Although Meth Is Irresistible, The New York Times Says, Addicts Often Prefer Small Cash Rewards
The success of "contingency management" belies the notion that addiction is an uncontrollable disease caused by a drug's impact on dopamine levels.
In a recent New York Times story, health reporter Jan Hoffman describes methamphetamine as irresistible, suggesting it is so pharmacologically compelling that using it inexorably leads to an addiction that is nearly impossible to escape. She also notes that people addicted to meth often will stop using it in exchange for small financial rewards ranging from $10 to $65.
The contradiction at the heart of Hoffman's story illustrates the folly of viewing drug addiction as a straightforward chemical reaction that can be reliably produced by combining a brain with a psychoactive agent. That take unsurprisingly appeals to hard-line drug warriors. But it is also embraced by many people who advocate a kinder, gentler "public health" approach to substance abuse.
Both versions are biologically reductive, gliding over the personal, social, and economic factors that explain why some people use a given drug occasionally while others become so absorbed with it that it dominates their lives. A drug-focused understanding of addiction is fundamentally dehumanizing because it treats people as passive victims rather than autonomous agents who respond to circumstances and incentives.
Hoffman says methamphetamine is "a highly addictive stimulant" that "has been spreading aggressively across the country." In her telling, meth has a mind of its own, but people who use it have no such agency.
You might be skeptical of Hoffman's take, especially since this is the same reporter who previously embraced the dubious notion that P2P-derived methamphetamine ("super meth") is inherently more powerful and addictive than pseudoephedrine-derived methamphetamine. But while Hoffman cited no scientific basis for that claim, she does offer a theory that she thinks explains why some people develop life-disrupting meth habits.
"Meth causes the brain to release exorbitant amounts of dopamine, the feel-good neurotransmitter," Hoffman writes, paraphrasing Kristen B. Silvia, a physician who runs an addiction treatment program in Portland, Maine. In dopamine terms, Silvia says, the experience of using crack cocaine is "three times" as powerful as "the best meal ever, the best sex ever, [or] the best day of your life." By that same measure, she says, methamphetamine is 10 times as rewarding as those pleasures.
That account sounds scientific, but it is hard to reconcile with data on drug use. In the 2023 National Survey on Drug Use and Health, for instance, 3.5 percent of respondents reported that they had ever tried crack, while 0.2 percent said they had used it in the previous month. In other words, 94 percent of people who had tried crack, which according to Silvia's math is three times better than "the best day of your life," were not still using it even as often as once a month. The numbers for methamphetamine were similar: Just 10 percent of lifetime users reported past-month use.
The dopamine-focused explanation of addiction also seems inconsistent with the success of the "contingency management" program that Silvia oversees. Here is how Hoffman describes that approach to addiction treatment:
Patients typically come in twice a week for a urine drug screen. If they test negative, they are immediately handed a small reward: a modest store voucher, a prize or debit card cash. The longer they abstain from use, the greater the rewards, with a typical cumulative value of nearly $600. The programs, which usually last three to six months, operate on the principle of positive reinforcement, with incentives intended to encourage repetition of desired behavior.
Hoffman links to studies indicating that contingency management "produces better outcomes for stimulant addiction than counseling or cognitive behavioral therapy." She adds that "follow-up studies of patients a year after they successfully completed programs show that about half remained stimulant-free."
Those findings belie the notion that methamphetamine's dopamine rewards compel continued use. Contingency management could not possibly work if drug addicts were the chemical slaves that Hoffman makes them out to be. To the contrary, the technique relies on the premise that even the heaviest drug users make choices in response to the incentives they face.
Research confirms that hypothesis. "Despite the popular conception that addicted people will choose any dose of a drug over any other experience," Columbia University neuropsychopharmacologist Carl Hart notes in his 2013 book High Price, "this is not what we find in the lab." In Hart's research, heavy crack users were offered a choice between another hit of their favorite drug and small cash prizes: $5 each time, with a maximum of $50 for the day. They often chose the money over the crack. "Even around drugs, addicted people are not simply slaves to craving," Hart writes. "They can make rational choices."
Hoffman resists that conclusion. "Given the ferocity of meth addiction, it almost defies credulity that small rewards can quell drug hunger," she writes. "But treatment experts say that as negative screening results accrue and abstinence builds, the immediacy of a reward and the ability to purchase something satisfying can bathe the brain in cascades of frequent, modest dopamine jolts."
In short, it's still all about the dopamine. Yet Hoffman already has informed us that even "the best meal ever," "the best sex ever," or "the best day of your life" offers just one-tenth the rewards of meth. If so, it is hard to see how the "modest dopamine jolt" from "the ability to purchase something satisfying" with a $10 debit card could possibly compete.
"What does contingency management tell us about addiction?" asks Stanton Peele, a psychologist who has been exploring the subtleties of the latter subject for half a century. The success of that treatment model refutes the widely accepted idea that "addiction is an uncontrollable disease," he says, and shows that "giving people something in real life" is "better than playing mind games with them in any type of therapy."
Real-life rewards, of course, are not limited to modest cash prizes. As Peele has been explaining for many years, people with intact and loving families, strong social support, good jobs, and stable lives that include involvement with meaningful activities are much less likely to develop harmful relationships with drugs than people who lack those things. If you "tell people they don't have an uncontrollable disease," he says, "they can quit," provided they have "the means to attain better (more permanent and self-initiated) rewards than the addiction provides."
