual or group treatment as usual or no treatment).
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Benefits Minus Costs
Benefits by Perspective
Taxpayer Benefits by Source of Value
Benefits Minus Costs Over Time (Cumulative Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in discounted dollars. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Citations Used in the Meta-Analysis

Bickel, W.K., Marsch, L.A., Buchhalter, A.R., & Badger, G.J. (2008). Computerized behavior therapy for opioid-dependent outpatients: a randomized controlled trial. Experimental and Clinical Psychopharmacology, 16(2), 132-143.

Chopra, M.P., Landes, R.D., Gatchalian, K.M., Jackson, L.C., Buchhalter, A.R., Stitzer, M.L., . . . Bickel, W.K. (2009). Buprenorphine medication versus voucher contingencies in promoting abstinence from opioids and cocaine. Experimental and Clinical Psychopharmacology, 17(4), 226-236.

Garcia-Rodriguez, O., Secades-Villa, R., Higgins, S.T., Fernandez-Hermida, J.R., Carballo, J.L., Errasti, P.J.M., & Al-halabi, D.S. (2009). Effects of voucher-based intervention on abstinence and retention in an outpatient treatment for cocaine addiction: a randomized controlled trial. Experimental and Clinical Psychopharmacology, 17(3), 131-138.

Higgins, S.T., Delaney, D.D., Budney, A.J., Bickel, W.K., Hughes, J.R., Foerg, F., & Fenwick, J.W. (1991). A behavioral approach to achieving initial cocaine abstinence. The American Journal of Psychiatry, 148(9), 1218-1224.

Higgins, S.T., Budney, A.J, Bickel, W.K., Hughes, J.R., Foerg, F., & Badger, G. (1993). Achieving Cocaine Abstinence with a Behavioral Approach. American Journal of Psychiatry, 150(5), 763-769.

Secades-Villa, R., Garci?a-Rodríguez, O., García-Fernández, G., Sànchez-Hervàs, E., Fernández-Hermida, J.R., & Higgins, S.T. (2011). Community reinforcement approach plus vouchers among cocaine-dependent outpatients: twelve-month outcomes. Psychology of Addictive Behaviors : Journal of the Society of Psychologists in Addictive Behaviors, 25(1), 174-9.

Secades-Villa, R., Garci?a-Rodri?guez, O., Higgins, S.T., Ferna?ndez-Hermida, J.R., & Carballo, J.L. (2008). Community reinforcement approach plus vouchers for cocaine dependence in a community setting in Spain: six-month outcomes. Journal of Substance Abuse Treatment, 34(2), 202-207.