High Price

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. 8 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. 9 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. 10 And Silverman’s group has replicated these findings several times, in different populations of people with addictions.
    While there are multiple benefits to this line of research, one of the most important is that participants’ drug-taking behaviors are being replaced with real-world job skills. In this way, these programs ultimately pay for themselves by helping those who were formerly unemployable become productive workers. When alternative reinforcers are made available to those who formerly lacked them, drug problems can be overcome.
    A nd in my own case, at Columbia in the summer of 1999 I finally reaped the reward I’d been seeking for so long: a faculty position job at an Ivy League university. I’d continued putting in long hours, studying my human participants as intently as I’d once watched my rats (though, thankfully, I didn’t have to operate on the people). At the New York State Psychiatric Institute, in upper Manhattan, I would hole up in my office, analyzing data and thinking about my research. Although the cubicle-sized room had a window with a breathtaking view of the Hudson River, I kept the shade down: the only thing I wanted to see was my data or the research