A brief measure of non-drug reinforcement: Association with treatment outcomes during initial substance use recovery

BACKGROUND

Translational research demonstrates that drug use is inversely associated with availability and engagement with meaningful non-drug reinforcers. Evaluation of non-drug reinforcement in treatment-receiving clinical populations is limited, likely owing to the time intensive nature of existing measures. This study explores the association of non-drug reinforcers with treatment outcomes using a novel, brief measure of past month non-drug reinforcement quantifying three elements: relative frequency, access, and enjoyability.

METHODS

Respondents enrolled in substance use treatment (residential, intensive outpatient, and medically managed withdrawal) in clinics across the United States (N = 5481) completed standardized assessments of non-drug reinforcement and treatment outcomes (i.e., return to use and life satisfaction) one-month after treatment discharge. Non-drug reinforcement measures (availability, engagement, enjoyability) were used as predictors of return to use and life satisfaction using generalized linear models.

RESULTS

Non-drug reinforcement indices were associated with return to use and life satisfaction in unadjusted models (e.g., 12.4 % versus 58.3 % return to use for those with the highest and lowest availability, respectively). Consistent results were observed in models adjusted for sociodemographic variables and risk factors (i.e., sleep disturbance, anhedonia, stress). Comparisons by drug class generally showed lower non-drug reinforcement among patients reporting heroin or methamphetamine as their primary drug.

CONCLUSIONS

Results highlight the importance of non-drug reinforcement during the first month following treatment. Rapid measurement of non-drug reinforcement in stepped care settings may illuminate critical deficits in early stages of behavior change, identify those at greatest risk for return to use, and provide targets for treatment to improve recovery trajectories.

Cognitive Dissonance in the Self-assessed Health in Brazil: A CUB Model Analysis Using 2013 National Health Survey Data

This study ai ms to verify and analyze the existence of cognitive dissonance in the self-assessment of health by individuals in Brazil, that is, the difference between self-rated health and the health status of individuals. To accomplish this, we use data from the 2013 National Health Survey, which collected the self-assessments that individuals made of their health and information about their health status. This information was used to build indices that seek to represent a person's health status in relation to chronic illnesses, physical and mental well-being, eating habits and lifestyle. To identify the presence of cognitive dissonance, the CUB (Combination of a discrete Uniform and shifted Binomial distributions) model was used, which relates self-assessed health with the developed indices. Cognitive dissonance was identified in self-assessed health in relation to eating habits and lifestyle, and this dissonance may be associated with a present bias in the self-assessment of health in Brazil.

Goals for Adherence with Low-cost Incentives (GOALS): a protocol for a randomized controlled trial evaluating the impact of small airtime incentives on ART adherence among young people living with HIV in Kampala, Uganda

BACKGROUND

Treatment outcomes of HIV-positive individuals are threatened by low antiretroviral therapy (ART) adherence, a problem that is particularly acute among youth. Incentives are a promising tool to support ART adherence, but traditional incentive designs rewarding uniformly high levels of the desired health behavior may demotivate those with low levels of the behavior. In this study, we investigate the effectiveness of alternative approaches to target-setting for incentive eligibility using subgoals (i.e., individual-specific, interim targets leading up to the optimal target).

METHODS / DESIGN

We will enroll 628 HIV-positive youth between ages 15 and 30 into a 3-year randomized controlled trial. Participants will be randomized 1:1:1:1 to a control arm or one of three intervention arms (n = 157 each) that allow them to enter a prize drawing for small incentives if their ART adherence meets the given goal. In the first arm (T1, assigned subgoal), goals will be externally assigned and adapted to their initial adherence level. In the second arm (T2, participatory subgoal), participants can set their own interim goals. In the third arm (T3, fixed goal), all participants must reach the same target goal of 90% adherence. T1 and T2 participants are required to reach 90% adherence by month 12 to participate in a larger prize drawing. The control group receives the usual standard of care. All four groups will receive weekly motivational messages; the three treatment groups will additionally receive reminders of their upcoming prize drawing. Adherence will be measured continuously throughout the intervention period using electronic devices and for 12 months post-intervention. Surveys will be conducted at baseline and every 6 months. Viral loads will be measured annually. The primary outcome is Wisepill-measured adherence and a binary measure for whether the person took at least 90% of their pills. The secondary outcome is the log-transformed viral load as a continuous measure.

DISCUSSION

Our study is one of the first to apply insights about the psychology and behavioral economics of goal-setting to the design of incentives, by testing whether conditioning the eligibility threshold for incentives on subgoals (interim goals leading up to the ultimate, high goal) improves motivation and adherence more than setting a uniformly highly goal, and a comparison group.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05378607. Date of registration: May 18, 2022.

Healthcare System

"Comprehensive Healthcare for America" is a largely single-payer reform proposal that, by applying the insights of behavioral economics, may be able to rally patients and clinicians sufficiently to overcome the opposition of politicians and vested interests to providing all Americans with less complicated and less costly access to needed healthcare.

Conviction Narrative Theory: A Theory of Choice Under Radical Uncertainty

Conviction Narrative Theory (CNT) is a theory of choice under radical uncertainty-situations where outcomes cannot be enumerated and probabilities cannot be assigned. Whereas most theories of choice assume that people rely on (potentially biased) probabilistic judgments, such theories cannot account for adaptive decision-making when probabilities cannot be assigned. CNT proposes that people use narratives-structured representations of causal, temporal, analogical, and valence relationships-rather than probabilities, as the currency of thought that unifies our sense-making and decision-making faculties. According to CNT, narratives arise from the interplay between individual cognition and the social environment, with reasoners adopting a narrative that feels 'right' to explain the available data; using that narrative to imagine plausible futures; and affectively evaluating those imagined futures to make a choice. Evidence from many areas of the cognitive, behavioral, and social sciences supports this basic model, including lab experiments, interview studies, and econometric analyses. We propose 12 principles to explain how the mental representations (narratives) interact with four inter-related processes (explanation, simulation, affective evaluation, communication), examining the theoretical and empirical basis for each. We conclude by discussing how CNT can provide a common vocabulary for researchers studying everyday choices across areas of the decision sciences.

Economic Perspectives on Food Choices, Marketing, and Consumer Welfare

This contribution reviews the main normative and positive arguments that can used in the assessment of the costs and benefits of food marketing restrictions, focusing specifically on theoretical and empirical developments in the economics of advertising, consumer behaviour and industrial organization since the 70s.

The Intersection of Behavioral Economics and the General Medicine Literature

Judgment and decision-making influence health-related behavior and clinical decision-making and, ultimately, health. It has been estimated that more than half of health disorders derive from behavioral consequences of unhealthy choices. We considered the question of how to better understand and improve decision-making in health and medicine through a narrative review of use and examples of concepts from Behavioral Economics, a field of study that combines insights from behavioral science and economic decision-making, in the 3 highest-impact general medicine journals.

Can nudges save lives?

To assess the promotion of life saving behaviors and determine the sustainability of nudge message effects, this paper examines nudges that promote evacuation during heavy rainfall, preventative COVID-19 infection behaviors, and COVID-19 vaccination. The results showed that altruistic gain messages may have more sustained effects than others in promoting both evacuation during heavy rainfall and contact reduction behaviors as a measure against COVID-19 infection. Specifically, social influence nudges that use a gain frame to convey that a person's behavior promotes the behavior of others are effective for both heavy rainfall evacuations and encouraging COVID-19 vaccination.

Identifying Patterns of Alcohol Use and Obesity-Related Factors Among Emerging Adults: A Behavioral Economic Analysis

BACKGROUND

Although heavy alcohol consumption and maladaptive eating behaviors have been shown to co-occur among college students, less is known about the co-occurrence of these behaviors in a more diverse community-dwelling, emerging adult sample. The purpose of this study was to: (i) identify classes of emerging adults by their reported alcohol consumption patterns, food addiction symptoms, and body mass index; and (ii) determine whether these classes differed on indices of behavioral economic reinforcer pathology (e.g., environmental reward deprivation, impulsivity, alcohol demand).

METHOD

Emerging adult participants were recruited as part of a study on risky alcohol use (n = 602; 47% white, 41.5% Black; mean age = 22.63, SD = 1.03). Participants completed questionnaires on alcohol and food-related risk factors and underwent anthropometric assessment.

RESULTS

Latent profile analysis suggested a four-profile solution: a moderate alcohol severity, overweight profile (Profile 1; n = 424, 70.4%), a moderate alcohol severity, moderate food addiction + obese profile (Profile 2; n = 93, 15.4%), a high alcohol severity, high food addiction + obese profile (Profile 3; n = 44, 7.3%), and a high alcohol severity, overweight profile (Profile 4; n = 41, 6.8%). Individuals in Profile 1 reported significantly lower levels of environmental reward deprivation than either Profile 2 or 3, and participants in Profile 3 reported significantly higher environmental reward deprivation than those in Profile 4 (p < 0.001). Profile 4 demonstrated significantly higher alcohol demand intensity and Omax and lower demand elasticity than Profile 1, Profile 2, or Profile 3. Profile 4 also demonstrated significantly greater proportionate substance-related reinforcement than Profile 1 (p < 0.001) and Profile 2 (p = 0.004).

CONCLUSION

Maladaptive eating patterns and alcohol consumption may share common risk factors for reinforcer pathology including environmental reward deprivation, impulsivity, and elevated alcohol demand.

Intravenous Alcohol Administration Selectively Decreases Rate of Change in Elasticity of Demand in Individuals With Alcohol Use Disorder

BACKGROUND

Alcohol demand is a key behavioral economic concept that provides an index of alcohol's relative reinforcing value. Initial studies have reported that alcohol demand increases during alcohol administration and in response to alcohol cues. However, the extent to which these effects are observed explicitly in samples composed of individuals with alcohol use disorder (AUD) and are operative in conjunction with each other has not been studied.

METHODS

To address this gap in the literature, we assessed alcohol demand during an alcohol challenge and subsequent alcohol cue-exposure paradigm in non-treatment-seeking, alcohol-dependent (i.e., DSM-IV criteria) participants (N = 27). Specifically, participants completed 2 counterbalanced intravenous, placebo-controlled, alcohol administration sessions followed by a controlled cue-exposure paradigm. At baseline and at breath alcohol concentration of 0.06 g/dl, participants completed the alcohol purchase task, assessing estimated alcohol consumption at escalating prices. Participants were also assessed for alcohol demand following each cue exposure.

RESULTS

During alcohol administration, there was a significant decrease in the rate of change in elasticity compared with placebo, and during the cue-reactivity paradigm, there was a significant main effect such that alcohol cues decreased the rate of change in elasticity relative to water cues. There were no statistically significant differences in other demand indices.

CONCLUSIONS

These findings provide further evidence that alcohol administration increases price insensitivity and extends the literature on alcohol's effects on demand by using a clinical sample with AUD and by adding a placebo-alcohol condition.

Latent Profile Analysis of Heavy Episodic Drinking in Emerging Adults: A Reinforcer Pathology Approach

BACKGROUND

Heavy episodic drinking (HED) is a major public health problem among emerging adults (individuals 18 to 25), but with considerable heterogeneity in concurrent substance use and psychopathology. The current study used latent profile analysis (LPA) to detect discrete subgroups of HED based on alcohol, other drug severity, and concurrent psychopathology. A reinforcer pathology approach was used to understand motivational differences among the latent subgroups.

METHODS

Participants were 2 samples of emerging adults reporting regular HED, 1 Canadian (n = 730) and 1 American (n = 602). Indicators for the LPA were validated dimensional self-report assessments of alcohol severity, cannabis severity, other drug severity, nicotine dependence, depression, anxiety, posttraumatic stress disorder, and attention-deficit/hyperactivity disorder. Reinforcer pathology indicators were measures of alcohol demand, proportionate substance-related reinforcement, and discounting of future rewards.

RESULTS

The LPA yielded parallel 3-class solutions in both samples. The largest subgroup was characterized by comparatively low substance severity and psychopathology (Low overall severity). The second largest subgroup was characterized by comparatively high alcohol and other drug severity (excluding tobacco) and high levels of psychopathology (Heavy alcohol & high psychiatric severity). The third subgroup exhibited high alcohol, smoking and intermediate levels of other substance use and psychopathology (Heavy alcohol, smoking, & intermediate psychiatric severity). The Heavy alcohol & high psychiatric severity and Heavy alcohol, smoking, & intermediate psychiatric severity subgroups exhibited significantly higher alcohol demand, greater proportionate substance-related reinforcement, and steeper delay discounting.

CONCLUSIONS

Parallel latent subgroups of emerging adults engaging in HED were present in both samples, and the high-risk subgroups were significantly differentiated by the reinforcer pathology indicators. These latent profiles may ultimately inform heterogeneity in the longitudinal course of HED in emerging adults.

Impact of sin taxes on consumption volumes of sweetened beverages and soft drinks in Saudi Arabia

Background: The consumption of sweetened drinks plays a major role in increasing the burden of diseases such as obesity and cardiovascular diseases. The prevalence rate of obesity and overweight individuals in Saudi Arabia has increased alarmingly among children over the past decade, revealing a crucial need the initiate and monitor effective prevention measures of obesity. Hence, this paper aims to measure the impact of sin taxes of sugar-sweetened beverages on the consumption level of such beverages in Saudi Arabia. Building enough evidence to guide other countries in the Eastern Mediterranean Region (EMR) on how to reduce the level of sugar intake consumption to reduce obesity and malnutrition has an impact on the economy as a whole.

Methods: The excise taxes on sugar-sweetened beverages were applied in 2017. The impact of this was measured using a time series data set that covered sales volumes of soft drinks in Saudi Arabia from 2010 to 2020.

Results: Sin taxes had a significant negative impact on the sales volume over the years. A significance level of <1% was found as sales volume of soft drinks decreased by 57.64% from 2010 to 2017 when sin taxes were applied on energy and soft drinks.

Conclusions: Sin tax policy is recommended to other countries in the EMR to reduce obesity levels among children. These recommendations advocate the recommended priority actions by the World Health Organization for the strategy on nutrition for the EMR 2020-2030.

Nicotine reduction does not alter essential value of nicotine or reduce cue-induced reinstatement of nicotine seeking

Reduction of nicotine content in tobacco products is a regulatory control strategy intended to decrease smoking dependence, and is hypothesized to produce gradual reductions of nicotine intake. Rats were initially trained to self-administer 0.06 mg/kg/infusion nicotine (Phase 1), which was followed by a threshold procedure to determine nicotine demand via a behavioral economics (BE) paradigm (Phase 2). Rats then either self-administered the training dose (high dose group), or were switched to a low dose of nicotine (0.001 mg/kg/infusion; low dose group) in Phase 3. Both groups then underwent a second threshold procedure and demand curves were re-determined (Phase 4). In Phase 5, responding for nicotine was extinguished over the course of 21 sessions. Cue-induced reinstatement was then evaluated (Phase 6). Rats in the low dose group maintained a steady amount of infusions, and thus, did not compensate for nicotine reduction. Rats in the low dose group also showed similar demand elasticity and nicotine seeking (Phase 6) compared to the high dose group, indicating that nicotine reduction did not decrease nicotine demand or seeking. Further, both groups displayed resistance to extinction, indicating that nicotine reduction did not facilitate extinction learning. These results suggest that although compensation of intake does not occur, decreasing the dose of nicotine does not alter nicotine reinforcement value or relapse vulnerability. Further, these results indicate persistence of nicotine-motivated behavior after self-administration of a low nicotine dose. Translationally, these results suggest that alternative strategies may be needed to achieve positive smoking cessation outcomes.

Perceived Importance of Factors in Cannabis Purchase Decisions: A Best-worst Scaling Experiment

BACKGROUND

Consumers' access to cannabis has been considerably expanded in US states where recreational cannabis was legalized and commercialized. However, little is known about the important factors influencing consumers' purchase decisions in cannabis retail dispensaries. This study examined cannabis users' perceptions of the relative importance of policy-relevant factors when they made cannabis purchase decisions.

METHODS

An online survey was administered to 817 adult cannabis users in seven states in the US (California, Colorado, Maine, Massachusetts, Nevada, Oregon, and Washington) that had approved cannabis commercialization by the time of interview in January 2018. Twenty policy-relevant cannabis attributes were evaluated, including those pertaining to product characteristics, quality, package characteristics, price and free sample, store characteristics, and restrictions on use. A best-worst scaling experiment was employed, which asked respondents to select the most and the least important attributes in a choice scenario. Each respondent answered 10 choice scenarios, each including a random combination of four attributes out of the 20. The relative importance of each attribute was evaluated using hierarchical Bayesian estimation of mixed logit models.

RESULTS

Overall, 'quality', 'strain type', 'price', 'THC' (tetrahydrocannabinol) and 'pesticide' were the top five important attributes affecting cannabis users' willingness to buy cannabis in a dispensary. These five attributes jointly accounted for approximately half of the total importance. In subsample analysis, both recreational and dual-purpose users attached higher importance to 'quality', 'THC', and 'price', whereas medical users tended to think 'CBD' (cannabidiol) and 'pesticide' were more important. All cannabis users perceived 'package' to be the least important attribute. Gender had no major differences in perceptions.

CONCLUSIONS

Cannabis users in general perceived product characteristics, quality, and price to be important factors in their willingness to buy cannabis in dispensaries. There were heterogeneities in the perceptions by cannabis use purposes. The findings might deserve consideration in cannabis policy design.

Preresolution Drinking Problem Severity Profiles Associated with Stable Moderation Outcomes of Natural Recovery Attempts

BACKGROUND

Higher problem severity contraindicates moderation drinking in treatment samples, but has not been well investigated in natural recovery samples with more prevalent moderation outcomes, nor have single studies assessed multiple severity indicators. Therefore, we integrated 5 prospective studies of recent natural recovery attempts to identify multi-indicator profiles that distinguished moderation from abstinence or unstable resolution involving relapse. The study evaluated whether moderation was distinguished by a generalized lower severity profile or whether more complex profiles better differentiated outcomes.

METHODS

Community-dwelling problem drinkers in the southeastern United States (N = 616, 67% male, 65% white, mean age = 46.5 years) enrolled soon after stopping alcohol misuse without treatment were followed prospectively for a year. Outcome predictors assessed at enrollment included preresolution drinking practices, alcohol-related problems, alcohol dependence, and a behavioral economic measure of the reward value of drinking based on preresolution spending on alcohol versus saving for the future.

RESULTS

Latent profile analysis of severity indicators supported a 4-profile solution: (i) global low risk on all indicators, (ii) global high risk on all indicators, (iii) high risk limited to drinking practices only, and (iv) high risk limited to alcohol dependence and alcohol-related problems only. Outcomes differed by profile membership (p < 0.01). Multinomial logistic regression analyses showed that the global low risk and heavy drinking risk only profiles were associated with stable moderation during the 1-year follow-up. The high dependence and alcohol problems risk profile was associated with both abstinence and relapse during the follow-up (ps < 0.05).

CONCLUSIONS

Consistent with prior research, moderation was associated with lower alcohol dependence, problems, and reward value. Participants who simply drank heavily and did not have elevated risk on other indicators also had a higher probability of moderation. Results support using multidimensional severity indicators that encompass functional variables in addition to drinking practices to predict outcomes.

Behavioral Economics Incentives to Support HIV Treatment Adherence (BEST): Protocol for a randomized controlled trial in Uganda

Background

Many HIV-positive patients do not appropriately adhere to their antiretroviral medication (ART). This leads to higher viral loads and greater probability of HIV transmission. Present bias—a tendency to give in to short-term temptations at the expense of long-term outcomes—is a potential driver of low adherence. In this study we test a novel intervention rooted in behavioral economics that is designed to overcome present bias and increase ART adherence.

Methods/design

We will enroll 330 HIV-positive patients at Mildmay Hospital in Kampala, Uganda, into a 2-year randomized controlled trial. Participants will be randomized to one of three groups. The first intervention group (T1, n = 110) will be eligible for small lottery prizes based on timely clinic visits and demonstration of viral suppression. Group 2 (T2, n = 110) will be eligible for the same lottery prizes conditional on high adherence measured by a medication event management system (MEMS) cap. The control group (n = 110) will receive the usual standard of care. Adherence will be measured continuously throughout the intervention period and for 12 months post-intervention to evaluate effect persistence. Surveys will be conducted at baseline and then every 6 months. Viral loads will be measured annually. Primary outcomes are whether the viral load is detectable and MEMS-measured adherence. Secondary outcomes are the log-transformed viral load as a continuous measure and a binary measure for whether the person took at least 90% of their ART pills.

Discussion

Our study is one of the first to investigate the effectiveness of lottery incentives for improving ART adherence, and in addition, it compares the relative efficacy of using electronically measured adherence versus viral load to determine lottery eligibility. MEMS caps are relatively costly, whereas viral load testing is now part of routine clinical care in Uganda. BEST will test whether directly incentivizing viral suppression (which can be implemented using readily available clinic data) is as effective as incentivizing electronically measured adherence. Cost-effectiveness analyses of the two implementation modes will also be performed.

Trial registration

ClinicalTrials.gov, NCT03494777. Registered on 11 April 2018.

High Opportunity Cost Demand as an Indicator of Weekday Drinking and Distinctly Severe Alcohol Problems: A Behavioral Economic Analysis

INTRODUCTION

Behavioral economic theory views addiction as a reinforcer pathology characterized by excessive demand for drugs relative to alternatives. Complementary to this theory, Lamb and Ginsburg (Pharmacology Biochemistry and Behavior, 164, 2018, 62) describe addiction as a behavioral allocation disorder and predict that decisions to drink under increasingly stringent constraints are a central indicator of addiction. This study used a modified demand-curve paradigm to examine alcohol demand in the context of a next-day contingency (high opportunity cost demand) as a specific indicator of a severe pattern of alcohol problems.

METHODS

Participants were 370 undergraduates (61.1% female, 86.5% white, Mage  = 18.8) reporting multiple past-month heavy drinking episodes (5/4 drinks per occasion for men/women) who completed 2 versions of an alcohol purchase task (APT), along with measures of past-month alcohol use and problems. In 1 APT (low opportunity cost), students imagined they had no next-day responsibilities, and in the other APT (high opportunity cost), they imagined having a 10:00 am test the next day. Item-response theory analyses were used to determine mild and severe alcohol problems from the Young Adult Alcohol Consequences Questionnaire (Journal of Studies on Alcohol, 67, 2006, 169), and the most and least severe binge drinking days throughout the week.

RESULTS

Low opportunity cost demand (β = 0.15, p = 0.02) significantly predicted beyond high opportunity cost demand for the least severe problems, and high opportunity cost demand (β = 0.17, p = 0.009) significantly predicted beyond low opportunity cost demand for the most severe problems. Similarly, low opportunity cost demand (β = 0.26, p < 0.001) was more highly associated with weekend drinking, whereas high opportunity cost demand (β = 0.21, p = 0.001) was more highly associated with weekday drinking.

CONCLUSIONS

The current results suggest high opportunity cost alcohol demand is a distinct marker of severe alcohol problems among college student heavy drinkers.

Willing to Work But Not to Wait: Individuals with Greater Alcohol Use Disorder Show Increased Delay Discounting Across Commodities and Less Effort Discounting for Alcohol

BACKGROUND

Delay discounting refers to the devaluation of a reward given increasing delays to delivery. Similarly, effort discounting refers to the devaluation of a reward given increasing effort required to obtain it. Individuals with substance use disorder show higher rates of delay discounting, exacerbating short-term positive reinforcement at the expense of long-term consequences. This study explores how effort discounting compares to delay discounting behavior among alcohol users as well as how these preferences change between monetary and alcohol rewards.

METHODS

A total of 100 participants completed an online survey through Amazon Mechanical Turk. Participant alcohol use was evaluated using DSM-5 and the Alcohol Use Disorders Identification Test criteria. All participants completed 4 randomized discounting tasks involving delay or effort discounting, in which the reward was money or alcohol. A follow-up experiment (n = 423) added the alcohol purchase task to assess alcohol valuation.

RESULTS

Individuals with greater alcohol use disorder (AUD) severity discounted future money and alcohol significantly more than those with less AUD. However, individuals meeting more DSM-5 criteria were only willing to perform more effort for alcohol. The follow-up experiment replicated these findings and demonstrated that individuals with greater AUD also showed an increased valuation of alcohol and alcohol value-mediated effort discounting.

CONCLUSIONS

These results suggest that individuals with greater AUD were less willing to wait for money or alcohol. While all participants were willing to work for money regardless of AUD severity, individuals with greater AUD showed increased valuation of alcohol drinks and were willing to exert more effort to obtain alcohol. Together, these results paint a picture of individuals with increased AUD as both more impulsive and willing to work to obtain alcohol, contributing to our understanding of decision making among individuals who abuse substances.

The Behavioral Economics of Alcohol Demand in French and American University Students

BACKGROUND

Behavioral economic approaches have revealed several characteristics of alcohol demand (e.g., intensity, elasticity, and essential value) in university students; however, these approaches have not yet examined alcohol demand among students outside of the United States. The current study examined alcohol demand among student samples in the United States and France using a hypothetical alcohol purchase task (APT) and a novel APT Choice task, in which nonalcoholic beverages were concurrently available at a fixed low price.

METHODS

Participants at each site (United States, n = 132; France, n = 132) were asked to complete an Internet-based survey including the APT, APT Choice, Alcohol Use Disorders Identification Test, Daily Drinking Questionnaire, and Drinking Motives Questionnaire-Revised Short Form. Group demand functions were produced for each of the 2 samples in both country-specific and standardized drink units, and the exponential demand equation was fitted to each of the APT and APT Choice demand curves. Slope analyses were performed on the Non-Alcoholic Cross-Price demand to assess substitutability.

RESULTS

APT data revealed that in both samples, alcohol price and consumption were inversely related and demand measures were significantly associated with other alcohol measures. In addition, the availability of a nonalcoholic alternative reduced alcohol demand in both samples, with evidence of substitutability revealed by increases in cross-price consumption.

CONCLUSIONS

Low-cost alcohol is associated with increased alcohol consumption in both French and U.S. university students, and concurrent availability of a nonalcoholic beverage within the APT both reduces alcohol demand and demonstrates behavioral economic substitutability. These findings will inform future studies investigating behavioral and environmental factors underlying transcultural differences and specific prevention efforts.

What Is Addiction? How Can Animal and Human Research Be Used to Advance Research, Diagnosis, and Treatment of Alcohol and Other Substance Use Disorders?

The current article highlights key issues in defining, studying, and treating addiction, a concept related to but distinct from substance use disorders. The discussion is based upon a roundtable discussion at the 2017 annual meeting of the Research Society on Alcoholism where Warren K. Bickel and John C. Crabbe were charged with answering a range of questions posed by Kenneth J. Sher. All the presenters highlighted a number of central concerns for those interested in assessing and treating addiction as well as those seeking to conduct basic preclinical research that is amenable to meaningful translation to the human condition. In addition, the discussion illustrated both the power and limitations of using any single theory to explain multiple phenomena subsumed under the rubric of addiction. Among the major issues examined were the important differences between traditional diagnostic approaches and current concepts of addiction, the difficulty of modeling key aspects of human addiction in nonhuman animals, key aspects of addiction that have, to date, received little empirical attention, and the importance of thinking of recovery as a phenomenon that possibly involves processes distinct from those undergirding the development and maintenance of addiction.

Evaluating Behavioral Economic Models of Heavy Drinking Among College Students

BACKGROUND

Heavy drinking among college students is a significant public health concern that can lead to profound social and health consequences, including alcohol use disorder. Behavioral economics posits that low future orientation and high valuation of alcohol (alcohol demand) combined with deficits in alternative reinforcement increase the likelihood of alcohol misuse. Despite this, no study has examined the incremental utility of all 3 variables simultaneously in a comprehensive model.

METHODS

This study uses structural equation modeling to test the associations between behavioral economic variables-alcohol demand (latent), future orientation (measured with a delay discounting task and the Consideration of Future Consequences [CFC] scale), and proportionate substance-related reinforcement-and alcohol consumption and problems among 393 heavy drinking college students. Two models are tested as follows: (i) an iteration of the reinforcer pathology model that includes an interaction between future orientation and alcohol demand; and (ii) an alternative model evaluating the interconnectedness of behavioral economic variables in predicting problematic alcohol use.

RESULTS

The interaction effects in Model 1 were nonsignificant. Model 2 suggests that greater alcohol demand and proportionate substance-related reinforcement are associated with greater alcohol consumption and problems. Furthermore, CFC was associated with alcohol-related problems and lower proportionate substance-related reinforcement but was not significantly associated with alcohol consumption or alcohol demand. Finally, greater proportionate substance-related reinforcement was associated with greater alcohol demand.

CONCLUSIONS

Our results support the validity of the behavioral economic reinforcer pathology model as applied to young adult heavy drinking.

Low-Cost Behavioral Nudges Increase Medicaid Take-Up Among Eligible Residents Of Oregon

Efforts to reduce the ranks of the uninsured hinge on take-up of available programs and subsidies, but take-up of even free insurance is often less than complete. The evidence of the effectiveness of policies aiming to increase take-up is limited. We used a randomized controlled design to evaluate the impact of improved communication and behaviorally informed "nudges" designed to increase Medicaid take-up among eligible populations. Fielding randomized interventions in two different study populations in Oregon, we found that even very low-cost interventions substantially increased enrollment. Effects were larger in a population whose members had already expressed interest in obtaining coverage, but the effects were more persistent in low-income populations whose members were already enrolled in other state assistance programs but had not expressed interest in health insurance. The effects were similar across different demographic groups. Our results suggest that improving the design of enrollment processes and using low-cost mass-outreach efforts have the potential to substantially increase insurance coverage of vulnerable populations.

Active Choice and Financial Incentives to Increase Rates of Screening Colonoscopy-A Randomized Controlled Trial

Behavioral economic approaches could increase uptake for colorectal cancer screening. We performed a randomized controlled trial of 2245 employees to determine whether an email containing a phone number for scheduling (control), an email with the active choice to opt in or opt out (active choice), or the active choice email plus a $100 incentive (financial incentive) increased colonoscopy completion within 3 months. Higher proportions of participants in the financial incentive group underwent screening (3.7%) than in the control (1.6%) or active choice groups (1.5%) (P = .01 and P < .01). We found no difference in uptake of screening between the active choice and control groups (P = .88). The $100 conditional incentive modestly but significantly increased colonoscopy use. ClinicalTrials.gov no: NCT02660671.

Prospective Analysis of Behavioral Economic Predictors of Stable Moderation Drinking Among Problem Drinkers Attempting Natural Recovery

BACKGROUND

As interventions have expanded beyond clinical treatment to include brief interventions for persons with less severe alcohol problems, predicting who can achieve stable moderation drinking has gained importance. Recent behavioral economic (BE) research on natural recovery has shown that active problem drinkers who allocate their monetary expenditures on alcohol and saving for the future over longer time horizons tend to have better subsequent recovery outcomes, including maintenance of stable moderation drinking. This study compared the predictive utility of this money-based "Alcohol-Savings Discretionary Expenditure" (ASDE) index with multiple BE analogue measures of behavioral impulsivity and self-control, which have seldom been investigated together, to predict outcomes of natural recovery attempts.

METHODS

Community-dwelling problem drinkers, enrolled shortly after stopping abusive drinking without treatment, were followed prospectively for up to a year (N = 175 [75.4% male], M age = 50.65 years). They completed baseline assessments of preresolution drinking practices and problems, analogue behavioral choice tasks (Delay Discounting, Melioration-Maximization, and Alcohol Purchase Tasks), and a Timeline Followback interview including expenditures on alcohol compared to voluntary savings (ASDE index) during the preresolution year.

RESULTS

Multinomial logistic regression models showed that, among the BE measures, only the ASDE index predicted stable moderation drinking compared to stable abstinence or unstable resolutions involving relapse. As hypothesized, stable moderation was associated with more balanced preresolution allocations to drinking and savings (odds ratio = 1.77, 95% confidence interval = 1.02 to 3.08, p < 0.05), suggesting it is associated with longer-term behavior regulation processes than abstinence.

CONCLUSIONS

The ASDE's unique predictive utility may rest on its comprehensive representation of contextual elements to support this patterning of behavioral allocation. Stable low-risk drinking, but not abstinence, requires such regulatory processes.

The Potential of Behavioral Economics to Promote Safe Infant Sleep Practices

Objectives The purpose of this commentary is to highlight the potential of six Behavioral Economics (BE) concepts for promoting infant safe sleep practices. The rate of sleep-related deaths has not decreased over the last decade. It may be time to consider a novel paradigm to address this public health concern. BE has not yet been specifically considered for encouraging safe infant sleep practices. Methods This commentary features an integration of behavioral economic concepts and findings from the infant safe sleep literature. Results Six BE concepts-salience, choice overload, loss aversion, social norms, framing, and the identifiable victim effect- were identified for their potential in developing novel interventions for reducing sleep-related deaths during the first year of life. Conclusions BE strategies differ significantly from non-BE approaches for this public health concern. BE strategies appear feasible for widespread dissemination should they ultimately be efficacious.

The Behavioral Economics and Neuroeconomics of Alcohol Use Disorders

BACKGROUND

Behavioral economics and neuroeconomics bring together perspectives and methods from psychology, economics, and cognitive neuroscience to understand decision making and choice behavior. Extending an operant behavioral theoretical framework, these perspectives have increasingly been applied to understand the alcohol use disorders (AUDs), and this review surveys the theory, methods, and findings from this approach. The focus is on 3 key behavioral economic concepts: delay discounting (i.e., preferences for smaller immediate rewards relative to larger delayed rewards), alcohol demand (i.e., alcohol's reinforcing value), and proportionate alcohol-related reinforcement (i.e., relative amount of psychosocial reinforcement associated with alcohol use).

FINDINGS

Delay discounting has been linked to AUDs in both cross-sectional and longitudinal studies and has been investigated cross-sectionally using neuroimaging. Alcohol demand and proportionate alcohol-related reinforcement have both been robustly associated with drinking and alcohol misuse cross-sectionally, but not over time. Both have also been found to predict treatment response to brief interventions. Alcohol demand has also been used to enhance the measurement of acute motivation for alcohol in laboratory studies. Interventions that focus on reducing the value of alcohol by increasing alternative reinforcement and response cost have been found to be efficacious, albeit in relatively small numbers of randomized controlled trials (RCTs). Mediators and moderators of response to these interventions have not been extensively investigated.

FUTURE DIRECTIONS

The application of behavioral economics and neuroeconomics to AUDs has given rise to an extensive body of empirical work, although significant gaps in knowledge remain. In particular, there is a need for more longitudinal investigations to clarify the etiological roles of these behavioral economic processes, especially alcohol demand and proportionate alcohol reinforcement. Additional RCTs are needed to extend and generalize the findings for reinforcement-based interventions and to investigate mediators and moderators of treatment success for optimization. Applying neuroeconomics to AUDs remains at an early stage and has been primarily descriptive to date, but has high potential for important translational insights into the future. The same is true for using these behavioral economic indicators to understand genetic influences on AUDs.

Initial Development of a Brief Behavioral Economic Assessment of Alcohol Demand

Due to difficulties with definition and measurement, the role of conscious craving in substance use disorders remains contentious. To address this, behavioral economics is increasingly being used to quantify aspects of an individual's acute motivation to use a substance. Doing so typically involves the use of a purchase task, in which participants make choices about consuming alcohol or other substances at various prices and multiple indices of alcohol demand are generated. However, purchase tasks can be limited by the time required to administer and score them. In the current study, a brief 3-item measure, designed to capture three important indices of demand that are derived from demand curve modeling (intensity, O_max, and breakpoint), was investigated in a group of 84 heavy drinkers. Participants underwent a cue-reactivity paradigm that is established to increase both conscious craving and alcohol demand on traditional purchase tasks. All three indices of demand for alcohol measured using the abbreviated measure increased significantly in response to alcohol cues, analogous to what has been observed using a traditional purchase task. Additionally, the correlations between these indices and subjective craving were modest-to-moderate, as has been found in studies comparing craving to the indices derived from purchase tasks. These findings suggest that this abbreviated measure may be a useful and efficient way to capture important and distinct aspects of motivation for alcohol. If these results are confirmed, this measure may be able to help increase the portability of behavioral economic indices of demand into novel research and clinical contexts.

The behavioral economics of driving after drinking among college drinkers

BACKGROUND

Driving after drinking (DAD) among college students is a significant public health concern, yet little is known about specific theoretical risk factors for DAD, beyond drinking level, among college student drinkers. This study had the following aims: (i) to examine the associations between elevated alcohol demand and DAD, (ii) to determine whether demand decreases in response to a hypothetical driving scenario, (iii) to determine whether drivers who report DAD in the past 3 months would show less of a reduction in demand in response to the hypothetical driving scenario, and (iv) to determine whether delayed reward discounting (DRD) is associated with DAD.

METHOD

Participants were 419 college students who reported at least 1 day of past-month alcohol use. Participants completed 2 alcohol purchase tasks (APTs) that assessed hypothetical alcohol consumption across 17 drink prices with and without a driving scenario, a delay-discounting task, and a series of questions regarding DAD.

RESULTS

In logistic regression models that controlled for drinking level, demographics, and sensation seeking, participants reporting higher demand intensity (95% confidence interval [95% CI] [1.04, 2.34]), breakpoint (95% CI [1.23, 2.28]), Omax (95% CI [1.03, 1.53]), and lower elasticity (95% CI [0.15, 1.02]) were more likely to report DAD. Additionally, in analyses of covariance, DAD(+) participants exhibited significantly less of a reduction in demand between the standard and the driving APT (intensity, p < 0.01, breakpoint, p = 0.05, and Omax , p < 0.01). A binary logistic regression model with identical covariates revealed that DRD is not associated with DAD.

CONCLUSIONS

DAD is associated with elevated/inelastic demand and less sensitivity to a hypothetical driving scenario. Drinkers with elevated demand should be prioritized for DAD intervention efforts.

Elevated alcohol demand is associated with driving after drinking among college student binge drinkers

BACKGROUND

Alcohol-impaired driving among college students represents a significant public health concern, yet little is known about specific theoretical and individual difference risk factors for driving after drinking among heavy drinking college students. This study evaluated the hypothesis that heavy drinkers with elevated alcohol demand would be more likely to report drinking and driving.

METHOD

Participants were 207 college students who reported at least 1 heavy drinking episode (4/5 or more drinks in 1 occasion for a woman/man) in the past month. Participants completed an alcohol purchase task that assessed hypothetical alcohol consumption across 17 drink prices and an item from the Young Adult Alcohol Consequences Questionnaire that assessed driving after drinking.

RESULTS

In binary logistic regression models that controlled for drinking level, gender, ethnicity, age, and sensation seeking, participants who reported higher demand were more likely to report driving after drinking.

CONCLUSIONS

These results provide support for behavioral economics models of substance abuse that view elevated/inelastic demand as a key etiological feature of substance misuse.

Understanding the effects of stress and alcohol cues on motivation for alcohol via behavioral economics

BACKGROUND

Psychological stress and alcohol cues are common antecedents of both ongoing drinking and relapse. One candidate mechanism of risk from these factors is acute increases in craving, but experimental support for this hypothesis is mixed. Furthermore, the combination of stress and cues has been largely unstudied. The current study employed a behavioral economic approach to investigate the combined roles of psychosocial stress and alcohol cues on motivation for alcohol.

METHODS

In a sample of 84 adult heavy drinkers, we examined the effects of an acute laboratory stress induction and an alcohol cue exposure on subjective craving and stress, arousal, and behavioral economic decision making. Primary dependent measures included an intertemporal cross-commodity multiple-choice procedure (ICCMCP), incorporating both price and delay elements, an alcohol purchase task (APT), measuring alcohol demand, and a monetary delay discounting task, measuring intertemporal choice.

RESULTS

The stress induction significantly increased stress, craving, and the incentive value of alcohol on the ICCMCP and APT. Stress-related increases in value on the ICCMCP were mediated by increased alcohol demand. Exposure to alcohol cues only significantly affected craving, APT breakpoint, and arousal. Delay discounting was not affected by either stress or cues.

CONCLUSIONS

These results reveal unique behavioral economic dimensions of motivation for alcohol following acute stress and an alcohol cue exposure. More broadly, as the first application of this approach to understanding the role of stress in drug motivation, these findings support its utility and potential in future applications.

Differences in Risk Aversion between Young and Older Adults

Research on decision-making strategies among younger and older adults suggests that older adults may be more risk averse than younger people in the case of potential losses. These results mostly come from experimental studies involving gambling paradigms. Since these paradigms involve substantial demands on memory and learning, differences in risk aversion or other features of decision-making attributed to age may in fact reflect age-related declines in cognitive abilities. In the current study, older and younger adults completed a simpler, paired lottery choice task used in the experimental economics literature to elicit risk aversion. A similar approach was used to elicit participants' discount rates. The older adult group was more risk averse than younger adults (p < .05) and also had a higher discount rate (15.6-21.0% vs. 10.3-15.5%, p < .01), indicating lower expected utility from future income. Risk aversion and implied discount rates were weakly correlated. It may be valuable to investigate developmental changes in neural correlates of decision-making across the lifespan.

Delayed Reward Discounting and Alcohol Misuse: The Roles of Response Consistency and Reward Magnitude

Delayed reward discounting (DRD) is a common index of impulsivity that refers to an individual's devaluation of rewards based on delay of receipt and has been linked to alcohol misuse and other maladaptive behaviors. The current study investigated response consistency and reward magnitude effects in two measures of DRD in a sample of 111 undergraduates who consumed an average of 10.7 drinks/week. These variables were also examined in relation to alcohol use and misuse. Results indicated highly consistent performance on both measures of DRD, although significant differences were evident based on task parameters. There was also clear evidence of a magnitude effect on DRD. Finally, a number of significant associations between DRD and both alcohol use and misuse were found. These findings suggest that individuals possess a relatively consistent cognitive template for DRD choice preferences, but that the template systematically varies by both reward magnitude and delay length.