Bryan Caplan  

The Price of Cold Turkey

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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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The author at Anger Management in a related article titled DAILY ROUND UP writes:
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COMMENTS (11 to date)
Scott Scheule writes:

Cheers.

Chris writes:

There's a big difference between saying that people can modify their drug consumption if given an incentive and saying that addiction is a free choice. The neurobiological basis of addiction is increasingly well understood. It has been established for decades that certain parts of the brain respond to drugs and that these pathways become reinforced by repeated exposure. I have seen addicts in the hospital and these people are not freely choosing to take drugs. They usually enter drug rehabilitation seeking help in overcoming their addiction.

Bryan, you've come to sound increasingly like a flack for the Church of Scientology. As another commentatory has pointed out, you seem to be locked up in the ivory tower with little real-world experience. Trying getting out there and interacting with real people. Try doing some volunteer work and see real-life addicts and schizophrenics. The volunteer department of your county hospital should be able to point you in the right direction. They are truly ill and deserve our compassion and help. The overall impact of your postings demonstrates that you don't have a compassionate bone in your body, which probably makes you proud, but to the rest of us looks like stunted growth.

T.R. Elliott writes:

Hurrah. Economists are not only energy experts, they're medical professionals. A quick look at a smidgeon of data, and conclusions are easily drawn. Perhaps economists quick to draw conclusions such as this have gone to the "Frist school" of medical diagnosis, the one that looks at video tapes and comments on the eye tracking of a woman with no visual brain center.

jaimito writes:

Contrary to Chris, I think Bryan had an interesting insight. Rewards work, even on severe physiological addictions.

Anecdote. At 19 I stopped going to class and spent my days in the library. My parents, desperate, asked my uncle Ivor - a business genius - to talk to me. He said he will pay me montly salary and bonuses for achievement. He set a big prize for getting the degree at the end of the year, something impossible. The salary was paid me by his treasurer, in a big factory, with much ceremony. After the third montly salary I started working and finished first in my class. Money talks. At least, to me.

Bryan, I would love somebody manipulating me (paying me) to lose overweight. But no one cares. My uncle z"l is long dead.

Mark Bigelow writes:
I look at these results and see further evidence that addiction is not a "disease," but a free choice.

I totally agree with that statement. It seems to me like the researchers are merely finding that people are more addicted to money than alcohol or AOD.

To play the devil's advocate a little, perhaps these are only temporal results. If they extended the study to 1 year instead of 8 weeks, how many more people would they lose? It may be easy enough to quit for 8 weeks, with the knowledge that you'll have money to buy more when you're done, but what about for 1 year or indefinitely? Perhaps they could re-do the study and tell the participants it will be indefinite and then measure the results?

N. writes:

Sounds to me like it creates a market for 'recovering addicts.'

If you subsidize the number of cocaine users who try to quit, do you not run the risk of encountering those who become users just to receive the reward for quitting?

Robert Schwartz writes:

When I was much younger, a very long time ago, I was a freshman in law school, and I had a two pack a day cigarette habit. My then girlfriend and my parents were on my case to quit. One fine spring morning about two weeks before finals (a real stress point in the lives of young law students), I left my apartment and to walk to class. As I passed a dumpster I tossed my cigarettes in there. And that was it. I never smoked again.

I am a real skeptic about addiction theory.

Mr. Econotarian writes:

The neurobiology of addiction is understood at the level of neurons, but very little is understood at the level of the entire brain.

You may have a part of your neural system become addicted to drugs, but other (conscious or unconscious) neural systems may provide a level of inhibition that drowns out the "addicted" part.

Money is seen by many to be a representation of power. Having power is addicting (through endogenous opiates). Thus your own addiction to power may inhibit addictions to cocaine, etc.

James writes:

I wonder what the addiction believers would accept as negative evidence to their belief in the existence of addiction.

scarhill writes:

Apropos N's comment, see Charles Murray's Losing Ground, where he walks through through a "thought experiment" to design a program of incentives to encourage people to quit smoking. He demonstrates pretty convincingly that you can't do it unless you have disincentives as well. (Note that the program that Bryan describes does.)

Jim

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