High Price

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