The Price of Cold Turkey

What does a psychiatrist call it when you pay people to stop consuming alcohol and/or drugs, and run frequent tests to make sure they are holding up their end of the deal? Contingency management. According to “Contingency Management: Incentives for Sobriety,” an excellent survey article by Higgins and Petry:

Contingency management (CM) is a strategy used in alcohol and other drug (AOD) abuse treatment to encourage positive behavior change (e.g., abstinence) in patients by providing reinforcing consequences when patients meet treatment goals and by withholding those consequences or providing punitive measures when patients engage in the undesired behavior (e.g., drinking). For example, positive consequences for abstinence may include receipt of vouchers that are exchangeable for retail goods, whereas negative consequences for drinking may include withholding of vouchers or an unfavorable report to a parole officer.

I wish they chose a more transparent name, but the results of this well-developed literature are striking even to me. There have been lots of good experiments where addicts are randomly assigned to either the experimental group, where they get conditional rewards for abstinence, and a control group, where they get unconditional rewards. Paying people to ditch their favorite vice is amazingly effective, though admittedly a lot of the sample sizes are small.

For example, one study of 38 cocaine-dependent adults randomly assigned patients to one of several treatments. CM was one of them. The results:

In the CM condition, patients received vouchers for submitting cocaine-negative urine specimens. Fifty-eight percent of patients in the CM condition remained in treatment throughout the study, compared with 11 percent of patients in the comparison group… Sixty-eight percent of clients in the CM condition maintained at least 8 weeks of continuous cocaine abstinence, compared with 11 percent of patients in the comparison group.

Economists have done a number of studies showing that the demand for drugs usually considered highly addictive is still fairly elastic. The CM literature goes a bit further: Instead of estimating elasticity, it estimates the total consumer’s surplus of the marginal addict, by seeing how much you have to pay people to reduce their consumption to zero.

As might be expected, psychiatrists look at these results and see only another tool for “helping” people who probably don’t want to be helped in the first place. In contrast, I look at these results and see further evidence that addiction is not a “disease,” but a free choice.

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