BBC Radio 4 recently ran a fascinating one-off programme called Sugaring the Pill on schemes that pay people to lose weight, get vaccinated or stay off drugs. Payment turns out to be particularly effective at keeping addicts clean and this caught my eye because it seems to go against some of the core scientific beliefs about persistent drug users.
The programme explores the ethics of payment programmes and the public’s discomfort, particularly when applied to drugs, with handing out rewards for something we should perhaps be doing anyway.
Payment as treatment is known in the medical literature as ‘contingency management’ and has been found to be most effective in keeping heroin and cocaine addicts clean.
As the programme, and the research summary linked above, describe, a typical payment scheme will give a ticket for every clean urine test – usually starting with a small value like £1, and increasing by 50p each time.
Only when the patient has completed a whole series of clean drug tests, maybe after a month or two, can they exchange their tickets for shopping vouchers which they can spend in the high street.
The fact that these schemes are so effective is surprising, because they rely on abilities thought to be lacking or impaired in addicts – mainly the capacity to delay rewards and gratification.
There is now a host of research showing that addicts have problems with temporal discounting. We all have the tendency to judge future benefits as significantly less important than immediate ones but this seems to be enhanced in drug users who greatly overly prioritise rewards that arrive sooner.
Also, persistent drug use is widely believed to alter the brain’s reward system so positive reinforcement (wanting benefits) becomes less persuasive than negative reinforcement (the desire to escape an unpleasant sensation).
So, for people who should be primarily motivated by immediate chemical rewards over long-term abstract benefits, a slowly accumulating shopping voucher scheme would be the last thing you would predict to have such a reliable effect on keeping people off the smack or blow.
I note this purely as a curious inconsistency and if you have any suggestions that might explain it, do add them in the comments.
The BBC programme is excellent, by the way, and is also available as a podcast.