High Price (34 page)

In the study I briefly described in the preface to this book, cocaine users were given a choice between various doses of cocaine and various amounts of vouchers for cash or merchandise.
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On average, on the street, our participants spent $280 a week on cocaine. These were not casual or irregular users.

Marian Fischman’s research group when I arrived at Columbia in 1998. From left, Marian is the fifth person standing. Herb Kleber is seated next to me.

Our procedure worked like this. First, we recruited frequent crack users through ads in the
Village Voice
and from referrals by other users provided by those who replied to the ads. Then we screened the volunteers for health problems that would ethically preclude their participation in cocaine research (for example, heart disease). We also screened their urine to ensure that it was positive for cocaine, though we did not reveal that we were confirming their use in this fashion.

Those who were cleared to participate were paid to stay for two to three weeks in a ward at Columbia-Presbyterian Hospital in Harlem (now New York–Presbyterian). Before we did any of this, of course, we’d applied for and received special licenses to work with illegal drugs on human subjects and been cleared by an ethics committee called an institutional review board (IRB). Then we obtained the cocaine from a pharmaceutical company, keeping it locked in the pharmacy with other controlled substances, using careful procedures to account for all of it.

On days participants were scheduled to smoke cocaine, each one would sit in a small room with a computer at a desk, where we could observe them through a one-way mirror. A nurse was in a nearby room, monitoring her or his vital signs and lighting the crack pipe when cocaine was chosen. When they smoked crack, participants were blindfolded so that they couldn’t see the size of the rock they were getting. We didn’t want them to have visual cues that might amplify or diminish their expectations about the hit.

At the very start of each day, before having to make any choices, participants had a “sample” trial. That meant that they were allowed to try the dose of cocaine we were making available that day and to see and hold the cash or merchandise vouchers on offer. Both the researchers and the participants were blinded as to whether actual cocaine or placebo was placed in the crack pipe. After the user had sampled the day’s dose, he or she would participate in five “choice trials,” spaced fifteen minutes apart. When a choice was available, an image of two squares would appear on the computer and the participant had to either click the left (crack) or right (voucher) side of the mouse to indicate their choice.

In order to actually get the drug or voucher, they then had to press the space bar on the keyboard two hundred times. During their first four choice sessions, the choice was between a voucher for five dollars in cash or the day’s cocaine dose; during the last four, they had the choice of the dose or the five-dollar merchandise voucher.

Again, the results were similar to those seen comparing different rewards in the animal literature and in earlier human trials. When larger cocaine doses were available, users almost always chose cocaine over the cash or merchandise voucher. So far, this was congruent with the idea that addiction makes people place drugs first. But the rest of the data demolished that theory, showing that lower doses were often resisted. Despite the popular conception that addicted people will choose any dose of drug over any other experience—especially once they’ve already had a taste of it to kindle their craving—this is not what we find in the lab. Even around drugs, addicted people are not simply slaves to craving. They can make rational choices.

This was the case even though the alternative in each choice had only a maximum value of five dollars. In total, our participants could earn up to fifty dollars each day by participating in two complete sessions, which was a significant sum given their usual low income. But if the “first hit produces irresistible craving” theory were true, any dose should have had infinite value during the moment of choice. The cocaine users shouldn’t have been able to think beyond the five dollars to the fifty—or about the particular dose, if the idea that people with addiction are totally out of control once they start using drugs is true.

Nonetheless, on average, users in our studies smoked two fewer doses of cocaine when the alternative was cash as opposed to merchandise.
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This meant that cash money was 10 percent more effective than vouchers in suppressing cocaine use. The conventional wisdom about addictive behavior being completely irrational couldn’t at all account for this result. If people addicted to cocaine always went for drugs no matter what, there should have been no difference.

Because our findings were so different from what most people have been taught about drugs, critics sometimes argued that they only really showed that these crack users were saving their money to buy more cocaine on the street later. That itself, however, doesn’t even support the conventional view of addiction. Weren’t addicted people supposed to be unable to resist drugs that were in front of them and be incapable of saving up for drugs or anything else later? And why would someone turn down pure pharmaceutical cocaine in a legal setting in favor of possibly being beat on the street and getting stepped-on (adulterated) drugs illegally in the future?
That
would truly be irrational under the logic of the idea of addiction as something that “hijacked” the brain and took control of the will in favor of immediate drug-seeking.

Alternatively, some folks predictably claimed that the users we recruited “weren’t really addicted.” People who were genuinely addicted would never have turned down free crack cocaine, they said. If we’d studied participants with genuine drug problems, they argued, we would have had very different results. Our participants, however, clearly had arranged their lives around crack. They weren’t rich folks who had an extra few hundred bucks a month to spend on cocaine: they typically had unstable living arrangements and few or nonexistent family ties. Many had been convicted of crack-cocaine-related crimes and all had tested positive for cocaine on multiple occasions during the screening process. Most could tell you where to get the best and most inexpensive cocaine in the city. If this wasn’t “real” addiction, what was?

The more I studied actual drug use in human beings, the more I became convinced that it was a behavior that was amenable to change like any other. So why did it seem so intractable in neighborhoods like the one where I’d grown up—and why did people there rarely even question their beliefs about drugs? A key problem is that poor people actually have few “competing reinforcers.” Crack isn’t really all that overwhelmingly good or superpowerfully reinforcing: it gained the popularity that it achieved in the hood (again, far less than advertised) because there weren’t that many other affordable sources of pleasure and purpose and because many of the people at the highest risk had other preexisting mental illnesses that affected their choices.

And that was why, despite years of media-hyped predictions that crack’s expansion across classes was imminent, it never “ravaged” the suburbs or took down significant percentages of middle- or upper-class youth. Though the real proportion of people who became addicted to crack in the inner city was low, it was definitely higher than it was among the middle classes, just as is true for other addictions, including alcohol. Money has a way of insulating people from consequences. In addition, it carries with it more reasons for abstaining—there are things a high-socioeconomic-status person
has
to do that are incompatible with being intoxicated. Becoming an addict is tantamount to disavowing one’s social niche.

High socioeconomic status provides more access to employment, and alternative sources of meaning, purpose, power, and pleasure, as well as better access to mental health care. The differences in the prevalence of crack problems are mainly related to economic opportunity, not special properties of cocaine. While drug use rates are pretty similar across classes (and often, actually lower among the poor), addiction—like most other illnesses—is not an equal-opportunity disorder. Like cancer and heart disease, it is concentrated in the poor, who have far less access to healthy diets and consistent medical care.

Moreover, research on alternative reinforcers has now shown repeatedly that they can be effective in changing addictive behavior. This kind of treatment is called contingency management (CM). The idea comes from basic behaviorism: our actions are governed to a large extent by what we are rewarded for in our environment. These cause-and-effect relationships where a reward is dependent (contingent) upon the person either doing or (in the case of drugs) not doing a particular behavior can be used to help change all types of habits.

In fact, part of the reason we wanted to compare the responses of crack users to vouchers for cash in our study, as opposed to vouchers for merchandise, was ultimately to understand what types of reinforcement would work best to aid recovery. There is now a whole body of literature showing that providing alternative reinforcers improves addiction treatment outcomes. It is far more effective than using punitive measures like incarceration, which often is less useful in the long run. Although while incarcerated many people stop or at least reduce their drug use, jail and prison themselves don’t provide positive alternatives to replace drug habits. When heavy drug users return to their communities, they are not better equipped to find work and support themselves and their families; instead, having a criminal record and a gap in their résumé makes finding work even harder.

Reward-based CM treatments are sometimes controversial because they can be portrayed in the media as “paying addicts to stop using.” Many people think it’s unfair to those who “do the right thing” by not taking drugs to see drug users getting paid to behave the way they should behave anyway. Cash rewards are especially touchy, since the users could presumably simply buy drugs with the money.

But I see it differently, and here’s why. Indeed, we’ve all probably observed how people respond to rewards in multiple areas of life. It’s often seen most clearly in parenting: for example, if my sons want a new computer, I expect them to maintain a certain GPA. In most workplaces, if the boss offers a raise for achieving certain goals, employees will do their best to hit those targets. Because drug use is governed by the same principles that govern other behaviors, contingency management treatment uses these ideas to change addictive behavior.

Importantly, using alternative reinforcers in treatment doesn’t make it more expensive, in part because it makes it more effective. When contingency management techniques are specifically applied not only to supporting recovery but also to developing skills that are in demand by employers, the costs are cut even further because the work itself produces value, not to mention reducing people’s need for government benefits.

One study randomly assigned treatment-seeking cocaine users to either contingency management plus behavioral counseling or to a traditional twelve-step focused counseling treatment, which involves referring people to meetings of twelve-step groups like Alcoholics Anonymous and teaching them about the steps involved. Patients in the contingency management arm of the study received vouchers for merchandise whenever they had drug-free urines. Fifty-eight percent of participants in the contingency management group completed the twenty-four-week outpatient treatment—compared to just 11 percent in the twelve-step group. In terms of abstinence, 68 percent achieved at least eight weeks cocaine-free, versus just 11 percent in the twelve-step condition.
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And after the rewards are stopped, people in CM are no more likely to relapse than other treatment graduates. Since more people complete treatment with CM, this makes for an overall reduction in relapse.

More than three dozen studies have now been conducted on contingency management, used in the treatment of opioid, cocaine, alcohol, and multiple-drug addiction.
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They show that contingency management typically does better than treatment that does not use it—and that larger, faster rewards are more effective than smaller and less quickly received incentives. This, again, is exactly what research on other types of behavior would predict. Cash, as we showed, is more effective than merchandise as a reinforcer.

The most exciting CM research currently being conducted is work by Ken Silverman and his colleagues at Johns Hopkins University. They have developed what they call a “therapeutic workplace” in which CM is used to help train drug users for jobs in data entry. One study, for example, found that the therapeutic workplace nearly doubled abstinence rates from opioids and cocaine among pregnant and postpartum addicted women, from 33 percent to 59 percent in urine samples taken three times a week.
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And Silverman’s group has replicated these findings several times, in different populations of people with addictions.