A Contextualized Reinforcer Pathology Approach To Addiction: Psychology

nature reviews psychology https://doi.org/10.
1038/s44159-023-00167-y
Perspective Check for updates
A contextualized reinforcer
pathology approach to addiction
Samuel F. Acuff1, James MacKillop2,3 & James G. Murphy 4
Abstract Sections
Behavioural economic accounts of addiction conceptualize harmful Introduction
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]
Nature Reviews Psychology | Volume 2 | May 2023 | 309–323 309

Perspective
Introduction Drug demand

In 2020, an estimated 138.5 million Americans aged 12 or older reported Across behavioural economic models, the reinforcing value (or
alcohol use in the past month, and 61.6 million reported a binge drink- ‘demand’ in behavioural economic terms) of substance use is measured
ing episode (four or five drinks for women or men, respectively) in the by the level of consumption or the amount of behavioural (or monetary)
past month1. Rates of alcohol consumption have remained relatively output emitted to engage in the activity15. Real or hypothetical purchase
stable over the past decade, with some upward trends for women and tasks are usually used to measure drug or alcohol value. In a typical alco-
older adults possibly amplified by the COVID-19 pandemic2,3. Illicit drug hol purchase task, individuals report how many drinks they would pur-
use is also rising: nearly one in five Americans reported illicit drug use chase during a hypothetical drinking scenario at each price in a series
of some kind in the past year, and 43.5 million Americans reported of escalating prices16. Responses across each of a specific (monetary)
cannabis use in the past year1. These trends in the USA are generally cost are plotted to create a demand curve and produce indices that
mirrored around the world1,4,5. Although many use alcohol or illicit reflect an index of drug value (Fig. 1a). Human and laboratory animal
drugs without suffering notable clinical concerns, a minority use at research has consistently demonstrated that, within a closed economy
high levels, resulting in diagnoses of substance-use disorder and a (a choice economy with defined constraints on access to drugs and no
range of acute to chronic substance-related problems. Serious harms, access to any commodities outside the economy), response to a drug
such as alcohol-related mortality, overdose and cirrhosis, are on the reinforcer decreases as the cost of acquiring the substance increases17
rise6,7, with notable increases during the COVID-19 pandemic8, even (Fig. 1a). Purchase tasks mirror (but are more cost- and time-effective
as other causes of death are decreasing9. The public health impact of than18,19) laboratory progressive ratio tasks in which animals or human
these harms are monumental and result in billions of dollars in financial participants have the opportunity to self-administer a substance as the
costs each year10. cost for doing so (for example, the number of button presses required
Myriad policies have been developed to reduce or eliminate the or the monetary expenditure) progressively increases20.
burden of substance use. Yet alcohol- and drug-related morbidity and Individual differences in the degree to which costs lead to a
mortality have increased over the past two decades7,11,12, suggesting that decrease in responding index between-person valuation of a drug
existing strategies are far from adequate. Robust and valid theories are or drug demand (Fig. 1a). Reinforcer pathology suggests that these
needed to guide treatment and policy development. Specifically, it is individual differences reflect strength of motivation for the drug and
incumbent upon psychological theories of addiction to explain the should be correlated with levels of alcohol use and alcohol-related
following: why people consume drugs; why some people use alcohol problems13,14. Indeed, indices of drug demand, in particular maximum
and drugs in a manner that contributes to health and social problems, consumption, expenditure level and sensitivity to changes in drug
while others are able to use moderately with minimal consequences; price, show robust correlations with consumption16,21–24, substance-
why many people are able to reduce patterns of alcohol and drug use, use problems25,26, and substance-use disorder27. Demand indices are
often without participating in formal treatment, while others experi- also robust prospective predictors of drinking behaviour even after
ence chronic, escalating patterns of use; and why substance-related controlling for past alcohol consumption28,29. In other words, meas-
morbidity and mortality have increased over the past two decades and ures that aggregate a series of hypothetical drinking decisions across
in particular over the past few years7,11,12. escalating costs have predictive utility over and above measures of
In this Perspective, we provide an overview of a contemporary recent drinking practices.
behavioural economic theoretical account of addiction, the reinforcer
pathology model, which suggests that drug consumption is the result Delay discounting
of overvaluation of smaller immediate rewards and drug-specific rein- Costs and benefits across choice options are unevenly distributed
forcement. Next, we highlight limitations of the reinforcer pathology across time, such that some reinforcers, like drug use, have relatively
model and describe an extension, the contextualized reinforcer pathol- greater immediate benefits (for example, intoxication, euphoria,
ogy model, that highlights the critical role of alternative reinforcers in social facilitation, anxiety reduction and withdrawal relief) and health
addiction motivation. We then review empirical literature across the and social costs that are substantially delayed (and probabilistic). By
translational spectrum that supports this model. Finally, we review contrast, other reinforcers, such as earning a college degree, have
relevant literature on increases in addiction-related morbidity and mor- relatively immediate costs (attending class, studying and paying tui-
tality and addiction-related health disparities that might be understood tion) and delayed (and probabilistic) rewards (satisfaction of earning
and potentially ameliorated via contextualized reinforcer pathology. good grades and graduating; higher-quality employment and salary).
This critical temporal element to reward valuation for drugs versus
Reinforcer pathology alternatives is captured by delayed reward discounting, which is the
A behavioural economic account of substance use refers to a set of relative preference for smaller, sooner rewards compared to larger,
empirical methods and models of decision-making that integrate later rewards30. Delayed reward discounting describes how much the
microeconomic and operant learning theory principles to understand value of an activity or commodity decreases as a function of its tempo-
the decision-making processes and contextual features that influence ral ‘distance’ from the current moment. Empirical research suggests
substance consumption over time. that the subjective current value of delayed rewards decreases more
The most popular contemporary behavioural economic steeply with initial delays, consistent with a hyperbolic decay function,
model — reinforcer pathology13,14 — suggests that addiction is marked rather than at a constant rate31 (Fig. 1b). One implication of hyperbolic
by within-individual differences in relative reinforcing value (high drug discounting is that the preference for smaller immediate versus larger
demand) and a more general decision-making bias that overvalues delayed rewards shifts dynamically as a function of time to reward
smaller immediate rewards relative to larger delayed rewards (high availability, exhibiting steep devaluation at initial delays and shallower
delay discounting) as central aetiological risk factors. These two key devaluation at further delays. Thus, humans and laboratory animals
concepts of the reinforcer pathology model are described below. generally prefer larger, later rewards when reward receipt for both

Perspective
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
Importantly, discounting applies to all delayed rewards, and rates

of discounting vary considerably across commodities34,35. Further-
more, steep discounting (a greater preference for smaller immediate
rewards over larger delayed rewards) can be adaptive when it comes to
securing reinforcers in dangerous or deprived environments in which
delayed rewards are also highly uncertain (as in the idiom, ‘a bird in the
hand is worth two in the bush’). Nevertheless, steep delay discounting
might be an especially relevant decision-making bias that contrib-
T2 T1
utes to frequent drug use because positive drug effects (euphoria,
Delay to rewards
enhanced focus, or reduced pain and anxiety) tend to occur imme-
diately, whereas their costs or negative effects are generally delayed Fig. 1 | Behavioural economic demand and delayed reward discounting.
(ranging from hours for acute illness or hangover to years for health a, Representation of a behavioural economic demand curve, which can be
and social impacts). Additionally, in modern society, legal and illegal plotted using data from purchase tasks. As cost increases, consumption
drug reward is often easy to obtain and imposes little upfront cost. decreases. Demand indices that can be extracted from the data include intensity
(consumption at zero cost), breakpoint (the price at which consumption is fully
A central tenet of the contemporary reinforcer pathology model is
suppressed) and elasticity (the rate of change in consumption as a function of
that the temporal window of value allocation substantially determines
cost). b, Representation of the change in value of two rewards as a function of the
the relative value of the reinforcers operating in that window13. In other
delay to reward receipt. The reward from substance use is smaller, but the receipt
words, higher substance value, and therefore persistent substance is nearer in time, whereas the reward from an alternative is larger, but receipt is
consumption even at high costs, can be attributed to a preference for further delayed in time. When receipt of both rewards are distant in time, the
immediate rewards because the value of more distal rewards dimin- value of the larger reward is greater. However, owing to the hyperbolic nature
ishes very quickly as they fall outside a person’s time horizon. In turn, of delayed reward discounting, the value of the immediate reward increases at
the reinforcer pathology model has led to intervention approaches a greater rate as reward receipt becomes closer in time. Thus, an individual might
focused on expanding the temporal horizon of decision making (that experience a preference reversal, in which the value of the immediate reward
is, reducing delay discounting)36–39. surpasses the value of the delayed reward when receipt of the immediate reward
is imminent.
Alternative reinforcement
The contemporary reinforcer pathology model is subject to several
underemphasized considerations that are critical for understanding
choice behaviour. The reinforcer pathology model emphasizes that being equal, but the influence of alterative reinforcers frequently vio-
steep discounting contributes to preference for drug rewards relative to lates this assumption. Thus, studies in the addiction literature over the
alternative rewards. However, it does not emphasize the environment, past two decades have focused on reductionistic accounts of absolute
including the availability of drugs and the relative reinforcing efficacy responding, closed economies, and the differences in between-person
of substance-free alternative reinforcers, as contributing factors to choice preferences for delayed and substance rewards. Consequently,
elevated demand or discounting, or as direct contributors to risk for these critical behavioural economic variables are now often considered
harmful alcohol and drug use40. The contemporary reinforcer pathol- static individual difference variables, which deviates from decades of
ogy approach emphasizes, and typically measures, drug reinforcing research showing that the economy and choice context influence the
value and delay discounting with the assumption of all other things relative value of a drug15,41–43.

Perspective
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
Within-individual determinants Reinforcer pathology Environmental determinants
b
Aggregated behavioural patterns
Delayed reward discounting Alternative reinforcement Behavioural economic demand
Temporal windows Access/constraints on alternatives Access/constraints on drugs or alcohol
Discrete choice contexts
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.

Perspective
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
High constraints on alternatives Low constraints on alternatives

Value of alternatives
Value of substance
Value of substance
Low constraints on drugs and alcohol High constraints on drugs and alcohol
Inexpensive alcohol easily available from neighbourhood bars and liquor

Alcohol is easily available but there are constraints on drinking related
stores; most social reinforcement experienced in drinking situations; less
to important next-day responsibilities (work and group biking in the park)
concern about the impact of hangovers on job performance after losing job
Time Time
Value of substance
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

Perspective
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
tives, consider patterns of reinforcement for two individuals. Both

individuals drink the same amount of alcohol per week, but person 1
versus allocates less time to other activities, such as work, family, and hobbies
0% compared to person 2. Consequently, reinforcement from substance
use is a larger percentage of the overall ‘reinforcement pie’ for per-
Cost son 1, and they are therefore more likely to have problems related to
for one f
unit
of ipt o er drinking and are more vulnerable to chronic alcohol-related harms.
the s rece rc
ubst
ance im e to e reinfo These lines of research provide support for the premise that prefer-
T iv
rnat
alte ence for a substance depends on the relative constraints on access to
other available reinforcers in the choice context. Thus, drug consump-
High-value alternative available
tion is in part an inverse function of access to alternative rewards. This
100%
conclusion contrasts with early work in laboratory animals and humans
that consistently found that alcohol and other drugs often continue to
substance use
Likelihood of
be self-administered at high rates under schedules of reinforcement in

which a reward is only provided after a specified number of responses
(fixed ratio or progressive ratio schedules) and when no alternative
versus 0% reinforcers are available76,77. These results are consistent with the law
of absolute responding, which suggests that as the amount of rein-
Cost forcement for a given commodity increases, the amount of behaviour
for one f
unit
of ipt o er allocated toward that commodity increases hyperbolically66. However,
the s rece rc
ubst
ance im e to e reinfo these experiments lack validity: people are rarely presented with only
T iv
rnat
alte one choice in daily life. Indeed, substance consumption decreases
Fig. 4 | Interactions between substance cost and alternative reward. The
when alternatives are concurrently available alongside substance
likelihood of using a substance is based on the cost of the substance, the delay self-administration78–83.
to the receipt of the alternative reward, and the value of the alternative reward. The matching law provides a framework for understanding how
Across both plots, substance use is most likely when the substance cost is low and addiction might develop in certain contexts. For example, the ‘primrose
when the delay to the alternative is high. As the cost of the substance increases, path’ model, which developed from early experiments with the match-
the likelihood of use decreases. Further, as the alternative reward receipt ing law84–86, suggests that addictive drugs have greater local utility than
becomes closer in time, the likelihood of use decreases. However, when there is most competing alternatives, and therefore the addictive drug will
a high-value alternative available (an activity that generates a positive affective almost always be selected when local utility is maximized (that is, when
state or sense of accomplishment or alleviates an aversive state; bottom panel) the individual uses a proximal frame of reference). However, charac-
the likelihood of use across all delays and substance costs are attenuated relative teristics of addictive drugs (such as tolerance and adverse physical and
to when a low-value alternative (a non-stimulating or aversive activity; top panel)
social effects associated with patterns of heavy use) reduce the value of
is available.
both the drug itself and alternatives. Thus, as choices accumulate, the
value of both options reduce over time, but the value of the addictive
drug remains higher when maximizing local utility. When an organism
reinforcement from that option and that behaviour is reflected pro- maximizes global utility each successive choice is considered in the
portionally based on the frequency of responding relative to other calculation of the potential value of the next choice option (choices and
reinforcers65,67. That is, consummatory behaviour matches the local associated rewards are bundled together into an aggregated outcome).
reinforcement contingencies. Behavioural allocation consistent with Most salutary alternative choices to drug consumption are distributed
the matching law is generally adaptive and does not imply a pathologi- choices with immediate effort costs (for example, work or exercise) and
cal pattern of responding but is instead a quantitative codification of delayed rewards (for example, affluence or health). Thus, maximization
the assumptions made about choice under different conditions68. of global utility would result in a pattern of choices favouring the alter-
The matching law has two critical implications for theories of native reward. According to proponents of the primrose path model
substance use. First, the response rate for various reinforcers might an analysis of the available commodities is needed to understand their
serve as a measure of reinforcement value. In line with this theoreti- effect on future choice84–86, and addiction might be driven in part by
cal premise, applied human researchers have developed indices of stable, between-individual differences in the choice strategies dictated
reinforcement for humans based on time allocation and discretion- by either local or global frames of reference85. However, what is lacking
ary spending for alcohol and non-alcohol activities as well as activity in these analyses, as in the reinforcer pathology model, is that drug use
enjoyment, with activities that are engaged in frequently and rated as will be influenced by the substantial between- and within-individual dif-
subjectively enjoyable classified as highly reinforcing69. ferences in constraints on access to drugs versus alternative reinforcers
Second, operant behaviour is a zero-sum outcome set dependent across environmental contexts (Fig. 3).
upon the available reinforcers and an individual’s response rate to each Contemporary accounts of reinforcer pathology have under-
reinforcer. The introduction of any alternative eliciting a non-zero emphasized the matching law and overemphasized individual dif-
response rate will shift response rates, and therefore the reinforcement, ferences in reinforcing value and delay discounting40,87. However,
for all other choices in the choice context65. This is consistent with there is historical and theoretical precedent to assume a conceptual

Perspective
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:
Independent Substitutes Complements
Commodity 1
Commodity 2
Consumption
Consumption
Consumption
Price of commodity 1 Price of commodity 1 Price of commodity 1

Perspective
(continued from previous page)

A1 through which reinforcement, and therefore response rate, might
R1 =
1 + KD1 systematically differ.
The nested nature of these three behavioural economic variables
where R1 represents the obtained reinforcement, A1 equals the mathematically does not necessarily reflect their importance in
amount of the delayed reinforcer, K is an impulsivity constant understanding behaviour. Instead, the most frequently observed
representing individual variation in the degree to which delay symptoms of substance-use disorder can at least partially explain
will affect obtained reinforcement and D1 represents delay the emphasis that has been placed on each of these variables in the
to receipt. Mathematically, delayed reward discounting is a scientific literature, in addition to the relative dearth of research on
special case of the matching law, which explicates a mechanism other aspects of the model (such as behavioural complements).
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

Perspective
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

Perspective
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

Perspective
Box 2
A behavioural economic perspective on drug criminalization

Since the Harrison Act in 1914, criminalization of drugs has been Thus, criminalization as it stands in the USA traps incarcerated and
institutionalized in the USA. The reinforcer pathology model might formerly incarcerated people in a system that diminishes access to
suggest that increasing costs is the most logical solution to reduce and engagement in alternative activities. Although increasing costs
drug use on both a personal and public health level. On a public might reduce use in some cases, introducing opportunity costs that
health level, costs for legal substances have been increased through effectively eliminate the possibility for most lucrative future valued
the use of taxes, in the spirit of liberal paternalism, in a way that alternatives inadvertently increases the value of the substance.
respects individual choice while encouraging healthy behaviour. Such Indeed, the War on Drugs, which was intended to eliminate drug use,
increases do appear to be associated with some reductions in use. has largely failed: rates of drug consumption have remained relatively
However, costs have also been increased by federally prohibiting the stable, and it created a thriving illicit drug market.
use and distribution of illicit drugs, and the resulting punishment often A contextualized behavioural economic approach to minimizing
directly interferes with access to the potential for robust alternative drug use and the harms of drugs would recommend a legal system
rewards that effectively compete with substance use. Those who calibrated to introduce costs that are mild enough to have some
have committed a federal offence in the USA lose rights, including effect on decreasing overall drug use without crippling those who
the right to vote, the right to travel abroad, the right to employment use drugs in future endeavours with alternative reinforcers, while
(in some cases), the right to public social benefits and housing, and simultaneously increasing access to those alternatives. This would
the right to parental benefits. Many job and college applications also require a comprehensive analysis of the effect of policies on access
require reporting of conviction history, which discourage formerly to, and the costs and benefits of, drugs and alternatives, and a
incarcerated people from applying and employers from hiring198,199, wholesale realignment of punishment contingencies towards those
regardless of skill level. These policies reduce the chances to establish that maximize access to and reinforcement from alternatives and
a more conventional and prosocial life following incarceration. minimize drug reward.
populations186,187. In Appalachia and the northeastern USA, there has Conclusions

been a large decline in critical industries that previously supported the The findings reviewed here demonstrate that, across levels of analysis,
regions economically188. In many cases, this has led to a lack of availabil- alternative reinforcement is inversely related to substance use and
ity of meaningful work and decreased financial resources with which to serves as a critical factor in maintaining motivation and as a mechanism
attain alternative substance-free reinforcement (such as hobbies, out- of behaviour change that can be targeted in intervention and prevention.
door green spaces and travel/leisure) that is life-enhancing and which Importantly, alternative reinforcement fits within and extends beyond
might make the difference to whether someone chooses to use drugs. behavioural economic models of addiction. Specifically, according to
Fortunately, some public health evidence points to possible solu- a contextualized reinforcer pathology model, reductions in substance
tions. In the 1990s, Icelandic adolescents reported very high rates of sub- use can be attributed to a shift in the cost/benefit analysis driven by an
stance misuse189. In response, a population-level prevention programme increase in the cost of the substance, an increase in the value of alterna-
aimed at reducing substance misuse among adolescents and young tives, or a widening of the temporal window of value allocation, all of
adults was implemented190. This programme entailed increasing costs which have some impact on one another. For some individuals, a change
of substance use (for example, national media campaigns discouraging in circumstances may reduce the value of a substance (for example,
smoking; positive peer influence campaign to discourage smoking; a alcohol use might decline after leaving college owing to a reduction in
national ban on all tobacco and alcohol advertising) while also increas- the social reinforcement associated with alcohol use). Other individuals
ing access to alternatives (for example, organized youth activities)191. might reduce their substance use owing to the rising costs of use (for
Rates of substance use among Icelandic adolescents plummeted from example, a spouse threatening divorce) that begin to outweigh the
1997 to 2014, alongside increases in primary prevention factors such as benefits derived from using. Still others might reduce substance use
parental monitoring and engagement in organized sports192. Because as they become increasingly involved with alternatives (such as jobs,
of this programme, Iceland was the only country among 36 European families or exercise) that introduce an opportunity cost of use. Finally,
countries participating in the European School Survey Project on Alco- consistent with the ‘primrose path’ model15, some individuals might
hol and Other Drugs (ESPAD) that demonstrated consistent declines in have trouble reducing their substance use because the direct effects of
substance use among adolescents193. drugs can lead to diminishing engagement and availability of alternative
Collectively, these examples highlight how patterns at the popu- reinforcement, progressively resulting in reward impoverishment that
lation level are consistent with fundamental behavioural principles increases the likelihood of seeking substance reinforcement. These
related to the importance of alternative reinforcers for reducing harm- phenomena reflect both within-individual and between-individual level
ful substance use. A contextualized reinforcer pathology model that constructs operating in parallel to neuroadaptations that occur with
fully accounts for both within-individual and environmental con- persistent substance use in neurobiological models.
tingencies might help to inform public health initiatives to reduce Emphasizing alternative reinforcers in behavioural economic
substance use. models reframes choice models of addiction as contextual models.

Perspective
Decisions are made in a specific context, with the parameters of the 7. Long-term trends in deaths of despair; Report Of The Social Capital Project. Joint
Economic Committee https://www.jec.senate.gov/public/_cache/files/0f2d3dba-9fdc-
context defined within continuums of time and space. This contex- 41e5-9bd1-9c13f4204e35/jec-report-deaths-of-despair.pdf (2019).
tual approach shifts from a focus on individual difference variables 8. White, A. M., Castle, I.-J. P., Powell, P. A., Hingson, R. W. & Koob, G. F. Alcohol-related
(for example, absolute degree of delay discounting) to a focus on the deaths during the COVID-19 pandemic. J. Am. Med. Assoc. 327, 1704–1706 (2022).
9. Remington, P. L. & Brownson, R. C. Fifty years of progress in chronic disease
process by which contextual variables influence within-individual epidemiology and control. Morb. Mortal. Wkly Rep. 60, 70–77 (2011).
variables (for example, demand and delayed reward discounting) over 10. Sacks, J. J., Gonzales, K. R., Bouchery, E. E., Tomedi, L. E. & Brewer, R. D. 2010 national
time. The value of a substance is not a fixed property, but rather is sys- and state costs of excessive alcohol consumption. Am. J. Prev. Med. 49, e73–e79 (2015).
11. Friedman, J., Beletsky, L. & Schriger, D. L. Overdose-related cardiac arrests observed
tematically influenced by contextual factors in the environment50,56,57 by emergency medical services during the US COVID-19 epidemic. JAMA Psychiat. 78,
according to a temporal periodicity194. The value of a substance can 562–564 (2020).
also be modified through intervention approaches that target both 12. Patterson, S., Westfall, J. & Miller, B. F. Projected Deaths Of Despair During The
Coronavirus Recession (Well Being Trust, 2020).
the environmental context — specifically to increase the response 13. Bickel, W. K. & Athamneh, L. N. A reinforcer pathology perspective on relapse. J. Exp.
cost associated with drug use and reduce the response cost associated Anal. Behav. 113, 48–56 (2020).
14. Bickel, W. K., Johnson, M. W., Koffarnus, M. N., MacKillop, J. & Murphy, J. G. The behavioral
with alternatives — and within-individual variables (such as demand
economics of substance use disorders: reinforcement pathologies and their repair.
and discounting). Annu. Rev. Clin. Psychol. 10, 641–677 (2014).
A contextual approach emphasizes the impact of the environment 15. Rachlin, H. Four teleological theories of addiction. Psychon. Bull. Rev. 4, 462–473 (1997).
16. Murphy, J. G. & MacKillop, J. Relative reinforcing efficacy of alcohol among college
on behaviour and clarifies that choice models should not be conflated
student drinkers. Exp. Clin. Psychopharmacol. 14, 219–227 (2006).
with a moral model of addiction. The moral model (grounded in moral 17. Zhang, S. et al. A Bayesian hierarchical model for individual participant data meta-analysis
Puritanism) articulates the cause of substance use as a conscious, voli- of demand curves. Stat. Med. 41, 2276–2290 (2022).
18. Kaplan, B. A. et al. Understanding alcohol motivation using the alcohol purchase task:
tional choice emerging from within a person for immediate pleasure
a methodological systematic review. Drug. Alcohol. Depend. 191, 117–140 (2018).
over more societally acceptable activities (even if the choice comes 19. Martínez-Loredo, V., González-Roz, A., Secades-Villa, R., Fernández-Hermida, J. R.
at a high cost). By contrast, the contextualized reinforcer pathology & MacKillop, J. Concurrent validity of the Alcohol Purchase Task for measuring the
reinforcing efficacy of alcohol: an updated systematic review and meta-analysis.
model suggests that the cause of substance use is a set of temporally Addiction https://doi.org/10.1111/add.15379 (2020).
extended external contingencies, such as the relative availability and 20. Jacobs, E. A. & Bickel, W. K. Modeling drug consumption in the clinic using simulation
response cost associated with drugs versus alternatives, that contrib- procedures: demand for heroin and cigarettes in opioid-dependent outpatients.
Exp. Clin. Psychopharmacol. 7, 412–426 (1999).
utes to patterns of substance use over time. This bidirectional model 21. Lemley, S. M., Kaplan, B. A., Reed, D. D., Darden, A. C. & Jarmolowicz, D. P. Reinforcer
also emphasizes that patterns of drug use affect both the choice context pathologies: predicting alcohol related problems in college drinking men and women.
and the decision-making processes that contribute to addiction. Drug. Alcohol. Depend 167, 57–66 (2016).
22. Pickover, A. M., Messina, B. G., Correia, C. J., Garza, K. B. & Murphy, J. G. A behavioral
Finally, contextualized reinforcer pathology provides a theoreti- economic analysis of the nonmedical use of prescription drugs among young adults.
cal framework for widespread implementation of prevention, clinical Exp. Clin. Psychopharmacol. 24, 38–47 (2016).
and public policy initiatives that increase the availability of alternative 23. Aston, E. R., Metrik, J., Amlung, M. T., Kahler, C. W. & MacKillop, J. Interrelationships
between marijuana demand and discounting of delayed rewards: convergence in
reinforcement across levels of analysis. At the individual level, clini- behavioral economic methods. Drug. Alcohol. Depend. 169, 141–147 (2016).
cal interventions that target alternative reinforcement demonstrate 24. Petry, N. M. & Bickel, W. K. Polydrug abuse in heroin addicts: a behavioral economic
robust efficacy147,158,160. A critical next step is the effective dissemination analysis. Addiction 93, 321–335 (1998).
25. Acuff, S. F., Soltis, K. E., Dennhardt, A. A., Berlin, K. S. & Murphy, J. G. Evaluating
of these interventions, and some, such as contingency management, behavioral economic models of heavy drinking among college students. Alcohol. Clin.
have begun to be incorporated into mainstream treatment settings195. Exp. Res 42, 1304–1314 (2018).
At the level of public health, the sociopolitical environment has facil- 26. Aston, E. R., Metrik, J. & MacKillop, J. Further validation of a marijuana purchase task.
Drug. Alcohol. Depend. 152, 32–38 (2015).
itated increases in substance use through contemporary adverse 27. Bertholet, N., Murphy, J. G., Daeppen, J. B., Gmel, G. & Gaume, J. The alcohol purchase
economic conditions and historic trends of intentional isolation, exclu- task in young men from the general population. Drug. Alcohol. Depend 146, 39–44
sion from meaningful alternative reinforcement and occupational (2015).
28. Gex, K. S. et al. Change in alcohol demand following a brief intervention predicts change
opportunity, and economic constraints. In both cases, the adverse in alcohol use: a latent growth curve analysis. Alcohol Clin. Exp. Res. 46, 1525–1538 (2022).
impact on substance use can be explained through the framework of 29. Gaume, J. et al. Behavioral economics indices predict alcohol use and consequences in
contextualized reinforcer pathology and leads to the public policy young men at 4-year follow-up. Addiction 117, 2816–2825 (2022).
30. Mazur, J. E. in The Effect Of Delay And Of Intervening Events On Reinforcement Value (eds
recommendation of supporting access to salutary and meaningful Commons, M. L., Mazur, J. E., Nevin, J. A. & Rachlin, H.) 55–73 (Lawrence Erlbaum, 1987).
alternative reinforcers. 31. Ainslie, G. & Herrnstein, R. J. Preference reversal and delayed reinforcement. Anim. Learn.
Behav 9, 476–482 (1981).
32. Vuchinich, R. E. & Heather, N. (eds) Choice, Behavioural Economics And Addiction
Published online: 21 March 2023 (Pergamon/Elsevier Science, 2003).
33. Vuchinich, R. E. Alcohol abuse as molar choice: an update of a 1982 proposal. Psychol.
References Addict. Behav. 9, 223–235 (1995).
1. Key substance use and mental health indicators in the United States: results from the 34. Odum, A. L. & Rainaud, C. P. Discounting of delayed hypothetical money, alcohol, and
2020 National Survey on Drug Use and Health. Substance Abuse and Mental Health food. Behav. Process. 64, 305–313 (2003).
Services Administration https://www.samhsa.gov/data/ (2021). 35. Odum, A. L. et al. Delay discounting of different outcomes: review and theory. J. Exp.
2. McKetta, S. & Keyes, K. M. Heavy and binge alcohol drinking and parenting status in the Anal. Behav. 113, 657–679 (2020).
United States from 2006 to 2018: an analysis of nationally representative cross-sectional 36. Rung, J. M. & Madden, G. J. Experimental reductions of delay discounting and impulsive
surveys. PLoS Med. 16, e1002954 (2019). choice: a systematic review and meta-analysis. J. Exp. Psychol. Gen. 147, 1349–13831
3. Acuff, S. F., Strickland, J. C., Tucker, J. A. & Murphy, J. G. Changes in alcohol use during (2018).
COVID-19 and associations with contextual and individual difference variables: 37. Voss, A. T., Jorgensen, M. K. & Murphy, J. G. Episodic future thinking as a brief alcohol
a systematic review and meta-analysis. Psychol. Addict. Behav. 36, 1–19 (2022). intervention for heavy drinking college students: a pilot feasibility study. Exp. Clin.
4. Global Status Report On Alcohol And Health 2018. WHO https://www.who.int/ Psychopharmacol. 30, 313–325 (2021).
publications/i/item/9789241565639 (2018). 38. Stein, J. S., Tegge, A. N., Turner, J. K. & Bickel, W. K. Episodic future thinking reduces delay
5. World Drug Report 2021. United Nations https://www.unodc.org/unodc/en/data-and- discounting and cigarette demand: an investigation of the good-subject effect. J. Behav.
analysis/wdr2021.html (2021). Med. 41, 269–276 (2018).
6. Tapper, E. B. & Parikh, N. D. Mortality due to cirrhosis and liver cancer in the United 39. Bulley, A. & Gullo, M. J. The influence of episodic foresight on delay discounting and
States, 1999–2016: observational study. BMJ 362, k2817 (2018). demand for alcohol. Addict. Behav. 66, 1–6 (2017).

Perspective
40. Bickel, W. K. et al. in Recent Advances In Research On Impulsivity And Impulsive Behaviors 72. Carroll, M. E., Krattiger, K. L., Gieske, D. & Sadoff, D. A. Cocaine-base smoking in rhesus
(eds De Wit, H. & Jentsch, J. D.) 139–162 (Springer, 2020). monkeys: reinforcing and physiological effects. Psychopharmacology https://doi.org/
41. Hursh, S. R. Economic concepts for the analysis of behavior. J. Exp. Anal. Behav. 34, 10.1007/BF02247123 (1990).
219–238 (1980). 73. Griffiths, R. R., Troisi, J. R. II, Silverman, K. & Mumford, G. K. Multiple choice procedure: an
42. Hursh, S. R. Behavioral economics. J. Exp. Anal. Behav 42, 435–452 (1984). efficient approach for investigating drug reinforcement in humans. Behav. Pharmacol. 4,
43. Heyman, G. M. How individuals make choices explains addiction’s distinctive, 3–13 (1993).
non-eliminable features. Behav. Brain Res. 397, 112899 (2021). 74. Griffiths, R. R., Bigelow, G. E. & Liebson, I. A. Effect of ethanol self-administration
44. Hume, D. A Treatise Of Human Nature (eds Norton, D. F. & Norton, M. J.) (Clarendon Press, on choice behavior: money vs. socializing. Pharmacol. Biochem. Behav. 3, 443–446
2000). (1975).
45. Tucker, J. A., Buscemi, J., Murphy, J. G., Reed, D. D. & Vuchinich, R. E. Addictive behavior 75. Griffiths, R. R., Rush, C. R. & Puhala, K. A. Validation of the multiple-choice procedure for
as molar behavioral allocation: distinguishing efficient and final causes in translational investigating drug reinforcement in humans. Exp. Clin. Psychopharmacol. https://doi.org/
research and practice. Psychol. Addict. Behav. https://doi.org/10.1037/adb0000845 10.1037/1064-1297.4.1.97 (1996).
(2022). 76. Ahmed, S. H. Trying to make sense of rodents’ drug choice behavior. Prog. Neuro-
46. Heilig, M., Mackillop, J. & Leggio, L. Addiction as a brain disease revised: why it psychopharmacol. Biol. Psychiat. 87, 3–10 (2018).
still matters, and the need for consilience. Neuropsychopharmacology https://doi. 77. Ahmed, S. H. & Koob, G. F. Transition from moderate to excessive drug intake: change
org/10.1038/s41386-020-00950-y (2021). in hedonic set point. Science https://doi.org/10.1126/science.282.5387.298 (1998).
47. Volkow, N. D., Koob, G. F. & McLellan, A. T. Neurobiologic advances from the brain disease 78. Augier, E. et al. A molecular mechanism for choosing alcohol over an alternative reward.
model of addiction. N. Engl. J. Med. 374, 363–371 (2016). Science 360, 1321–1326 (2018).
48. Bennett, A. & Golub, A. in APA Addiction Syndrome Handbook Vol. 1 Foundations, 79. Ahmed, S. H. Individual decision-making in the causal pathway to addiction:
Influences, And Expressions Of Addiction (eds Shaffer, H. J., LaPlante, D. A. & Nelson, S. E.) contributions and limitations of rodent models. Pharmacol. Biochem. Behav. 164, 22–31
195–210 (American Psychological Association, 2012). (2018).
49. Singer, M. Anthropology and addiction: an historical review. Addiction 107, 1747–1755 80. Hutsell, B. A., Negus, S. S. & Banks, M. L. A generalized matching law analysis of cocaine
(2012). vs. food choice in rhesus monkeys: effects of candidate “agonist-based” medications on
50. Acuff, S. F. & Murphy, J. G. Commentary on Martínez-Loredo et al.: Where do we go from sensitivity to reinforcement. Drug. Alcohol. Depend. 146, 52–60 (2015).
here? Increasing the clinical utility of alcohol purchase tasks by expanding our definition 81. Chow, J. J. & Beckmann, J. S. Remifentanil–food choice follows predictions of relative
of constraint. Addiction 116, 2651–2652 (2021). subjective value. Drug. Alcohol Depend. 218, 108369 (2021).
51. Amlung, M. T. & MacKillop, J. Understanding the effects of stress and alcohol cues on 82. Negus, S. S. Rapid assessment of choice between cocaine and food in rhesus monkeys:
motivation for alcohol via behavioral economics. Alcohol. Clin. Exp. Res. 38, 17801789 effects of environmental manipulations andtreatment with d-amphetamine and
(2014). flupenthixol. Neuropsychopharmacology 28, 919–931 (2003).
52. Rose, A. K., Brown, K., MacKillop, J., Field, M. & Hogarth, L. Alcohol devaluation has 83. Madsen, H. B. & Ahmed, S. H. Drug versus sweet reward: greater attraction to and
dissociable effects on distinct components of alcohol behaviour. Psychopharmacology preference for sweet versus drug cues. Addict. Biol. 20, 433–444 (2015).
235, 1233–1244 (2018). 84. Herrnstein, R. J. & Prelec, D. in Choice Over Time (eds Loewenstein, G. & Elster, J.) 331–361
53. Ferguson, E., Bush, N., Yurasek, A. & Boissoneault, J. The effect of next day (Sage, 1992).
responsibilities and an adaptive purchase task on cannabis demand. Drug. Alcohol. 85. Heyman, G. M. Consumption dependent changes in reward value: a framework
Depend. 227, 108919 (2021). for understanding addiction. In Choice, Behavioural Economics And Addiction
54. Joyner, K. J. et al. High opportunity cost demand as an indicator of weekday drinking and (eds Vuchinich, R. E. & Heather, N.) 95–127 (Pergamon/Elsevier Science, 2003).
distinctly severe alcohol problems: a behavioral economic analysis. Alcohol. Clin. Exp. 86. Heyman, G. M. & Dunn, B. Decision biases and persistent illicit drug use: an experimental
Res. 43, 2607–2619 (2019). study of distributed choice and addiction. Drug. Alcohol. Depend. 67, 193–203 (2002).
55. Acuff, S. F., MacKillop, J. & Murphy, J. G. Integrating behavioral economic and social 87. MacKillop, J. The behavioral economics and neuroeconomics of alcohol use disorders.
network influences in understanding alcohol misuse among emerging adults. Alcohol. Alcohol. Clin. Exp. Res. 40, 672–685 (2016).
Clin. Exp. Res. https://doi.org/10.1111/acer.14351 (2020). 88. Baum, W. M. On two types of deviation from the matching law: bias and undermatching.
56. Acuff, S. F., Soltis, K. E. & Murphy, J. G. Using demand curves to quantify the reinforcing J. Exp. Anal. Behav. 22, 231–242 (1974).
value of social and solitary drinking. Alcohol. Clin. Exp. Res. 44, 1497–1507 (2020). 89. Alexander, B. K., Coambs, R. B. & Hadaway, P. F. The effect of housing and gender on
57. Acuff, S. F., Amlung, M. T., Dennhardt, A. A., MacKillop, J. & Murphy, J. G. Experimental morphine self-administration in rats. Psychopharmacology 58, 175–179 (1978).
manipulations of behavioral economic demand for addictive commodities: a meta-analysis. 90. Alexander, B. K., Beyerstein, B. L., Hadaway, P. F. & Coambs, R. B. Effect of early and later
Addiction 115, 817–831 (2020). colony housing on oral ingestion of morphine in rats. Pharmacol. Biochem. Behav. 15,
58. Bujarski, S., MacKillop, J. & Ray, L. A. Understanding naltrexone mechanism of action and 571–576 (1981).
pharmacogenetics in Asian Americans via behavioral economics: a preliminary study. 91. Ginsburg, B. C. & Lamb, R. J. Frustration stress (unexpected loss of alternative
Exp. Clin. Psychopharmacol. 20, 181–190 (2012). reinforcement) increases opioid self-administration in a model of recovery.
59. Dennhardt, A. A., Yurasek, A. M. & Murphy, J. G. Change in delay discounting and Drug. Alcohol. Depend. 182, 33–39 (2018).
substance reward value following a brief alcohol and drug use intervention. J. Exp. 92. Smith, M. A. & Pitts, E. G. Access to a running wheel inhibits the acquisition of cocaine
Anal. Behav. 103, 125–140 (2015). self-administration. Pharmacol. Biochem. Behav 100, 237–243 (2011).
60. Koffarnus, M. N., Jarmolowicz, D. P., Mueller, E. T. & Bickel, W. K. Changing delay 93. Cosgrove, K. P., Hunter, R. G. & Carroll, M. E. Wheel-running attenuates intravenous
discounting in the light of the competing neurobehavioral decision systems theory: cocaine self-administration in rats: sex differences. Pharmacol. Biochem. Behav. 73,
a review. J. Exp. Anal. Behav. 99, 32–57 (2013). 663–671 (2002).
61. Berry, M. S., Sweeney, M. M., Morath, J., Odum, A. L. & Jordan, K. E. The nature of 94. Lenoir, M. & Ahmed, S. H. Supply of a nondrug substitute reduces escalated heroin
impulsivity: visual exposure to natural environments decreases impulsive decision- consumption. Neuropsychopharmacology 33, 2272–2282 (2008).
making in a delay discounting task. PLoS One 9, e97915 (2014). 95. Huynh, C., Fam, J., Ahmed, S. H. & Clemens, K. J. Rats quit nicotine for a sweet reward
62. Snider, S. E. et al. Reinforcer pathology: narrative of hurricane-associated loss increases following an extensive history of nicotine use. Addict. Biol. 22, 142–151 (2017).
delay discounting, demand, and consumption of highly palatable snacks in the obese. 96. Carroll, M. E. Voluntary exercise as a treatment for incubated and expanded drug craving
Psychol. Addict. Behav. 34, 136–146 (2020). leading to relapse to addiction: animal models. Pharmacol. Biochem. Behav. 208, 173210
63. Bickel, W. K., George Wilson, A., Chen, C., Koffarnus, M. N. & Franck, C. T. Stuck in time: (2021).
negative income shock constricts the temporal window of valuation spanning the future 97. Miller, M. L. et al. Reciprocal inhibitory effects of intravenous d-methamphetamine
and the past. PLoS One 11, e0163051 (2016). self-administration and wheel activity in rats. Drug. Alcohol. Depend. 121, 90–96 (2012).
64. Sze, Y. Y., Stein, J. S., Bickel, W. K., Paluch, R. A. & Epstein, L. H. Bleak present, bright 98. Kim, J. S. & Kearns, D. N. Reduced ethanol self-administration in rats produced by the
future: online episodic future thinking, scarcity, delay discounting, and food demand. introduction of a high value non-drug alternative reinforcer. Pharmacol. Biochem. Behav.
Clin. Psychol. Sci. 5, 683–697 (2017). 184, 139–148 (2019).
65. Herrnstein, R. J. Formal properties of the matching law. J. Exp. Anal. Behav. 21, 159–164 99. Venniro, M., Panlilio, L. V., Epstein, D. H. & Shaham, Y. The protective effect of operant
(1974). social reward on cocaine self-administration, choice, and relapse is dependent on delay
66. Herrnstein, R. J. Relative and absolute strength of response as a function of frequency of and effort for the social reward. Neuropsychopharmacology 46, 2350–2357 (2021).
reinforcement. J. Exp. Anal. Behav. 4, 267–272 (1961). 100. Cohen, M., Liebson, I. A., Faillace, L. A. & Allen, R. P. Moderate drinking by chronic
67. de Villiers, P. A. & Herrnstein, R. J. Toward a law of response strength. Psychol. Bull. 83, alcoholics: a schedule dependent phenomenon. J. Nerv. Ment. Dis. 153, 434–444 (1971).
1131–1153 (1976). 101. Griffiths, R. R., Bigelow, G. E. & Liebson, I. A. Suppression of ethanol self-administration in
68. Rachlin, H. On the tautology of the matching law. J. Exp. Anal. Behav. 15, 249–251 (1971). alcoholics by contingent time-out from social interactions. Behav. Res. Ther. 12, 327–334
69. Acuff, S. F., Dennhardt, A. A., Correia, C. J. & Murphy, J. G. Measurement of substance-free (1974).
reinforcement in addiction: a systematic review. Clin. Psychol. Rev. 70, 79–90 (2019). 102. Bigelow, G. E. in International Handbook Of Alcohol Dependence And Problems
70. Hunt, P. S., Lant, G. M. & Carroll, C. A. Enhanced intake of ethanol in preweanling rats (eds Heather, N., Peters, T. J. & Stockwell, T.) 299–315 (Wiley, 2001).
following interactions with intoxicated siblings. Dev. Psychobiol. 37, 90–99 (2000). 103. Vuchinich, R. E. & Tucker, J. A. Behavioral theories of choice as a framework for studying
71. Carroll, M. E. in Advances In Behavioral Economics 37–68 (Ablex Publishing, 1996). drinking behavior. J. Abnorm. Psychol. 92, 408–416 (1983).

Perspective
104. Higgins, S. T., Bickel, W. K. & Hughes, J. R. Influence of an alternative reinforcer on human 135. Tucker, J. A., Cheong, J. W., James, T. G., Jung, S. & Chandler, S. D. Preresolution drinking
cocaine self-administration. Life Sci. https://doi.org/10.1016/0024-3205(94)00878-7 (1994). problem severity profiles associated with stable moderation outcomes of natural
105. Strickland, J. C. et al. Contribution of cocaine-related cues to concurrent monetary recovery attempts. Alcohol. Clin. Exp. Res. 44, 738–745 (2020).
choice in humans. Psychopharmacology 235, 2871–2881 (2018). 136. Tucker, J. A., Foushee, H. R. & Black, B. C. Behavioral economic analysis of natural
106. Strickland, J. C., Lile, J. A. & Stoops, W. W. Contribution of cannabis-related cues to resolution of drinking problems using IVR self-monitoring. Exp. Clin. Psychopharmacol.
concurrent reinforcer choice in humans. Drug. Alcohol. Depend. 199, 85–91 (2019). 16, 332–340 (2008).
107. Comer, S. D. et al. Effects of an alternative reinforcer on intravenous heroin self- 137. Tucker, J. A., Vuchinich, R. E. & Rippens, P. D. Environmental contexts surrounding
administration by humans. Eur. J. Pharmacol. 345, 13–26 (1998). resolution of drinking problems among problem drinkers with different help-seeking
108. Hogarth, L. & Hardy, L. Alcohol use disorder symptoms are associated with greater experiences. J. Stud. Alcohol 63, 334–341 (2002).
relative value ascribed to alcohol, but not greater discounting of costs imposed on 138. Tucker, J. A., Vuchinich, R. E. & Gladsjo, J. A. Environmental events surrounding natural
alcohol. Psychopharmacology 235, 2257–2266 (2018). recovery from alcohol-related problems. J. Addict. Nurs. https://doi.org/10.3109/
109. Haney, M., Comer, S. D., Ward, A. S., Foltin, R. W. & Fischman, M. W. Factors influencing 10884609409021737 (1994).
marijuana self-administration by humans. Behav. Pharmacol. 8, 101–112 (1997). 139. Witkiewitz, K., Litten, R. Z. & Leggio, L. Advances in the science and treatment of alcohol
110. Lile, J. A. et al. Pharmacological validation of a translational model of cocaine use use disorder. Sci. Adv. https://doi.org/10.1126/sciadv.aax4043 (2019).
disorder: effects of d-amphetamine maintenance on choice between intravenous 140. Vilsaint, C. L. et al. Development and validation of a Brief Assessment of Recovery Capital
cocaine and a non-drug alternative in humans and rhesus monkeys. Exp. Clin. (BARC-10) for alcohol and drug use disorder. Drug. Alcohol. Depend. 177, 71–76 (2017).
Psychopharmacol. 28, 169–180 (2020). 141. Best, D. & Hennessy, E. A. The science of recovery capital: where do we go from here?
111. Hart, C. L., Haney, M., Foltin, R. W. & Fischman, M. W. Alternative reinforcers differentially Addiction 117, 1139–1145 (2022).
modify cocaine self-administration by humans. Behav. Pharmacol. 11, 87–91 (2000). 142. McKay, J. R. Making the hard work of recovery more attractive for those with substance
112. Fischman, M. W. & Foltin, R. W. Self-administration of cocaine by humans: a laboratory use disorders. Addiction 112, 751–757 (2017).
perspective. Ciba Found. Symp. 166, 165–173 (1992). 143. Higgins, S. T., Heil, S. H. & Lussier, J. P. Clinical implications of reinforcement as a
113. Foltin, R. W., Haney, M., Bedi, G. & Evans, S. M. Modafinil decreases cocaine choice determinant of substance use disorders. Annu. Rev. Psychol. 55, 431–461 (2004).
in human cocaine smokers only when the response requirement and the alternative 144. Meyers, R. J., Roozen, H. G. & Smith, J. E. The community reinforcement approach.
reinforcer magnitude are large. Pharmacol. Biochem. Behav. 150–151, 8–13 (2016). Alcohol. Res. Health 33, 380–388 (2011).
114. Hogarth, L. & Field, M. Relative expected value of drugs versus competing rewards 145. Petry, N. M., Martin, B., Cooney, J. L. & Kranzler, H. R. Give them prizes, and they will
underpins vulnerability to and recovery from addiction. Behav. Brain Res. https:// come: contingency management for treatment of alcohol dependence. J. Consult. Clin.
doi.org/10.1016/j.bbr.2020.112815 (2020). Psychol. https://doi.org/10.1037/0022-006X.68.2.250 (2000).
115. Davison, M. & Baum, W. M. Choice in a variable environment: every reinforcer counts. 146. Petry, N. M., Barry, D., Alessi, S. M., Rounsaville, B. J. & Carroll, K. M. A randomized
J. Exp. Anal. Behav. 74, 1–24 (2000). trial adapting contingency management targets based on initial abstinence status of
116. Schneider, W. Reinforcer effectiveness as a function of reinforcer rate and magnitude: cocaine-dependent patients. J. Consult. Clin. Psychol. https://doi.org/10.1037/a0026883
a comparison of concurrent performances. J. Exp. Anal. Behav. 20, 461–471 (1973). (2012).
117. Young, J. S. Discrete-trial choice in pigeons: effects of reinforcer magnitude. J. Exp. Anal. 147. Bolívar, H. A. et al. Contingency management for patients receiving medication for
Behav. 35, 23–29 (1981). opioid use disorder: a systematic review and meta-analysis. JAMA Psychiat. 78, 1092–1102
118. Davison, M. & Baum, W. M. Every reinforcer counts: reinforcer magnitude and local (2021).
preference. J. Exp. Anal. Behav. 80, 95–129 (2003). 148. Higgins, S. T. et al. A behavioral approach to achieving initial cocaine abstinence.
119. Hallgren, K. A., Greenfield, B. L. & Ladd, B. O. Psychometric properties of the Adolescent Am. J. Psychiat. https://doi.org/10.1176/ajp.148.9.1218 (1991).
Reinforcement Survey Schedule — alcohol use version with college student drinkers. 149. Davis, D. R. et al. A review of the literature on contingency management in the
Subst. Use Misuse 51, 812–822 (2016). treatment of substance use disorders, 2009–2014. Prev. Med. https://doi.org/10.1016/
120. Delmée, L., Roozen, H. G. & Steenhuis, I. The engagement of non-substance-related j.ypmed.2016.08.008 (2016).
pleasant activities is associated with decreased levels of alcohol consumption in 150. Petry, N. M., Alessi, S. M., Hanson, T. & Sierra, S. Randomized trial of contingent prizes
university students. Int. J. Ment. Health Addict. https://doi.org/10.1007/s11469-017-9857-5 versus vouchers in cocaine-using methadone patients. J. Consult. Clin. Psychol. 75,
(2017). 983–991 (2007).
121. Audrain-McGovern, J. E., Rodriguez, D., Rodgers, K. & Cuevas, J. Declining alternative 151. Rawson, R. A. et al. A comparison of contingency management and cognitive-behavioral
reinforcers link depression to young adult smoking. Addiction 106, 178–187 (2010). approaches during methadone maintenance treatment for cocaine dependence.
122. Rogers, R. E. et al. Abstinence-contingent reinforcement and engagement in non-drug- Psychosoc. Treat. 59, 87–104 (2003).
related activities among illicit drug abusers. Psychol. Addict. Behav. 22, 544–550 (2008). 152. Epstein, D. H., Hawkins, W. E., Covi, L., Umbricht, A. & Preston, K. L. Cognitive-behavioral
123. Meshesha, L. Z., Dennhardt, A. A. & Murphy, J. G. Polysubstance use is associated with therapy plus contingency management for cocaine use: findings during treatment and
deficits in substance-free reinforcement in college students. J. Stud. Alcohol. Drugs 76, across 12-month follow-up. Psychol. Addict. Behav. 17, 73–82 (2003).
106–116 (2015). 153. Pfund, R. A., Ginley, M. K., Rash, C. J., & Zajac, K. Contingency management for treatment
124. Andrabi, N., Khoddam, R. & Leventhal, A. M. Socioeconomic disparities in adolescent attendance: a meta-analysis. J. Subst. Abuse Treat 133, 108556 (2021).
substance use: role of enjoyable alternative substance-free activities. Soc. Sci. Med. 176, 154. Archer, M., Harwood, H., Stevelink, S., Rafferty, L. & Greenberg, N. Community
175–182 (2017). reinforcement and family training and rates of treatment entry: a systematic review.
125. Andrabi, N., Leventhal, A. M. & Khoddam, R. Diminished alternative reinforcement Addiction 115, 1024–1037 (2020).
mediates socioeconomic disparities in adolescent substance ase: a longitudinal study. 155. De Crescenzo, F. et al. Comparative efficacy and acceptability of psychosocial
Drug. Alcohol. Depend. 171, e8 (2017). interventions for individuals with cocaine and amphetamine addiction: a systematic
126. Correia, C. J., Carey, K. B., Simons, J. S. & Borsari, B. E. Relationships between binge review and network meta-analysis. PLoS Med 15, e10027 (2018).
drinking and substance-free reinforcement in a sample of college students: a preliminary 156. Lewinsohn, P. M. in The Psychology Of Depression: Contemporary Theory And Research
investigation. Addict. Behav. 28, 361–368 (2003). 157–178 (1974).
127. Correia, C. J., Simons, J. S., Carey, K. B. & Borsari, B. E. Predicting drug use: application of 157. Daughters, S. B., Magidson, J. F., Lejuez, C. W. & Chen, Y. LETS Act: a behavioral activation
behavioral theories of choice. Addict. Behav. 23, 705–709 (1998). treatment for substance use and depression. Adv. Dual Diagn. 9, 74–84 (2016).
128. Van Etten, M. L., Higgins, S. T., Budney, A. J. & Badger, G. J. Comparison of the frequency 158. Daughters, S. B. et al. The effect of a behavioral activation treatment for substance use on
and enjoyability of pleasant events in cocaine abusers vs. non-abusers using a post-treatment abstinence: a randomized controlled trial. Addiction 113, 535–544 (2018).
standardized behavioral inventory. Addiction 93, 1669–1680 (1998). 159. Murphy, J. G. et al. A randomized controlled trial of a behavioral economic supplement
129. Tucker, J. A., Chandler, S. D. & Witkiewitz, K. Epidemiology of recovery from alcohol use to brief motivational interventions for college drinking. J. Consult. Clin. Psychol. 80,
disorder. Alcohol. Res. Curr. Rev. 40, 1–12. (2020). 876–886 (2012).
130. Lee, D. C., Stanger, C. & Budney, A. J. A comparison of delay discounting in adolescents 160. Murphy, J. G. et al. A randomized clinical trial evaluating the efficacy of a brief alcohol
and adults in treatment for cannabis use disorders. Exp. Clin. Psychopharmacol. https:// intervention supplemented with a substance-free activity session or relaxation training.
doi.org/10.1037/a0038792 (2015). J. Consult. Clin. Psychol. 87, 657–669 (2019).
131. Murphy, J. G. et al. Behavioral economic predictors of brief alcohol intervention 161. Gex, K. S. et al. A randomized pilot trial of a mobile delivered brief motivational
outcomes. J. Consult. Clin. Psychol. 83, 1033–1043 (2015). interviewing and behavioral economic alcohol intervention for emerging adults.
132. Schnoll, R. A. et al. Longitudinal changes in smoking abstinence symptoms and Psychol. Addict. Behav. https://doi.org/10.1037/adb0000838 (2022).
alternative reinforcers predict long-term smoking cessation outcomes. Drug. Alcohol. 162. Meshesha, L. Z. et al. Pilot trial investigating a brief behavioral economic intervention
Depend. 165, 245–252 (2016). as an adjunctive treatment for alcohol use disorder. J. Subst. Abuse Treat. 113, 108002
133. Worley, M. J., Shoptaw, S. J., Bickel, W. K. & Ling, W. Using behavioral economics to (2020).
predict opioid use during prescription opioid dependence treatment. Drug. Alcohol. 163. Mulia, N., Tam, T., Bond, J., Zemore, S. E. & Li, L. Racial/ethnic differences in life-course
Depend. 148, 62–68 (2015). heavy drinking from adolescence to midlife. J. Ethn. Subst. Abuse 17, 167–186 (2018).
134. Tucker, J. A., Vuchinich, R. E. & Rippens, P. D. Predicting natural resolution of 164. Mulia, N., Zemore, S. E., Murphy, R., Liu, H. & Catalano, R. Economic loss and alcohol
alcohol-related problems: a prospective behavioral economic analysis. Exp. Clin. consumption and problems during the 2008 to 2009 U.S. recession. Alcohol. Clin.
Psychopharmacol. 10, 248–257 (2002). Exp. Res. 38, 1026–1034 (2014).

Perspective
165. Probst, C., Roerecke, M., Behrendt, S. & Rehm, J. Gender differences in socioeconomic 188. Santopietro, G. D. & Zipper, C. E. in Appalachia’s Coal-Mined Landscapes: Resources And
inequality of alcohol-attributable mortality: a systematic review and meta-analysis. Communities In A New Energy Era (eds Zipper, C. E. & Skousen, J.) 287–310 (Springer,
Drug. Alcohol. Rev 34, 267–277 (2015). 2021).
166. Matthay, E. C., Mousli, L., Ponicki, W. R., Glymour, M. M. & Apollonio, E. A spatiotemporal 189. Sigfusdottir, I. D., Kristjansson, A. L., Thorlindsson, T. & Allegrante, J. P. Trends in
analysis of the association of California city and county cannabis policies with cannabis prevalence of substance use among Icelandic adolescents, 1995–2006. Subst. Abuse
outlet densities. Epidemiology 33, 715–725 (2022). Treat. Prev. Policy https://doi.org/10.1186/1747-597X-3-12 (2008).
167. Pedersen, E. R. et al. Examining associations between licensed and unlicensed outlet 190. Kristjansson, A. L. et al. Implementing the Icelandic model for preventing adolescent
density and cannabis outcomes from preopening to postopening of recreational substance use. Health Promot. Pract. 21, 70–79 (2019).
cannabis outlets. Am. J. Addict. 30, 122–130 (2021). 191. Kristjansson, A. L., James, J. E., Allegrante, J. P., Sigfusdottir, I. D. & Helgason, A. R.
168. Lee, J. P., Ponicki, W., Mair, C., Gruenewald, P. & Ghanem, L. What explains the concentration Adolescent substance use, parental monitoring, and leisure-time activities: 12-year
of off-premise alcohol outlets in Black neighborhoods. SSM Popul. Health 12, 100669 (2020). outcomes of primary prevention in Iceland. Prev. Med. 51, 168–171 (2010).
169. Romley, J. A., Cohen, D., Ringel, J. & Sturm, R. Alcohol and environmental justice: the 192. Kristjansson, A. L. et al. Population trends in smoking, alcohol use and primary
density of liquor stores and bars in urban neighborhoods in the United States. J. Stud. prevention variables among adolescents in Iceland, 1997–2014. Addiction 111, 645–652
Alcohol. Drugs 68, 48–55 (2007). (2016).
170. Brenner, A. B., Borrell, L. N., Barrientos-Gutierrez, T. & Diez Roux, A. V. Longitudinal 193. Hibell, B. et al. The 2011 ESPAD Report: substance use among students in 36 European
associations of neighborhood socioeconomic characteristics and alcohol availability on countries. ESPAD https://www.drugsandalcohol.ie/17644/ (2012).
drinking: results from the Multi-ethnic Study of Atherosclerosis (MESA). Soc. Sci. Med. 194. Merrill, J. E. & Aston, E. R. Alcohol demand assessed daily: validity, variability, and
145, 17–25 (2015). the influence of drinking-related consequences. Drug. Alcohol. Depend. https://
171. Hogarth, L. in Evaluating the Brain Disease Model of Addiction (Heather, N., Field, M., doi.org/10.1016/j.drugalcdep.2020.107838 (2020).
Moss, A. C. & Satel, S.) 216–236 (Routledge, 2022). 195. DePhilippis, D., Petry, N. M., Bonn-Miller, M. O., Rosenbach, S. B. & McKay, J. R. The
172. Lee, J. O. et al. Developmental pathways from parental socioeconomic status to adolescent national implementation of contingency management (CM) in the Department of
substance use: alternative and complementary reinforcement. J. Youth Adolesc. 47, Veterans Affairs: attendance at CM sessions and substance use outcomes. Drug. Alcohol.
334–348 (2018). Depend. 185, 367–373 (2018).
173. Oshri, A. et al. Socioeconomic hardship and delayed reward discounting: associations 196. Rachlin, H., Kagel, J. H. & Battalio, R. C. Substitutability in time allocation. Psychol. Rev.
with working memory and emotional reactivity. Dev. Cogn. Neurosci. 37, 100642 (2019). 87, 355–374 (1980).
174. Mullins, T. S., Campbell, E. M. & Hogeveen, J. Neighborhood deprivation shapes 197. William, B. M. Matching, undermatching, and overmatching in studies of choice. J. Exp.
motivational-neurocircuit recruitment in children. Psychol. Sci. 31, 881–889 (2020). Anal. Behav. 32, 269–281 (1979).
175. Collins, S. E. Associations between socioeconomic factors and alcohol outcomes. 198. Stewart, R. & Uggen, C. Criminal records and college admissions: a modified
Alcohol. Res. Curr. Rev. 38, 83–94 (2016). experimental audit. Criminology 58, 156–188 (2020).
176. Rothstein, R. The Color Of Law (W. W. Norton Co., 2017). 199. Craigie, T. A. Ban the box, convictions, and public employment. Econ. Inq. 58, 425–445
177. Kamin, D. Home appraised with a black owner: $472,000. With a white owner: $750,000. (2020).
The New York Times https://www.nytimes.com/2022/08/18/realestate/housing-
discrimination-maryland.html (2022). Acknowledgements
178. Humphreys, K. & Rappaport, J. From the community mental health movement to the war J.G.M. is supported by the Peter Boris Chair in Translational Addictions Research and a Tier 1
on drugs: a study in the definition of social problems. Am. Psychol. 48, 892–901 (1993). Canada Research Chair.
179. US Commission on Marihuana and Drug Abuse. Marihuana: A Signal of
Misunderstanding (New American Library, 1972).
180. Nellis, A. The color of justice: racial and ethnic disparity in state prisons. Sentencing
Author contributions
The authors contributed equally to all aspects of the article.
Project https://www.sentencingproject.org/wp-content/uploads/2016/06/The-Color-of-
Justice-Racial-and-Ethnic-Disparity-in-State-Prisons.pdf%7B%5C%25%7D0A (2016).
181. Zapolski, T. C., Pedersen, S. L., McCarthy, D. M., & Smith, G. T. Less drinking, yet more Competing interests
problems: understanding African American drinking and related problems. Psychol. Bull. J.G.M. is a principal in BEAM Diagnostics, Inc and a consultant to Clairvoyant Therapeutics, Inc.
140, 188–223 (2014). The other authors declare no competing interests.
182. Monnat, S. M. Factors associated with county-level differences in U.S. drug-related
mortality rates. Am. J. Prev. Med. 54, 611–619 (2018). Additional information
183. Knapp, E. A., Bilal, U., Dean, L. T., Lazo, M. & Celentano, D. D. Economic insecurity and Peer review information Nature Reviews Psychology thanks Yavin Shaham, who co-reviewed
deaths of despair in US counties. Am. J. Epidemiol. 188, 2131–2139 (2019). with Jonathan Chow, and the other, anonymous, reviewers for their contribution to the peer
184. CDC vital signs: opioid prescribing. Center for Disease Control and Prevention https:// review of this work.
www.cdc.gov/vitalsigns/opioids/index.html (2017).
185. Smallwood, R., Woods, C., Power, T. & Usher, K. Understanding the impact of historical Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in
trauma due to colonization on the health and well-being of indigenous young peoples: published maps and institutional affiliations.
a systematic scoping review. J. Transcult. Nurs. 32, 59–68 (2021).
186. Spillane, S. et al. Trends in alcohol-induced deaths in the United States, 2000–2016. Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this
JAMA Netw. Open 3, e1921451 (2020). article under a publishing agreement with the author(s) or other rightsholder(s); author self-
187. Brave Heart, M. Y. H. et al. Psychiatric disorders and mental health treatment in American archiving of the accepted manuscript version of this article is solely governed by the terms
Indians and Alaska Natives: results of the National Epidemiologic Survey on Alcohol and of such publishing agreement and applicable law.
Related Conditions. Soc. Psychiat. Psychiatric Epidemiol. https://doi.org/10.1007/s00127-
016-1225-4 (2016). © Springer Nature America, Inc. 2023

A Contextualized Reinforcer Pathology Approach To Addiction: Psychology

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Behavioural economic accounts of addiction conceptualize harmful Introduction

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Introduction Drug demand

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Importantly, discounting applies to all delayed rewards, and rates

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Within-individual determinants Reinforcer pathology Environmental determinants

Delayed reward discounting Alternative reinforcement Behavioural economic demand

Temporal windows Access/constraints on alternatives Access/constraints on drugs or alcohol

Discrete choice contexts

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High constraints on alternatives Low constraints on alternatives

Inexpensive alcohol easily available from neighbourhood bars and liquor

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tives, consider patterns of reinforcement for two individuals. Both

be self-administered at high rates under schedules of reinforcement in

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Independent Substitutes Complements

Price of commodity 1 Price of commodity 1 Price of commodity 1

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Nature Reviews Psychology | Volume 2 | May 2023 | 309–323 318

A behavioural economic perspective on drug criminalization

populations186,187. In Appalachia and the northeastern USA, there has Conclusions

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Nature Reviews Psychology | Volume 2 | May 2023 | 309–323 323

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