What price sobriety (in vouchers)?

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).

Similarly, research suggests that in addiction, the desire to take drugs become less modifiable by our executive system and so less amenable to voluntary control.

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.
 

Link to Sugaring the Pill info and streamed version.
Link to page with podcast (for four weeks).

9 Comments

  1. Matthew Gullo
    Posted November 3, 2010 at 10:42 am | Permalink

    I have published some ideas on this previously (doi:10.1016/j.neubiorev.2008.06.003). People vulnerable to addiction are highly sensitive to rewards generally (not just drugs) and value immediate reward over delayed reward, or even avoiding delayed punishment. This is a pre-existing propensity.

    The key to CM’s success is that it takes advantage of this propensity for ‘good’ ends. Money and vouchers compared to, say, not losing one’s job or going to jail, are more proximal rewards and thus more tangible. Rather than just trying to improve executive control, CM also engages the reward system to help redirect behaviour.
    Thus, it uses their preexisting impulsivity to help them – because being impulsive isn’t always a ‘bad’ thing.

  2. Matthew Gullo
    Posted November 3, 2010 at 10:51 am | Permalink

    I have published some ideas on this previously (doi:10.1016/j.neubiorev.2008.06.003). People vulnerable to addiction are highly sensitive to rewards generally (not just drugs) and value immediate reward over delayed reward, or even avoiding delayed punishment. This is a pre-existing propensity.

    The key to CM’s success is that it takes advantage of this propensity for ‘good’ ends. Money and vouchers compared to, say, not losing one’s job or going to jail, are more proximal rewards and thus more tangible. Rather than just trying to improve executive control, CM also engages the reward system to help redirect behaviour.

    Thus, it uses their preexisting impulsivity to help them – because being impulsive isn’t always a ‘bad’ thing.

  3. dlende
    Posted November 3, 2010 at 11:27 am | Permalink

    Vaughan,
    My take would be that this combines two effective approaches in one. As we know from Motivational Interviewing, people suffering from substance abuse are often motivated to change. MI works by reinforcing the reasons they have to change.

    However, “sobriety” is an abstract concept, an off-in-the-future idea. They might want it, but it is distant and not so real. Paying for the clean tests makes that immediate goal have an immediate reward, which they pay attention to. It reinforces soemthing they already want.

    Moreover, most users do have serious cash flow problems, as they try to maintain an often expensive habit. So money is definitely real to them.

    The other thing to add is a framing effect. Sobriety is generally a state defined by loss of something they like – and that means its value gets discounted. It’s also risky, not a sure thing.

    In contrast, a clean drug test has a positive reward, the money, associated with it. They are gaining something, and that is an easier choice for them than the risky choice to “maintain sobriety.”

  4. smykael
    Posted November 3, 2010 at 4:40 pm | Permalink

    dlende & Vaughn,

    Adding to your ideas regarding sobriety; not only does sobriety represent a loss of those wonderful chemical rewards, and not only does it exist in as an off-in-the-future goal, it is also impossible to remember what it feels like when you’re addicted. Seriously, you know that it’s something you used to be, and you know that for abstract reasons you want to get there, but like Heaven it becomes a mere article of faith. Money is real. Especially if you have an expensive habit.

  5. Posted November 3, 2010 at 6:26 pm | Permalink

    The standard view of addiction as a “hijacked brain” unable to change, react rationally or respond to reward at all is basically wrong. We’ve known for years that treatment that is punitive is ineffective— addiction wouldn’t exist if punishment worked because it is by definition, compulsive use *despite* negative consequences. Addicted people are overwhelmingly not seeking “extra” pleasure— they’re trying to reduce pain so adding more pain drives addiction not recovery.

    Kind, empathetic socially rewarding treatment is much more effective— so monetary rewards in a bleak life with little nondrug pleasure also make sense as an effective part of treatment. Contingency management research has shown this for years and you can even get users to choose money over drugs in the lab.

    Sadly, society wants to see addicts as hedonistic scum so the idea of paying people to stop using is a political nonstarter in most places. In the UK, today, the ACMD is meeting to decide a question that the data decided long ago— should people be able to stay on methadone without time limits? If you want people to stay alive, have less disease and commit less crime, the answer to that is YES. But politicians don’t like that, they see maintenance as giving addicts what they want— and I’m sure this will be received equally well.

    They want to spend my tax dollars on paying people to not to do what they shouldn’t be doing anyway?

  6. Posted November 3, 2010 at 11:03 pm | Permalink

    Hey vaughan,

    You may want to read Gene Heyman’s 2009 book Addiction. http://www.amazon.com/Addiction-Disorder-Gene-M-Heyman/dp/0674032985. He includes this finding as a major part of his theory.

  7. Jakob
    Posted November 4, 2010 at 1:23 pm | Permalink

    It’s puzzling how addicts’ increased reward discounting doesn’t undermine giving them delayed rewards. I guess it matters here that the rewards increase all the time. This would counter the discounting in two ways: the bigger the reward the less the discounting, and also because there is an element of immediate reward, namely in increasing the amount for every clean test.

  8. Posted November 5, 2010 at 1:23 pm | Permalink

    If I recall correctly, there is an explanation of addicts behaviour somewhere in the literature regarding the Iowa Gambling Task…

    Yes, here’s a paper discussing it:

    http://dept.wofford.edu/neuroscience/NeuroSeminar/pdfFall2008/a9.pdf

    Bechara suggests that its about insensitivity to future consequences, linked to orbitofrontal function. From my own research, I’ve formed a qualitative hunch (its not quite a hypothesis yet) that people can have seperate impairments to future consequences for rewards and future consequences to punishments.

    For example, the literature on psychopathy suggests psychopaths are less sensitive to fear and punishing stimuli, whilst maintaining sensitivity to rewards. Of course, psychopaths also lack empathy, which is something altogether different.

    My hunch is that people with low sensitivity to future punishments will indulge in risk taking or antisocial behaviours more frequently, which will include things like taking drugs. If however, these same people have intact sensitivity to rewards (and future rewards) then they may be able to inhibit their drug use by being motivated by that.

    In other words, there may be people who are insensitive to punishment based operant conditioning, even though they are still sensitive to reward based operant conditioning.

    From a social perspective, I also feel that the lack of prospects of future reward in some people’s social environment means that they may feel they have little to lose by taking various drugs. In contrast, us psychologists have a lot to lose (or plenty to gain by not taking drugs) such as failing a CRB check or getting the psychology job we want.


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