We then review empirical literature across the translational spectrum that supports this model. Next, we highlight limitations of the reinforcer pathology model and describe an extension, the contextualized reinforcer pathology model, that highlights the critical role of alternative reinforcers in addiction motivation. In this Perspective, we provide an overview of a contemporary behavioural economic theoretical account of addiction, the reinforcer pathology model, which suggests that drug consumption is the result of overvaluation of smaller immediate rewards and drug-specific reinforcement. Specifically, it is incumbent upon psychological theories of addiction to explain the following: why people consume drugs why some people use alcohol and drugs in a manner that contributes to health and social problems, while others are able to use moderately with minimal consequences why many people are able to reduce patterns of alcohol and drug use, often without participating in formal treatment, while others experience chronic, escalating patterns of use and why substance-related morbidity and mortality have increased over the past two decades and in particular over the past few years 7, 11, 12. Robust and valid theories are needed to guide treatment and policy development. Yet alcohol- and drug-related morbidity and mortality have increased over the past two decades 7, 11, 12, suggesting that existing strategies are far from adequate. Myriad policies have been developed to reduce or eliminate the burden of substance use. The public health impact of these harms are monumental and result in billions of dollars in financial costs each year 10. Serious harms, such as alcohol-related mortality, overdose and cirrhosis, are on the rise 6, 7, with notable increases during the COVID-19 pandemic 8, even as other causes of death are decreasing 9. Although many use alcohol or illicit drugs without suffering notable clinical concerns, a minority use at high levels, resulting in diagnoses of substance-use disorder and a range of acute to chronic substance-related problems. These trends in the USA are generally mirrored around the world 1, 4, 5. Illicit drug use is also rising: nearly one in five Americans reported illicit drug use of some kind in the past year, and 43.5 million Americans reported cannabis use in the past year 1. Rates of alcohol consumption have remained relatively stable over the past decade, with some upward trends for women and older adults possibly amplified by the COVID-19 pandemic 2, 3. In 2020, an estimated 138.5 million Americans aged 12 or older reported alcohol use in the past month, and 61.6 million reported a binge drinking episode (four or five drinks for women or men, respectively) in the past month 1. 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. 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. A third element of learning theory posits that harmful drug use depends on the relative constraints on access to other available activities and commodities in the choice context (alternative reinforcers), reflecting the substantial influence of environmental factors. These motivational processes are within-individual determinants of behaviour. Behavioural economic accounts of addiction conceptualize harmful drug use as an operant reinforcer pathology, emphasizing that a drug is consumed because of overvaluation of smaller immediate rewards relative to larger delayed rewards (delay discounting) and high drug reinforcing value (drug demand).
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