Decentering alcohol: Non-drug pleasure and reinforcement as an alternative target

The opinion and debate piece by Nicholls and Hunt [1] stimulates an interesting discussion on the importance of pleasure in public health-oriented research on alcohol. We agree that pleasure is an important concept in understanding alcohol use as well as other substance use, and that public health discourse limits its own efficacy by focusing primarily on harm without acknowledging many of the benefits people report experiencing from drinking (or other drug use). This idea is broadly consistent with the behavioral science literature, which posits that alcohol can function as a positive reinforcer by producing desirable effects (e.g. enhancing social connection, inducing pleasant subjective effects) that increase the likelihood of future alcohol use.

These reinforcing effects may, at least during any discrete use occasion, outweigh the costs, acute or chronic, of alcohol use [2]. Although humans are motivated by costly immediate harms [3], they are less so by delayed, diffuse, and uncertain ones [4-6]. This human aversion to immediate harms is matched by an innate, evolutionarily adaptive drive for pleasure or related positive subjective states. From a population perspective, harms associated with alcohol use are characteristically delayed, diffuse and uncertain for most people who use alcohol, if they experience problems at all, and rewards are often immediate and robust. In the case of social connection, for example, alcohol may help to facilitate a basic human need of social bonding [7, 8] while only inconsistently resulting in harms that lessen this potent reward. Ignoring the reality that many find alcohol to be pleasurable goes against the experience of many who drink and threatens to delegitimize public health messaging. A similar problem can be found in many treatment settings that focus almost exclusively on reiterating harms of alcohol while failing to acknowledge that drinking once served an adaptive function, even if for most it was maladaptive by the time treatment began.

Although perhaps conspicuously absent from public health messaging research, there is a rich history of experimental work describing the pleasurable effects of alcohol and other drugs [9-12]. These studies, typically conducted in the framework described by the United States Food and Drug Administration Human Abuse Potential guidelines, seek to evaluate subjective effects like ‘Good Effect’ or ‘Drug Liking’ and determine the potential for a drug's future misuse [13]. Notably, these studies highlight the role that pleasure, or more broadly positive reinforcing effects, play in determining future behavior—behaviors that evoke greater pleasure are more likely to be repeated in the future, and a drug's ‘abuse potential’ is at least in part related to its ability to induce pleasure.

In addition to understanding the importance of the reinforcing efficacy of alcohol, modern behavioral models of addiction have emphasized the importance of alternative, non-drug reinforcement that can effectively compete with substances [14, 15]. Research across the translational spectrum has demonstrated that behavioral allocation toward substance reinforcers is dependent upon the presence or absence of other reinforcers in the choice context [16-19]. Typically, addiction treatment focuses on explicit reduction in the value of a drug through pharmacological or behavioral methods. Interventions may instead (or may also) increase the value of non-drug alternatives that serve the same functional purpose that drugs do for a given patient. This idea is highlighted in the recent sober curious movement and the proliferation of non-alcoholic beverages (e.g. mocktails). Such approaches offer a mechanism of reducing alcohol use by introducing an alternative that, at least partly, retains many of the pleasurable functions of alcohol (e.g. social connection and acceptance, taste) and effectively serves as a competing option.

Public health serves a societal function and, as stated by the authors, is built on a foundational principle that long-term rewards, such as health, are better than short-term rewards. By necessity, public health typically takes a utilitarian, rather than Kantian, approach, valuing the whole over the individual, and focuses on the health of the public in addition to those pleasures that can be paired with health. However, we agree with the authors that public health risks its legitimacy by ignoring the experience of people who primarily experience the positive, rather than the negative, effects of alcohol. Perhaps a compromise: public health messaging only needs to acknowledge (rather than emphasize) the pleasures of alcohol, to broadly accept the human propensity for pleasure, and to intentionally leverage these empirical findings by emphasizing and increasing the availability of non-drug alternatives. Public health messages that can craft a compelling and competitive narrative of pleasure in other activities may be more effective than focusing exclusively on the pleasures or perils of alcohol alone.

Samuel F. Acuff: Conceptualization (equal); writing—original draft (lead); writing—review and editing (equal). Justin C. Strickland: Conceptualization (equal); writing—original draft (supporting); writing—review and editing (equal).

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