A Contextualized Reinforcer Pathology Approach To Addiction: Psychology
A Contextualized Reinforcer Pathology Approach To Addiction: Psychology
A Contextualized Reinforcer Pathology Approach To Addiction: Psychology
1038/s44159-023-00167-y
A contextualized reinforcer
pathology approach to addiction
Samuel F. Acuff1, James MacKillop2,3 & James G. Murphy 4
Abstract Sections
drug use as an operant reinforcer pathology, emphasizing that a drug Reinforcer pathology
is consumed because of overvaluation of smaller immediate rewards Alternative reinforcement
relative to larger delayed rewards (delay discounting) and high
Translational evidence
drug reinforcing value (drug demand). These motivational processes
Implications for public health
are within-individual determinants of behaviour. A third element of
learning theory posits that harmful drug use depends on the relative Conclusions
constraints on access to other available activities and commodities in
the choice context (alternative reinforcers), reflecting the substantial
influence of environmental factors. In this Perspective, we integrate
alternative reinforcers into the contemporary behavioural economic
account of harmful drug use — the contextualized reinforcer pathology
model — and review empirical literature across the translational
spectrum in support of this model. Furthermore, we consider how
increases in drug-related mortality and health disparities in addiction
can be understood and potentially ameliorated via a contextualized
reinforcer pathology model in which lack of alternative reinforcement
is a major risk factor for addiction.
Alpert Medical School, Brown University, Providence, RI, USA. 2Peter Boris Centre for Addictions Research,
1
Department of Psychiatry and Behavioural Neurosciences, McMaster University/St Joseph’s Healthcare Hamilton,
Hamilton, Ontario, Canada. 3Homewood Research Institute, Guelph, Ontario, Canada. 4Department of Psychology,
University of Memphis, Memphis, TN, USA. e-mail: [email protected]
options is distal, but preference often reverses as the availability of the a 100
Higher demand
smaller, sooner reward becomes imminent31 (Fig. 1b). Lower demand
Individuals vary in their time horizons for behavioural allocation, Intensity
influencing the rate at which they devalue delayed rewards. Thus,
utility maximization is relative to the temporal frame of reference. 10
Consumption
A local (shorter) time frame of reference typically compares discrete, Elasticity
independent choices (for example, should I drink alcohol tonight or
study for my exam?) to maximize short-term utility (enjoyment from
drinking and socializing). By contrast, a temporally extended global or 1
molar frame of reference compares two choices on the basis of their
anticipated value over the course of an extended pattern of behav-
iour that comprises many discrete choices that might accrue value Breakpoint
exponentially over time32,33. For example, consider a series of discrete 0.1
0.10 1.00 10.00 100.00 1,000.00
choices between watching TV and drinking alcohol versus exercising
Price ($)
each night over the course of a month. An evening spent watching TV
and drinking alcohol might have high immediate value that does not
necessarily aggregate over time (whereas costs might aggregate).
b Value of substance
By contrast, exercise might lead to benefits that are not immediately Value of alternatives
evident after one discrete event but instead emerge after consistently
engaging in a pattern of behaviour. This intertemporal choice dynamic
is foundational to behavioural economics, including applications to
substance-related harms33.
Value
Addiction might be better understood by simultaneously consider- role of alternative reinforcers in addiction motivation. We then describe
ing temporal discounting and drug-specific reinforcing value, alongside the matching law, which serves as a primary theoretical premise of
immediate and delayed costs and benefits of both the substance and alternative reinforcement.
alternatives over extended patterns of behaviour. Indeed, real-world
decision making occurs in an open economy in which an individual Contextualized reinforcer pathology
can typically choose between two or more options in a choice context. Contextualized reinforcer pathology posits that drug value, and conse-
When considering this broader choice context41,42, distal causal influ- quently the likelihood of drug consumption, is critically determined not
ences exerted by the characteristics of the choice economy emerge that only by temporal windows of value allocation, but also by the charac-
cannot be described by models of proximal causation44 and emerge teristics of environmental choice contexts (Fig. 3). The contextualized
only through a molar analysis of behaviour42,45. Although the contem- reinforcer pathology model is a molar theory of behaviour: behaviour
porary reinforcer pathology model acknowledges the importance is measured over extended temporal windows and diverse sets of con-
of relative value and often compares the immediate value of drugs straints to characterize the most likely behavioural output over time45.
to the delayed value of some alternative, the central tenets explicitly Constraints can be anything that influence the value of the commodi-
ignore the distal causal influence of the choice environment30,41,42,45. ties in the choice context50. From this perspective, behaviour can be
Indeed, the trenchancy of behavioural economics — and a distin- broadly explained through utility (value) maximization, in which choice
guishing factor from other theories of addiction — is its explicit scaf- outcomes maximize benefits and minimize costs over a specified and
folding to reconcile person-level and environmental factors (Fig. 2a). varying temporal window (that is, there is no assumption that human or
Other prominent theories of addiction emphasize factors within the non-human laboratory animals maximize utility in an ultimate sense).
person, be it through neurobiological46,47 or psychological mecha- A key assumption of contextualized reinforcer pathology is that a
nisms. By contrast, sociological48 and anthropological49 models empha- drug’s reinforcing value is not an innate quality of a drug but is instead
size environmental conditions over person-level factors. Although critically determined by characteristics of the choice environment.
proponents of other person-level theories have begun to integrate Although delayed reward discounting and behavioural economic
environmental factors46, behavioural economics provides a robust demand have been operationalized as stable, individual difference vari-
conceptualization that quantitatively and intuitively accounts for both ables, this is a feature of measurement; the stability in these constructs
within-individual and environmental factors, making this theory ideally is due in part to the stability of the environmental choice context and
positioned to enhance addiction research, intervention and preven- (lack of) availability of alternatives in the instructional sets. Value is
tion. In a discrete choice context, a person’s intertemporal orientation, influenced by factors across varying temporal and environmental
the constraints on the drug itself, and constraints on alternatives are (spatial) frames in a way that requires explanations of distal causation
all mutable environmental factors implicated as determinants of the (the level of public health in the environmental context influences
likelihood of drug consumption. Over time, each of these form distinct, individual drug value). In other words, a narrow spatial analysis might
predictable, aggregate patterns of behaviour that can be measured and ignore the environment altogether and focus on within-individual or
used as individual difference variables (Fig. 2b). between-individual variables that predict alcohol use. Expanding the
In this section, we present an extension to the reinforcer pathol- spatial analysis might reveal county-level differences in the availability
ogy model, the contextualized reinforcer pathology model, which of liquor stores and alternatives, such as parks and recreational oppor-
addresses the limitations described above and highlights the critical tunities, that might explain additional variance across populations
a
Neurobiology Cognitive psychology Anthropology Sociology
Personality psychology
Behavioural economics
b
Aggregated behavioural patterns
Fig. 2 | Situating behavioural economic theories of addiction. a, Although determinants by framing behaviour within a discrete choice context that is
most theories of addiction recognize diverse influences, disciplinary foci tend to heavily influenced by environmental factors; these discrete choice contexts
be oriented toward person-level factors or environmental factors. b, Behavioural are building blocks for patterns of behaviour over time, which aggregate into
economics bridges the connection between environmental and within-individual measurable individual difference variables.
Increasing drinking trajectory owing to diminishing access to alternatives Stable low-drinking trajectory owing to high access to alternatives
A salesperson who used to enjoy biking in a local Easy access to a number of enjoyable hobbies and safe
park loses his job and is less able to use the park owing well-maintained areas for outdoor exercise; college degree provides
to concerns about safety and deteriorating park conditions more financially lucrative job opportunities
Value of alternatives
Value of substance
Value of substance
Low constraints on drugs and alcohol High constraints on drugs and alcohol
Time Time
Value of substance
Value of alternatives
Fig. 3 | A contextualized reinforcer pathology approach. Two theoretical while engagement and availability of alternatives decrease. The right panel
examples depicting the effects of environmental constraints on the value of shows a scenario that would result in stable or decreasing levels of alcohol use
alternatives and alcohol at three time points. Blue represents reinforcement from over time. Initially, substance value is low, and the individual engages in many
alternative activities and red represents reinforcement from alcohol-related alternative activities. Over time, constraints on alternatives remain low. As
activities. The left panel shows a scenario most likely to result in increasing levels the individual enters emerging adulthood, they connect with friends through
of substance use. Initially, substance value is low, and the individual engages drinking, and therefore the value of alcohol rises slightly. However, the individual
in many alternative activities. However, over time the environmental context maximizes more global utility and continues to engage in available alternatives
places increasingly high constraints on alternatives (the local park shuts down, that effectively compete with the immediate rewarding effects of alcohol.
the individual cannot afford to go to college, the roads are bad for biking) Consequently, when the individual leaves college and drinking among friends
and low constraints on alcohol (easily available from local store, cheap, social declines, the individual’s drinking declines as well.
reinforcement from drinking). Consequently, alcohol value increases over time
in various counties. Expanding the spatial analysis further might Moreover, in the contextualized reinforcer pathology model,
reveal country-level differences in the acceptability of consumption pathology can be determined only within an individual’s functional con-
or state-level differences (for example, in legal status of cannabis), or text. Reinforcement learning is an adaptive process that occurs because
cultural differences across nations in the acceptability of public alcohol it results in reward or alleviation of distress; the reinforced behaviour
consumption. serves a function and drug behaviour is only ‘pathological’ when the
In the contemporary reinforcer pathology model, the pathology of behaviour leads to functional impairment in the short term (for exam-
overuse of a specific reinforcer resides in the internal decision-making ple, accidents, hangovers or missing work) or long term (for example,
processes of the individual, and the influence of the broader context is declining health or social functioning).
unaccounted for, whereas pathology in the contextualized reinforcer
pathology model resides in the interaction between the person and the The matching law
context. Studies have demonstrated that substance demand is malle- The importance of alternative reinforcement in decision making
able to numerous experimental manipulations, such as cue exposure broadly, and drug use specifically, is grounded in the behavioural
(controlled exposure to substance-related environmental stimuli)51,52, matching law65, a behavioural principle which states that the relative
opportunity cost (choosing the substance reinforcer at the expense rate of responding approximates the relative rate of reinforcement at
of an alternative that also carries value)53,54, the social context55,56, each alternative66 (Box 1). In an exemplar experiment66, pigeons were
and both pharmacological and psychosocial treatments57–59. Delay concurrently reinforced to peck two keys in an experimental cham-
discounting is also influenced by context36,60, including through expo- ber under independent variable-interval schedules of reinforcement.
sure to natural (as compared to man-made) environments61, shifts in In other words, each reinforcer was delivered following a specified
the time to receipt of alternatives31, and manipulations targeting the amount of time after the first key peck response, and the time between
temporal frame, such as episodic future thinking62–64. Indeed, although reinforcers varied throughout the task. Across five experimental ses-
the effects of alternative reinforcers, demand, and delayed reward sions, rates of responding corresponded almost perfectly with fre-
discounting are often studied in isolation, these factors may interact quency of reinforcement. These findings illustrate that the observed
to influence behaviour during a discrete choice (Fig. 4). response rate for each choice option is approximately equivalent to
Low-value alternative available other research showing that preference for drug reinforcers varies as
100% a function of the availability of non-drug reinforcers70–75. To illustrate
the zero-sum nature of reinforcement and the importance of alterna-
substance use
Likelihood of
Box 1
Historical review
There is historical and theoretical precedent to assume a conceptual, a subset of all possible choice interactions posited by economic
hierarchical and nested interconnectedness between behavioural theories of consumer demand41,42,196. The generalized matching law is:
economic demand, the matching law and delay discounting, which
each explain behaviour under increasingly specific conditions. Here B R
log 1 = s log 1 + log b
we illustrate the relationships between these three variables. B
2 R2
The matching law and demand where B and R are as defined above, s represents the slope of
The majority of decision-making occurs in open contexts with two the best-fitting line, and b represents the y-intercept. These two
or more reinforcers. The matching law was discovered through adjusting mathematical functions operate as free parameters and can
observations of allocated choice across available commodities and account for variations in the substitutability between two reinforcers,
suggests that reinforcement from each choice option ‘matches’ consistent with economic utility theory42,88,197. Unfortunately, a great
behavioural allocation: deal of research using behavioural economic demand in the field
of substance use has focused on the effect of price on behaviour
B1 R1
= under single-commodity conditions. These applications are more
B1 + B2 R1 + R2 consistent with the matching law of absolute single responding67
and do not account for the complexity of decision-making under
where B represents the rate of response (behaviour) at each available conditions of varying costs across commodities.
option (denoted by subscripts 1 and 2) and R represents the rate of
reinforcement at each available option (denoted by subscripts 1 and 2). The matching law and delayed reward discounting
In an open economy choice context with two concurrently available Early research using the matching law explored only immediate
reinforcers, reinforcement from commodity X might be independent reinforcement and therefore did not incorporate delay to reward
or dependent upon the schedule of reinforcement of commodity Y receipt as a factor65. Later iterations de-emphasized the strict behav-
(see figure). Two commodities are independent when changes in ioural operationalization of reinforcement and instead emphasized
the price of commodity A has no influence on the consumption value, a derived function that is a product of obtained reinforcement
of commodity Y. Two commodities are complementary when and other factors that might influence preference (such as price or
consumption of commodity Y decreases as the price for commodity X delay). The hyperbolic delayed reward discounting equation, which
increases, and vice versa. Two commodities are substitutes when is considered to match actual behaviour better than the exponential
consumption of commodity Y increases as the price for commodity equation, was developed as an extension of the matching law30.
X increases, and vice versa. These relationships are useful for The equation acknowledges that the temporal receipt of reinforce-
understanding decisions between using substances and other, ment plays a part in determining obtained reinforcement for a
non-substance alternatives. For example, there might be activities single reinforcer. A great deal of research suggests that respond-
that have complementary associations with alcohol use (spending ing for a single reinforcer fits the matching law of absolute single
time with friends or attending football games), activities that serve responding67:
as substitutes for alcohol use (preparing for an exam, exercising
kR1
or attending religious services), and activities that might have an B1 =
R1 + Re
independent association with alcohol use (dining or watching TV).
The generalized matching law was created in response to where B1 represents the response rate, R1 represents the obtained
criticisms that the strict form of matching law represented only reinforcement, Re represents ‘distractions’ from R1 (or error) and k
a special case of behavioural economic demand (when two represents the total range of behaviour. The hyperbolic discounting
commodities operate as perfect substitutes) and represents only equation explicates R1 as a mathematical derivative30:
Commodity 1
Commodity 2
Consumption
Consumption
Consumption
and nested interconnectedness between these three primary behav- a second group, and during sessions 15–21 for a third group. Rats in the
ioural economic variables (Box 1), which each explain behaviour under first group self-administered less methamphetamine across the first
increasingly specific conditions30,41,42,88. fourteen sessions compared to the rats in the second and third groups.
Self-administration in the second and third groups decreased when
Translational evidence the running wheel was introduced in sessions 8 and 15, respectively.
Next, we review translational evidence that supports and extends the When rats in the first group lost access to the running wheel, self-
fundamental matching law65 and shows that, across multiple levels of administration increased, but to similar levels as self-administration
analysis, enhancing access to alternative rewards meaningfully affects in the second and third groups when the running wheel was available.
engagement with substances over and above other necessary theoreti- These findings suggest that early life access to alternative reinforcers
cal mechanisms of addiction. We begin with a discussion of basic non- might be protective against later substance use, even in the context of
human animal and human research and then discuss applied clinical alternative reinforcement scarcity. However, this finding has not yet
translations in humans that demonstrate how increasing alternatives been extended to humans.
can be used as a treatment mechanism and intervention. Finally, animal work has integrated other behavioural economic
variables such as delayed reward discounting into models of alternative
Experimental non-human animal laboratory research reinforcement99. Experimenters trained rats on self-administration for
One influential set of studies (known as ‘rat park’) provides a potent an alternative reinforcer (60 seconds of social interaction with another
demonstration of the effect of the environment on drug administration rat) and for cocaine. Next, the rats were given choices between these
behaviour. Specifically, experimenters tested the influence of social two reinforcers over ten sessions. Across all sessions, rats showed a
exposure as an alternative reinforcer competing with morphine89,90. robust preference for social interaction over cocaine. Furthermore,
Rats randomized to either isolation or an enriched social environment increasing the delay between the lever press and receipt of the social
(with running wheels and other activities) were given access to mor- reward, and the effort required to obtain the social reward, increased
phine for 57 days. In the experimental sessions, they were allowed to cocaine self-administration, and there were individual differences in
make concurrent choices between morphine and water. Rats in the sensitivity to delay and effort contingencies.
enriched social environment consumed less of the morphine solu- It is important to note that although the effects of alternative
tion compared to isolated rats89,90. This general finding that alterna- reinforcers in the laboratory are robust, they vary across studies and
tive reinforcers reduce drug self-administration in concurrent choice experimental paradigms. Moreover, there is some evidence that neuro-
tasks among non-human laboratory animals has been replicated across biological differences might moderate the extent to which laboratory
substances78,91–96 and alternative reinforcers (such as food, sucrose and animals show reductions in drug use after an alternative is introduced78.
running wheels)78,91,93,97.
The effects of alternatives do not seem to be limited to experimen- Experimental human research. Human laboratory studies are consist-
tal paradigms in which rats choose between two rewards simultane- ent with non-human animal laboratory studies and show that, within
ously. In another study98, rats were trained to self-administer alcohol a discrete choice context, introducing alternatives reduces the use
after only one lever press until stable responding was achieved, after of drugs and self-administration. Early studies in the 1970s that con-
which rats lever-pressed for alcohol or sucrose in alternating sessions. trolled all features of an individual’s environment in residential alcohol
Rats reduced their responding to alcohol (that is, pressed the lever laboratories found that availability of an enriched environment contin-
fewer times) after being introduced to sucrose, even in the sessions gent upon moderate drinking (for example, social interaction) led to
when sucrose was not available, suggesting that the effects of non- reduced drinking74,100–102. In a seminal experimental study103, individu-
alcohol alternative reinforcers extend beyond the immediate choice als who drank alcohol but were not in alcohol treatment were offered
context. choices between alcohol and money. The amount of money available
Other laboratory animal research suggests that the order in which (either 2¢ or 10¢ per choice) and the delay between choosing money and
the reinforcers become available might influence the impact of alter- receiving it (either no delay, a 2-week delay, or an 8-week delay) were
native reinforcers on drug self-administration. In one study97, rats had manipulated103. When there was no delay, participants chose alcohol
access to d-methamphetamine self-administration for 21 experimental 42% of the time when the alternative was 2¢, but chose alcohol only 29%
sessions. Access to a running wheel (an alternative reinforcer) was also of the time when the alternative was 10¢. When the delay to monetary
available during sessions 1–14 for a first group, during sessions 8–21 for reward increased, preference for alcohol increased103. These findings
replicate established laboratory animal findings in humans and sug- and cultural substance-free resources that aid the journey to recov-
gested that human alcohol choice behaviour is partially dependent on ery140,141, and definitions of recovery increasingly account for holistic
the contingencies of the choice environment, such as alternative rein- improvements across valued life domains, in addition to reductions in
forcement and the delay to reward. These findings have been extended drug use.
to other drugs, such as cocaine104,105, cannabis106 and heroin107,108. There are also several efficacious addiction treatment approaches
However, people might choose to use drugs even when alterna- that attempt to reduce alcohol and drug use by increasing both the
tives are available if the value of the drug is sufficiently high109,110. For response cost associated with alcohol and drug use and access to and
example, in one study, participants chose between different doses engagement in substance-free activities142. These intensive outpatient
of cocaine and a fixed amount of money (US$6.00)110. As the dose of treatments explicitly attempt to reduce substance use by: regularly
cocaine increased, choices to consume cocaine increased. These find- monitoring alcohol and drug use using objective verification methods;
ings have been replicated across drugs107,109,111–114 and are consistent with systematically increasing the response cost of alcohol use (social and
an inverse relationship between drug reinforcement and the value of tangible rewards are administered contingent upon verified absti-
the alternative reinforcement available. nence); and systematically increasing the availability of rewarding alter-
Importantly, human laboratory studies have high experimental natives that are incompatible with substance use143. In the community
demands and limited ecological validity. Moreover, there are indi- reinforcement approach144, the latter is achieved by providing family
vidual differences in the availability and engagement in alternative and vocational counselling that increase social support and facilitate
reinforcement in the natural environment that are not captured by occupational skill building to increase the number of rewarding options
human laboratory studies. Thus, researchers have developed self- in the individual’s environment. Contingency management145–149 is
report measures modelled after the matching law that assess the another effective tool for reducing substance use, particularly in the
amount of substance-free reinforcement relative to substance-related short-term147, by delivering abstinence-contingent monetary vouch-
reinforcement in a person’s life over the course of a month. The most ers that can be used to purchase goods and services that can enhance
popular measures assess the amount of time spent engaged in the substance-free rewards (such as movie tickets, sporting equipment or
activity (rate of reward receipt)115,116 and the subjective enjoyment of money for hobbies)150. Treatment effects for contingency management
the activity (strength of the reinforcer)117,118. These measures can be are stronger than cognitive behavioural therapy for substance-use
combined to quantify substance-free and substance-related reinforce- disorder151. Contingency management has also been modified as an
ment, which can then be used to compute a relative reinforcement adjunct for other treatments152 and to increase treatment attendance,
ratio: substance-related reinforcement/(substance-free reinforce- with positive effects153. Likewise, there is extensive evidence support-
ment + substance-related reinforcement). Resource allocation meas- ing the efficacy of the community reinforcement approach alone154,
ures quantify relative reinforcement by examining the ratio of a single and the combination of contingency management and community
class of resource (for example, time or money) allocated to substance- reinforcement155.
related activities relative to resources allocated to other activities. Another approach, known as Life Enhancement Treatment for
Studies using these measures find that diminished alternative rein- Substance Use (LETS Act), uses behavioural activation, a treatment
forcement is associated with greater alcohol use25,119,120, smoking121, for depression grounded in increasing response-contingent positive
cocaine use122, and more general illicit drug use123–125 in adolescents124,125, reinforcement156, to increase alternatives to substance use. LETS Act is a
in emerging adults25,126 and in clinical populations127,128. group treatment delivered over eight sessions that focuses on generat-
ing, scheduling, engaging in and recording value-driven substance-free
Applied clinical research. Of the third of American adults who will behaviours that serve to increase daily positive reinforcement157. In
meet criteria for lifetime alcohol-use disorder, less than 25% will a randomized clinical trial, patients in residential treatment for sub-
seek treatment and 70% will improve without any formal substance-use stance use reported fewer negative consequences related to substance
treatment129. Increasing alternative reinforcement has been identified use and a greater likelihood of abstinence 12 months later158.
as a mechanism of successful change in substance use among individu- Finally, the Substance-Free Activity Session is a single session
als experiencing natural recovery and in randomized clinical trials for intervention that integrates behavioural economic and motivational
established interventions and treatment130–133. In studies of natural interviewing elements to reduce delay discounting and increase
recovery from alcohol-use disorders, individuals who reported lower engagement in goal-directed and enjoyable activities that are consist-
relative monetary expenditure towards savings versus alcohol in the ent with long-term goals. This approach has been used to supplement
year prior to an attempt to reduce drinking were less likely to success- standard brief alcohol- or drug-focused interventions with emerging
fully reduce or abstain from drinking134–136. Further, several studies adults who report binge drinking159–161 and adults in alcohol treat-
have demonstrated that stable long-term recovery from alcohol-use ment162. Specific Substance-Free Activity Session elements include
disorder is more likely when there are improvements across life-health discussion of future goals, personalized feedback on recent time allo-
domains that probably indicate enhanced availability of non-drug cated to activities that are consistent with those goals compared to
rewards137,138. Positive long-term outcomes among alcohol treatment time spent drinking or using drugs, episodic future thinking, and per-
recipients are accompanied by improvements in health, life satisfac- sonalized feedback on locally available substance-free activities that
tion and functioning in domains often adversely affected by problem are consistent with goals and interests (for example, doing homework,
drinking that probably motivated and reinforced recovery processes spending time with family or friends, or learning an instrument). This
and outcomes139. Although improvement in these domains during treatment targets behaviours (and bundles of alternative reward) at
recovery does not explicitly quantify or measure alternative reinforce- varying temporal windows across different levels of substance-use
ment, such improvements are consistent with the behavioural eco- severity. In one large multi-site trial, young adults participating in the
nomic perspective. Indeed, the term ‘recovery capital’ has been coined Substance-Free Activity Session who reduced their drinking showed
to reflect the importance of the accrued personal, social, financial sustained increased reinforcement from substance-free activities
at 16-month follow-up. Moreover, post-intervention reductions in Second, the set of policies officially known as the War on Drugs
alcohol use and alcohol-related problems were mediated by changes targeted communities of colour by shifting drug control policy toward
in proportionate reinforcement from substance-use activities relative punitive law enforcement approaches178. The War on Drugs included
to total reinforcement160. policies that classified and outlawed a range of drugs (some of which
Collectively, these preclinical and clinical lines of research show were, at the time, beginning to demonstrate therapeutic and medical
that insights from concurrent choice tasks translate to applied clini- potential179), set high legal penalties for small possession offences of
cal settings, and consistently reveal that increasing the availability of drugs primarily used in the Black community, reduced the number
valued alternative reinforcers reduces drug choices and promotes of community mental health centres and re-funnelled government
long-term changes in substance use. Moreover, increasing alterna- spending toward law enforcement (resulting in the militarization of
tive reinforcement is an evidence-based target for treatments for police)178, and intentionally spread misinformation about the harms
individuals across the severity spectrum. of drugs and drug users. These policies resulted in high rates of felony
incarceration among Black Americans, who are incarcerated at five
Implications for public health times the rate of white Americans180. These policies converge to spe-
Although not explicitly guided by behavioural economics, a great cifically stigmatize Black drug users and to decrease familial economic
deal of public health data supports the premise that greater availabil- stability and limit access to high-paying jobs and other rewarding
ity of alternative reinforcers reduces epidemiological risk of harmful alternatives among Black populations. Consistent with behavioural
substance use. Individuals who experience homelessness, poverty, economic theory, these reductions in access to alternative reward
unemployment and/or lower educational attainment bear a dispro- might contribute to drug use15,69. The historical economic deprivation
portionate burden of alcohol-related health and social consequences, and scarcity described above probably contributes to stress, reduced
including alcohol-related mortality163–165. Although other factors are access to health care, and more interactions with law enforcement.
certainly implicated, evidence supports the idea that behavioural eco- These factors might, in turn, account for the fact that, despite lower
nomic variables, particularly the economic deprivation and scarcity of overall drinking levels, Black Americans who do drink show greater
opportunity (that is, an environment lacking alternative reinforcers), relative levels of alcohol problems and alcohol-use disorder than does
are partially responsible. Individuals from lower socioeconomic back- opulation181 (Box 2).
the rest of the p
grounds are more likely to work and reside in environments with fewer Variability in rates of county-level drug-related mortality provide
alternative sources of reward and resources with which to cope with another excellent illustration of the public health implications of alter-
stress, a higher density of alcohol and cannabis retail outlets and illicit native reinforcement. Drug-related deaths are not equally distributed
drugs166,167 (with a greater concentration in Black neighbourhoods)168, across the USA but are instead concentrated in certain regions of the
and aggressive alcohol advertising campaigns169–171. One large study of country182. Drug overdose deaths in 2006–2015 were most likely to
adolescents from the Los Angeles area found that the longitudinal asso- occur in Appalachia, Oklahoma, the northeastern USA and New Mexico,
ciation between lower parental socioeconomic status and increased risk and less likely to occur in the midwestern and the southern states183.
for drug use is mediated by lower engagement in enjoyable substance- Alcohol overdose deaths were also high in the western USA, particularly
free activities172. Moreover, stress and poverty among adolescents and among Native American populations183. Importantly, although drug
young adults is associated with greater delayed reward discounting, supply, including prescribed opiate pain killers and from commercial
which might contribute to a preference for drug-related rewards173, alcohol outlets, is certainly a substantial factor, it does not fully explain
and neural responses to motivational reward anticipation might be the mortality in these counties. For example, counties with large Native
blunted among children living in neighbourhoods with greater dep- American populations in New Mexico and Oklahoma had greater rates
rivation of natural rewards174. Thus, the key within-individual variables of drug overdose in 2006–2015 (ref. 182), even though these counties
featured in the reinforcer pathology model (elevated delayed reward had comparable or lower rates of opioid overprescribing compared
discounting and drug reward valuation) are themselves influenced by to surrounding counties184. These data suggest that although opioid
contextual variables. prescribing rates are important, between-county variability might
Economic deprivation and scarcity of opportunities (and as a be further explained by economic and social characteristics associ-
result, an environment lacking alternative reinforcers) is particularly ated with access to reward. For example, greater economic distress,
prevalent for Black populations in the USA, who are more vulnerable housing distress (rent taking >30% of household income), and family
to the harms of drugs and alcohol (even after controlling for use)175. distress is associated with higher drug-related mortality, whereas a
Two sets of policy initiatives might be particularly relevant for under- higher number of religious establishments and a diversified economy
standing drug and alcohol-related harms in this community from the is associated with lower drug-related mortality182.
contextualized reinforcer pathology perspective. First, Black com- Variability in rates of county-level drug-related mortality demon-
munities were explicitly targeted through Federal Housing Admin- strate the impact of USA policy on drug- and alcohol-related harms.
istration policies in several ways, such as refusal to insure mortgages The history of the colonization and genocide of the Native American
for Black applicants, racial restrictive covenants, racial zoning and population during western expansion in the USA, in addition to ongoing
public housing176. In many cases, these policies prevented Black fami- USA policies that continue to marginalize Native American people, has
lies from building real estate equity as economic capital (a reality that resulted in a systematic lack of educational and occupational oppor-
insidiously persists today177), and forced Black communities into pol- tunities, and, in many cases, the disintegration of traditional Native
luted industrial zones with reduced access to quality education and American culture185. The lack of opportunity and disintegration of
healthcare176. This perpetuation of poverty reduces access to enriched culture diminish the opportunity to accumulate valuable alternative
environments with alternative reinforcers, such as parks and other reinforcers that effectively compete with substance use, which explains,
recreational facilities, that can effectively compete with immediate from the contextualized behavioural economic perspective, the high
and robust drug reinforcers. rates of drug and alcohol use and mortality among Native American
Box 2
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