Community reinforcement approach (CRA) for cocaine dependence in the Spanish public health system: 1 year outcome.
Secades-Villa R., Sánchez-Hervás E., Zacarés-Romaguera F. et al. Drug and Alcohol Review: 2011, 30, p. 606–612.

Emerging from its US home, the community reinforcement approach aiming to rearrange a patient's life outside the clinic to reinforce abstinence has been trialled for cocaine users at a Spanish drug treatment centre. Though therapeutic contact was equalised, patients did better than in standard treatment based on cognitive-behavioural principles.

Summary:
Often trialled in combination, contingency management approaches, which systematically apply incentives and sanctions, and the community reinforcement approach are recommended psychological interventions for addiction to cocaine and other stimulants.

Community reinforcement involves behavioural skills sessions intended to rearrange personal and community resources and develop alternative social activities to reinforce recovery from substance use problems. Though supported by research, there are questions over cost and feasibility in usual community contexts, especially outside the USA.

The featured study assessed the approach in a Spanish city at a public outpatient facility specialising in substance use problems, following up patients for a year after the intervention started. Patients selected for the study were adults without severe psychopathology who were seeking treatment for their dependence on cocaine. Nearly 9 in 10 of the 82 who joined the study were men. They averaged 31 years of age, had used cocaine for on average 10 years, and about three quarters were in full-time employment.

They were assigned at random to standard treatment or the community reinforcement approach, both offered for six months and with the same weekly frequency of sessions and total amount of therapeutic time. Following no set protocol, standard treatment included family sessions as appropriate and was based on cognitive-behavioural, relapse prevention principles. In contrast, community reinforcement was applied in line with a structured protocol setting the content for each session plus written 'homework' assignments, and therapists (different staff from in the standard treatment) had been intensively trained and were supervised weekly.

A year after treatment started, 34 patients (41% of the initial sample and 85% of those who completed treatment) could be reassessed, including 37% of those assigned to standard treatment and 44% community reinforcement.