narrator: what power would make a 55-year-old man who has had two heart attacks continue to smoke two packs of cigarettes a day? what force would make a pregnant woman continue to shoot heroin into her veins even though she is putting her life and the life of her unborn baby in danger? addiction: a state of compulsive physiological need for a habit-forming substance.

narrator: the use of illicit drugs is increasing in many parts of the world, especially in urban areas. and arising from this increase are a host of social and health relatedroblems connected with drug abuse. one is, of course, the risk associated with the abuse aspect, especially of injecting drugs and risk of infection; the criminality which is associated, and the violence which is associated with e of drugs; and then, of course the mental illness that appears to result also from prolonged drug use or even sometimes short-term drug use.

the populations that are most affected are poor populations and nority populations. narror: the specter of poverty hovers in the background of the drug world, but it is far from its only setting. drug use is as familiar to suburbia and the corridors of big business as it is on threets. the reality is drug addiction infiltrates all segments of humanity. the main common feature that we see across different types of addiction is really a commonality in characteristics of the addictions rather than characteristics of the people. lots of different people, perhaps everybody, is vulnerable to addiction. and one of the very interesting things is that different types of addiction have very extensive commonalities in their behavioral characteristics: they tend to have an onset in youth, they tend to be chronic relapsing disorders. sandra mcdonald: drug addiction is tough.

it is a horrible, sneaky, life destroying, family destroying illness. once a person gets in the grip of it, not understanding that it is a disease, they find a comfort level. and anytime you find a comfort level, escaping, getting high, to me is to escape. you're trying to get out of yourself and into the plane of not caring, or not having to care, or you're trying to just skip out on life. and that's where the addictive process or the behavior of addiction comes into play. you engage in the behavior repeatedly over time, and that behavior tends to become more and more dominant in terms of driving your other life activities. so it becomes the focal point for you. it tends to supplant family.

it supplants work. it supplants eating for a lot of folks. so it really becomes the center of the universe around which the rest of the behaviors tend to fly away. the amazing thing about addictions is they appear counter-intuitive. it appears that people are doing things that are producing bad effects for themselves. that's one of the very confusing things about trying to understand addictions. why do people appear to be engaging in self-destructive behavior? how much did you use yesterday? - a little bit of coke. - little bit of coke? you think she wanted to do that today? you think she wanted to be out there in the street, pregnant, homeless, and walking around in a state we call being "geeked up", because this crack cocaine has you on such a edge that all you can do is keep moving and jumping and flinching. well you think at six that was her goal? it was not. just like many other emotional illnesses,

or even medical illnesses, for most people, their understanding of their own substance use isn't clear. but when we look more closely at the behavioral pharmacology or the biology of addiction, we see that there's a biological normality to it. narrator: experts have learned that addiction to drugs or alcohol is a disease that has genetic as well as environmental triggers. we found that a gene involved in dopamine metabolism is important. dopamine is the brain's pleasure chemical. it's what makes you feel good if you have a pleasurable experience. and for high novelty seekers, doing something new, like bungee jumping, or having a new drug, or even a new sexual partner releases dopamine and makes people feel good. what this gene does is it controls how the brain responds to dopamine. so people with one version of the gene don't get much of a thrill from doing something new. they tend to be low novelty seekers.

people with a very slightly different version of the gene respond much more positively to dopamine and they're the people who are likely to be jumping out of an airplane or trying a new drug. there clearly are genetic risks. people do differ as a function of something that's being transmitted genetically from family to family. when you look at certain family complexes, you see these multi-generational, multi-affected families where the risk is just so high for the people becoming alcohol or drug users or abusers. certainly we know that in the alcoholism area, children of alcoholics are at about a threefold risk of becoming alcoholic themselves compared to children of non-alcoholics. and appropriate controlled studies have been done with adoptees and with twins to indicate that this is a genetically determined vulnerability. there have been very elegant studies showing that, for example,

if one of the pair of identical twins is a cigarette smoker, the co-twin is more likely to be a heavy drinker. and that suggests that it's the same genes that are involved in smoking and alcohol drinking just being expressed differently in different people. so this co-occurrence may represent a general vulnerability factor that may be reflected in personality characteristics that are genetically determined. people with family histories, people with co-morbid psychiatric disorders are at higher risk. psychological distress, another emotional illness, depression-- anxiety are highly associated with drug use. i've never met anybody who is abusing anything, and doesn't have some small, underlining mental health issue. because before you picked up the first drink, you probably didn't feel good about yourself,

or before you tooted or even smoked the first cigarette. low self-esteem takes you low, you don't feel good about yourself-- you feel different. and that's one of the characteristics of most addicts. narrator: environment is also an important element in determining the risk for addiction. dr. mccaul: because it's not like other genetically-affected illnesses that will express, to some extent independently of the person's behavior, or how the person interacts with their environment. this problem is very uniquely dependent on how the person interacts with their environment. if they don't expose themselves to the agent at risk, to the alcohol or to the drug, they'll never develop the disorder. narrator: the fact that drugs are so prevalent in our society just increases the environmental risk of exposure. poverty and drugs seem to be partners.

wherever there is a lull in the environment or the economy, it looks like drugs just come in-- the use of drugs, the ability-- drugs just come in. you can go to any community that is not of color, and it will take you blocks to find liquor stores. in our community, and this is mostly people of color-- i've seen this also in the california-- mexican-american, texas-- there's a liquor store on every corner. narrator: besides alcohol and tobacco-- both legal drugs-- what drugs are commonly abused? there are a wide variety of different types of compounds that are considered abused or addictive from the traditional hard drugs of abuse, heroin and cocaine, to more commonly used drugs, some of which are used medically for therapeutics, sedative, hypnotics, tranquilizers. others are...

like marijuana, alcohol, caffeine... on a gradient from the more exotic to the very commonplace, even considered dietary and often considered non-drugs. but there's a behavioral commonality across these. individuals can develop behavioral dependence on all of these compounds. narrator: some addictions are viewed as relatively harmless, like caffeine. dr. bigelow: one can become physically dependent on surprisingly low doses of caffeine. it appears that only about 100 milligrams a day is sufficient to produce physical dependence. that's the equivalent of two or three sodas, or maybe one or two cups of coffee. because the drug is so readily available, it doesn't produce a big problem. so it's an example of a well tolerated, widespread drug of dependence that's just accepted and used in society without major problems.

dr. mccaul: among drugs other than alcohol, marijuana is the most prevalent drug of choice in our society. so it does receive widespread use at this point in time particularly among younger people. but that doesn't make it a safe drug any more than alcohol, which is both legal and widespread in its use, is a safe drug. marijuana has toxic effects, because of its route of administration. the inhalation is just as nasty and toxic as cigarette smoking. dr. miotto: there appears to be an increased risk of cancer, of bronchitis, of asthma. the problem is compounded in that many marijuana smokers also smoke cigarettes. but it is also a psychoactive drug. it produces changes in brain chemistry and other physiology that... is toxic to the individual.

narrator: researchers are looking specifically at the effect marijuana has on brain receptors. dr. miotto: there is a large area of study looking at memory impairment with marijuana, and what hpens when you disturb this receptor by smoking marijuana. it's a debated area: does marijuana impair motivation? many people think of their "deadhead" friends who never finished college, or even started and have been smoking every day. that's harder to tease out if that was marijuana or some other factor. narrator: comp to rijuana, are more obvious, acss all populations of people. dr. miotto: we see a plight in urban america where crack cocaine is being sold on street corners by children to children. cocaine is a very powerfully reinforcing drug,

and people chase the high. they use it, but they want more and more and more. cocaine is a stimulant drug, so individuals will feel euphoric. they'll feel energized, awake, alert, excited. they'll have great self confidence in their abilities. and much of that will be a misperception on their part about what their real abilities are. dr. miotto: people tell me, "when i'm looking for crack... if you ask me, 'give me your right leg,' i would say, 'take it. i want crack now.'" so it disrupts families, lives, criminal behavior run rampant. one of the worst things for me... my wife had bought a bunch of new stuff-- new tv, this and that-- and she had a good job, and we had a little kid... and... she had went out.

and i sold everything. i took everything she bought for the kids, for her, for me, i sold it all. what really hurt, was that when she came back, the pain that she had, ...you know... i mean it was like a pain where she wasn't crying, she was like, wailing. and i mean i felt bad, but i still was getting high. cocaine has a very predictable set of physiological consequences in terms of its use, but they're very acute. they come on rapidly, and, depending on how you administer it, they'll come on more or less rapidly. they subside fairly rapidly. it has a short duration of action. narrator: this rapid high can pose serious health risks: disturbances in heart rhythm... heart attacks and strokes... respiratory failure and seizures.

we've had young people, athletes, die of heart attack due to toxicities of cocaine. narrator: heroin abuse is also on the rise, in part because of the increased purity of the drug, and a decrease in its price. heroin and cocaine really are, to some extent, almost at opposite ends of the spectrum in terms of their behavioral effects on the individuals that take them. and the effects differ over time. most people's initial exposure to heroin is a very unpleasant one, actually. so it tends to induce vomiting, and a lot of dysphoria and distress. dr. bigelow: the main subjective effect of heroin when it's used is to produce a subjective, dreamy euphoria in individuals. they tend to be sedatedat . the effects ll last perhaps an hour or so. with chronic use, the nature of the cycle becomes not just being high and then back to normal, but being high and then experiencing withdrawal sickness

and then using the drug and getting back to normal. once i got addicted to heroin, my life-- i can explain it real simple, i was either in jail, or out on the street using heroin. narrator: there are also health risks associated with using heroin. if it's injected, there's a risk of hepatitis, of aids, of hiv, of many infectious diseases that are transmitted by the needle. for both heroin and cocaine, many of the public health problems one sees are related to the illegality of the drugs, and the difficulty individuals have in getting it, and in self-administering it in sterile ways. so they're very high-risk of infection. narrator: people who are not caught in the web of addiction have a hard time understanding its power and depth. it's easy for us to say "just stop." unfortunately, in that state,

when people are physically dependent to drugs like alcohol or heroin, their brain is saying, "danger, don't stop this drug." we can recognize that, because in animal studies animals will tend to self-administer the same drugs that humans self-administer and abuse. so we don't need to think that there's something biologically abnormal about drug abuse, or that only some very abnormal or unusual individuals are vulnerable. i think the learning that goes on when individuals use drugs and discover the effects that they produce is probably irreversible. you're trying to get out of yourself and into the plane of not caring or not having to care or you're trying to just skip out on life. you don't want to do it this way anymore. "let's just get high." it takes a lot of intervention to get you off that plane.

narrator: one reason it's difficult to get "off the plane" is the physical distress of withdrawal. dr. mccaul: with heroin, they become nauseous, they develop muscle aches, they get gooseflesh. they can't sleep. they have the "cold turkey" which you hear talked about and the "kicking the habit" actually comes from the fact that the muscle spasms, the legs will often have muscle spasms and muscle aches, and they literally are kicking in their sleep, and kicking through their unrest. narrator: to provide a smoother, less painful transition, many treatment programs use substitute drugs, such as methadone for heroin users. the dosage is slowly reduced, as the addict adjusts to a drug-free existence. to ask people to taper from their drug of choice or substance of choice isn't successful, because if they could do that, they certainly wouldn't need medical treatment.

so what we ask them, is can we give you a substance similar or cross-tolerant, meaning that it works similarly in the brain as the substance of choice. dr. bigelow: the great advantages of drugs like methadone and lam are that they're orally effective, slow onset, long duration of action. so they prevent fluctuations in the individual highs and withdrawal. they provide a degree of stability. they eliminate injection drug use. they're very, very effective. because of what is often a pharmaceutical focus upon the development of treatments, it's easy to lose sight of the critical importance of concurrent behavior therapies. so all of the medications that are used in addiction treatment are virtually always used in conjunction with psychosocial counseling, psychological therapies in addition to the medication. a type of therapy that we use

is cognitive behavioral relapse prevention. that's a combination of several therapies, but we help treat people or help teach people what... the triggers are, what leads them to crave. and it's been shown in animal models that the chemicals-- the brain chemicals associated with reward and reinforcement-- already rise when people are anticipating cocaine. so when they tell you, "i just ended up at my drug dealer's house, i have no clue how," there's some brain chemistry evidence that that's the case, that the anticipation is creating a state of reward; they don't feel a choice. so we help to teach people that there is a choice. they need to learn a different routine... skills in terms of avoiding people, places and things that put them at risk. skills in terms of managing their own internal mood states

and feelings which can put them at risk. people often tie feelings of anger, or feelings of frustration, feelings of tension to the desire to drink or to use drugs. and so you have to teach them different ways of managing those internal mood states. dr. miotto: how do you learn to do things as straightforward as thought-stopping? stop those thoughts... how do you learn internal states? and for many people, those are subtle things that they don't even appreciate that drive their drug use. so relapse prevention is an important tool. even if we wanted to get better, and say don't even have alcohol near where people cannot drink responsibly, you can leave outreach's front door and across the street is a liquor store. so it's really that hard job of making people get secure enough to be able to survive in an area that's going to always have drugs.

narrator: for most addicts, it is unrealistic to believe they will be successful the first time they try to "kick the habit." dr. miotto: addiction is a chronic relapsing disease. sometimes people have to fail several times. for example, there's literature suggesting that people who try to quit smoking, after they try about seven to ten times, they're more likely to succeed. so something happens in the process where they learn what it's going to take to really abstain from cigarettes. you cannot beat up people because they relapsed. i don't like that word. "relapsed" to us, means that you returned to drug use. "oops, you slipped. oh, you know, he had a relapse." it's all so negative. why don't we say, "no, he just hasn't learned to recover yet. he'll get it. he'll get it." come on, we can start over."

individuals who simply believe they're going to proceed on willpower and don't anticipate the specific risk they're going to face, and develop strategies for coping with those risks are much more vulnerable to relapse than individuals who've been through these behavioral psychosocial treatments, and have anticipated and developed plans for dealing with the risk. relapse a lot of times equals recovery. it makes recovery stronger. i think people should have more than one opportunity to be administered treatment. they might not get it the first time or the second time. it might even take four or five times. but eventually if they keep coming back, they will get clean. and i've seen that in other people, and i've seen that in myself. narrator: often overlooked is the role families play in the cycle of addiction. there are definitely "dos and don'ts" for families. those "dos and don'ts" are often difficult to see

when they're in the middle of coping with someone with addictive disorder. that's why i think getting help is so important. do you not give them any money and they threaten they'll go out and live on the street, or worse, kill themselves? do you give them money and chances are, they'll use it for drugs or alcohol? it's easy to say, "oh, that family's enabling the situation," rather than just appreciating that this is complex and that families do desperate things in response to a desperate situation. family therapy can play a role in terms of helping to provide some supportive structures within the family system that will promote abstinence and promote the family's recovery. if the person though-- the spouse or the partner-- is also an addicted individual,

unfortunately you're often faced with a real dilemma or the patient is faced with a real dilemma in terms of continuing that relationship, or stopping their drug use. narrator: success can be achieved, but it takes time, commitment, and public support. my own perspective is that this is a health problem, first and foremost. it often, unfortunately, leads to criminal behaviors. there's no question about that, whether it's alcohol-related, assaultive behaviors or dwi's, or breaking and enterings to get the money to buy the drugs. but the disorder, the underlying problem is a health problem. we have been, for years, investing enormous amounts of money in legal action against the people who bring these drugs into the country,

deal these drugs and use these drugs. and i believe that that is important, but i don't think it ought to predominate in how we spend our federal dollars. ms. mcdonald: more than 90% of all the people in our country incarcerated are in there because of some drug offense. looks like we ought to do just the opposite of that. looks like we ought to learn from that and say "well... we really want to put a dent in this." then for every prison, we ought to have ten drug treatment centers that are free. and people ought to be able to go in and get better, and we ought to be able to let them stay until they get it. when i walk into the treatment program that i run, i see people who want to stop using drugs, who want to recover from their addiction, and they are not able to get help when they need it. we're full. we run a waiting list. we can't take in-- we can't begin to take in all of the people who are coming to us for help. so you detox somebody in three days, and then you send them to outpatient care

to go every day for 20 days, and think that they're going to halt a disease that's been with them for 20 years. give me a break. we could affect just such savings from a health perspective, from a legal perspective, from a family dissolution perspective. all of those could be impacted if, in fact, we could bring help to people more quickly, and we could help those who are seeking help more effectively. narrator: because getting help does make a difference to addicts traveling that long, difficult road toward life without drugs. lateef smalls: i promised myself a year, that i would give myself a year, and i would just have a relationship with me and my higher power. i didn't get into no other kind of relationships. and i focused on that-- i focused on going to meetings and trying to get educated about my disease. and... life just started getting so good it scared me.

i wouldn't trade it. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or visit us online at: call: new year's eve, 2002. just two years ago. in the sixth grade. july 11, 1994. i was shot by a teenage gang member. my son valentino was killed by a drunk driver.

my baby brother joseph was shot. i was sexually assaulted. my wife emma was killed by a drunk driver. my heart was ripped apart. the day this happened to us, our family died. at that time, i had no idea that i needed help or that my family needed help. i didn't know help was there. a detective told us about victims' assistance. we did receive help with the funeral and burial. they informed me of my court dates. th paid for my wheelchair-accessible van. if you're a victim of crime, seek help, because help is there for you. even if you never reported the crime... crime victims' assistance programs are there to help. justice isn't served until crime victims are.

and i think that's a message that i heard for a lot of my life, is that because i couldn't control this or i couldn't do this, i was some kind of a weak individual. alcoholics are not... bad people getting good. we're sick people getting well.

narrator: let's make a toast! whether it's a graduation, a wedding, a promotion, alcohol is an ingrained part of our society. 52% of americans drink, and many do so rponsibly. alcohol doesn't threaten their health or their relationships with others. but what happens when we don't drink responsibly? in many european countries, the use of alcohol is a part of a meal ritual, and it's not common to see adults drink, in the context of that meal, to intoxication. that's very different than american use of alcohol in many families, where it's a part of unwinding, relaxation-- drinking to the point of intoxication. so it's important to look at how it's used in the family and in the culture. jerry: i think down south,

alcohol is part of virtually every custom. everyone in my family drinks, some alcoholically, some not. children of alcoholics are at about a threefold risk of becoming alcoholic themselves compared to children of non-alcoholics. it appears that about half the variance in vulnerability for alcoholism is related to genetic factors, and the other half is related to environmental behavioral factors. certain personality traits are associated with increased risk for alcoholism. age can also be a contributing factor. people who begin drinking before the age of 15 are twice as likely to abuse alcohol, developing drinking patterns that repeatedly cause them problems. i was probably... about 14. i had probably had sips of beer and stuff like that before.

my mother died when i was 14, and shortly after that, you know, i saw what it did for other members of my family, older members of my family. they didn't feel. and i wanted not to feel. you know... alcohol is a very interesting drug to study because it's a drug that, when taken in small amounts, makes everyone a little bit less inhibited. that's why we drink it at a party. on the other hand, those same people, if they take a little bit more, may well feel nauseated by it or sleepy by it or distressed by it or dizzy by it, and they don't press on, and that may well be a biologically built-in thing. on the contrast, there are other patients who have certainly told me that when they had their first drink, maybe in their teens, they said, "this is it.

this is the nectar of the gods. this makes me feel so wonderful!" i mean, they describe a response to that drink that it's hard for us to share. it doesn't match our experience with alcohol, and we can imagine that this would well be not only part of their constitution, but be a vulnerability to turn to alcohol in a much more frequent way. i drank pretty much alcoholically from the very first drink i took. i drank, like, an entire bottle and didn't get sick and didn't pass out and just didn't feel, and that's-- you know, i didn't know that at the time. i thought that's the way everybody drank. and i did that on a regular basis, you know, for a long time. even if the drinker doesn't recognize the effects the alcohol is having,

the body does. alcohol causes memory loss and memory impairment. it causes vitamin deficiency. alcohol causes blackout. people often don't remember what they did... in a state of intoxication. the dangers of that are enormous. we see domestic violence-- abuse, rape, neglect-- occur in the context of alcohol. drinking changes behavior because alcohol affects the interaction among nerve cells in the brain. it acts on the parts of the brain that are responsible for drives and emotions, as well as the part that coordinates muscle movements. i was blackout drinking by that point quite often. and i'd... wouldn't know how i got home or how i drove, or how i-- you know, where my car was,

that kind of thing. alcohol can be compelling for different reasons, in that some people use it to cope, to unwind. they develop aberrant coping with their alcohol use. other people go on to become physically dependent. this dependence is alcoholism. when alcohol consumes a person's life, all other interests are neglected in pursuit of a drink. karen miotto: many people will say to me, "i'm not an alcoholic. i only drink on weekends. an alcoholic drinks more than that." if i see them a year later and their disease has progressed, "no, an alcoholic can't get to work. i'm drinking every night, but i go to work." and so ambivalence and denial are key factors in what ke people from seeking treatment and having... maybe less suffering due to their disease of addiction. i tried a number of geographical cures, you know, moving to different places

and trying different things. you know, i'm an alcoholic, and i take myself with me wherever i go. i moved to memphis, tennessee, and took a job there, and that was a really bleak period. it was probably a year of basic blackouts. don't remember a whole lot of living there. because the liver is the major detoxification site for alcohol, it's particularly at risk from chronic drinking. years of drinking can result in cirrhosis of the liver as alcohol begins to kill liver cells. 40% of chronic abusers develop alcoholic hepatitis, an inflammation of the liver. heavy drinking is also associated with cardiovascular disease and certain cancers. you know, most alcoholics get to a point where they want to stop, and... for non-alcoholics, their willpower can-- they can stop. "okay, well i'm just not gonna have this second drink."

i could never understand how anybody could leave half a glass on the table. i'd finish yours, too, because that just was not in my nature. i really believe i was born with this disease, and it's not a matter of willpower. and the whole disease concept, i myself struggled with that for a long time. my upbringing was such that, you know, you pick yourself up by your bootstraps and you just do it. and i tried to deal with my alcoholism that way for a long time, and i was never able to do it. the idea that people can say no, that they don't have to use today, is very difficult for us. if someone has schizophrenia, they can't say, "well, today i'm not going to hear voices." maybe they can learn to do some things to help their situation. so the very difficult area

in treating and in helping people with addiction is, how do i understand that you can say no today and how do i help you? mary elizabeth mccaul: we think and label these disorders as weaknesses of will and, in fact, that's generally not true at all. these are folks who are struggling with this alcohol or drug that has really taken over their ability to make good decisions and has taken control of their lives. jerry: i had gone home to the south... and... it was really an intervention, i guess, by my sister and brother and father and stepmother, and my husband at the time who said, "you know, you have a problem." and that was the first time i was able to say,

"yeah. it's about time somebody noticed." and i went into a... an in-patient treatment program for 21 days in florida. in-patient treatment is sometimes used when acute detoxification is required. about 10% of the patients need medication to help them with the effects of withdrawal. so what we ask them is, "can we give you a substance, similar or cross-tolerant-- meaning that it works similarly in the brain as the substance of choice-- and taper them off?" because people are frightened of stopping drugs when they're physically dependent. it's very distressing, and it's the negative reinforcement to continue drug use. if every time you stop drinking, you wake up and feel so sick you think, "i'd like to die

rather than be this sick again," what a powerful reinforcement to continue using every single day. during the detoxification period, patients participate in group therapy and alcohol education. it was... quite a revelation that there was a way to live without the necessity to... take something to medicate myself. one thing that i have found anecdotally and also is clear, is that many of these individuals are self-medicating. a lot of self-consciousness, phobias, inadequacies. and the alcohol's a way to sort of-- it's almost like an anti-anxiety pill for them. it is a feeling, i think, of not being connected... of not fitting in,

of not... of somehow not having what other people have. and i don't mean materially, and i don't mean-- it's just there was something missing and there was something always missing. that's the only way i know how to describe it. there was just this hole, and when i used and drank, i didn't feel that hole. i could fill that hole up, and that was the only solution that i had. when they feel that urge, rather than responding to it, which is what they've done for years, they need to learn strategies to help them avoid use at this point. and that's a large part of what treatment tries to do. it tries to teach skills, skills in terms of avoiding people, places, and things that put them at risk. there's sober-living houses where people move out of their environment and live

in a loosely structured treatment program where people go to so many meetings. there's rehabilitation centers that are very intensive and have all kinds of family therapy, occupational therapy, to try address all aspects of someone's life. one of the things that i've been certainly particularly interested in, in recent years, is medications development for the treatment of alcoholism. the first drug was approved back in 1948. it's antabuse, and it works by inducing a punitive action. people drink, if they're taking antabuse, it makes them sick. and the belief is that people won't do that again. maybe, maybe not. if they're not sufficiently motivated, they'll just stop taking the drug. the second drug that was approved is called naltrexone. it's really an exciting breakthrough in terms of the treatment of alcoholism

because it appears to be working at actually addressing some of the underlying physiology that may be affected by chronic alcohol exposure. for the first time we can start to look at ways to combine medication with psychosocial treatment. when people enter the treatment system, one of the reasons we often use group treatment or trained therapists is to help people move beyond "poor me" and say, "i've done terrible things, but i can change." one of the steps in the twelve-step program talks about making amends. that's a backbone of the twelve-step treatment, is how do you go beyond the things you've done to allow yourself to live another life?

you know, i take responsibility for the things that i did when i was out there drinking and using, and i've made amends for those things, and i don't use the disease concept as a cop-out for that. i'm responsible for what i did. now, was it a result of my having a disease? yes. but i guess, you know, that's the thing i'd most want people to know, is that, you know... this is not something that i had any conscious control over. if i had, i would've exercised it. typically with alcohol abuse, as with other addictions, individuals will need multiple attempts at cessation and control before they get their problem under control and give up the abuse-of-drinking style. basically, i lost everything.

you know, i wasn't working i, you know, lost the love and respect of my family, and that's real important to me. being a southerner, family is a key ingredient in my life. you know, i had never been in any kind of legal trouble. i got in legal problems, and things were published in the newspaper. you know, i lived in a tiny little town where everybody knew everybody, and, you know, it was delivered to their front door. so, yes, things got-- you know, they talk about in alcoholism that it's a progressive disease, and i don't think people realize what that means. and what it means is that even when you've had a long period of sobriety, which i had, the disease is still progressing,

and so when you decide to pick up a drink again, you don't pick up where you left off that period of time ago. you pick up as if you had drunk yesterday. it's possible sometimes for this to be interpreted negatively, suggesting that drug abusers and alcoholics never get better, that they're chronically relapsing. but we have lots of chronic diseases in medicine that are not hopeless simply because they're chronic. they require chronic treatment. there will be episodic instances of problems that need to be brought under control again, but these chronic diseases are treatable. people do get better. all any of us have is today. you know, this is the only day i've been sober. all the other ones add up and give me tool toain sober, i'm stil the same distae from a drink as somebody sober two days or 30 days or 10 years or 20 years.

sobriety, for me, it's an inside job. it's about in here, and it's about keeping that hole filled up. many different addictions tend to go together. for example, if you've ever been to a meeting of alcoholics anonymous, you'll find that even people who are now not drinking tend to smoke very heavily. there's a tremendous amount of overlap, and some people think that's because once you start smoking, that's going to lead you to other drugs. that's probably not the reason. the probable reason is that there are certain personality configurations which lead to addiction to all sorts of substances, and therefore, all of the different addictions actually have a genetic connection. addiction is a chronic relapsing disease. sometimes, people have to fail several times. for example, there's literature suggesting that people who try to quit smoking, after they try about seven to ten times,

they're more likely to succeed. so something happens in the process, where they learn what it's going to take to really abstain from cigarettes. george bigelow: interestingly, people report cigarette smoking being more difficult to stop than heroin use or cocaine use. we don't know that that's due to the biology of nicotine addiction compared to these others or simply due to the widespread availability and access to tobacco that people have during the period in which they're trying to quit. people don't abuse substances that don't have some desirable effect. and so this illustrates one of-- people smoke their cigarette, they feel calm, they feel freer of anxiety, they feel perhaps able to concentrate and face their day. so you are altering a substance that's naturally in the brain, and you're doing it very quickly. within five minutes, you have nicotine entering directly into the brain and changing brain chemistry.

of course, if cigarettes caused just a harmless change in brain chemistry, there wouldn't be a problem. but, as most people know, smoking is a dangerous habit. it is the leading source of preventable illness and death in the united states. every year, approximately 430,000 people die in this country as a result of using tobacco products. it is responsible for about 30% of all cancer deaths in the united states. in fact, 87% of lung cancer cases are smoking-related. well, i think most people know-- and if they don't, they should-- that smoking has got to be the worst thing that anybody could be doing, and it comparatively is the... you know, i think the one environmental exposure that is the strongest, the most associated with morbidity and mortality, and it's terrible.

nothing comes close to it in, you know, terms of impact on the population. there are over 4,000 chemical compounds present in the gases and particles that make up cigarette smoke. some are poisonous; some irritate the lungs; some cause cancer. when nicotine enters the body, it increases the heart rate and narrows the blood vessels. blood pressure rises. smoking very much predisposes people to develop lung cancer. not everyone who smokes will develop it, but it is a known cause of lung cancer. men in the united states began to smoke heavily in the early 1900s. women began after the second world war in the 1940s, and what we have seen happen with lung cancer incidence rates, with about a 30- to 40-year time lag, is to see the dramatic increase in the incidence of lung cancer, first, among men, and then followed by an increase in the incidence among women.

cigarette smokers are more than twice as likely to have a heart attack or stroke than non-smokers. it's also the main cause of emphysema and chronic bronchitis, two serious problems that damage the lungs. despite these findings, many people don't seem to be paying attention to the dangers, especially teenagers. karen miotto: the earlier you start smoking, the harder it is to stop smoking. basic scientists believe that that may actually be due to altered brain chemistry, that there may be a window of vulnerability in children and adolescents that interferes with development by smoking earlier. many people will die an early preventable death because of a decision made as a child. only 11% of adult smokers started the habit after age 18. risk factors that parents should look for... are they are suffering from other emotional problems,

conduct problems, poor school performance? teenagers who are susceptible to peer pressure or are rebellious may also be more likely to start smoking, and once they start, it's difficult to stop. nicotine is a powerfully addictive drug. if you ask people about their first smoking experiences, most people will tell you that they were ghastly. very unpleasant. they made them dizzy. it made them nauseous. they had these nasty reactions to this stuff which probably is our body's way of telling us, "stop now! enough already!" but we don't, and people do tend to continue in their use, and further down the road, what you see is a very different looking complex of behaviors, much of which revolves around physical dependence at that point. so people's bodies become habituated to the presence of these drugs. but smoking often begins at an age when we feel invincible. the health risks may not show up for years later.

i can say to them, "well, if you don't quit smoking, there's a good chance you may get lung cancer, and you may die at age 75 instead of dying at age 80." well, they're 30 years old. both of those things are quite remote and are really meaningless to them. so instead of taking that approach, i take the approach that, "well, you know, if you don't quit smoking there's a very good chance by the time you're 45 or so, you're going to be impotent. now, i don't know if that means anything to you, but it may have some impact on your wife and may adversely affect you," i said. "and if you have any children," i said, you're not going to be able to go out and play ball with your kids, and when your kids grow up and your kids have grandkids, you can forget about ever baby-sitting the grandkids because you're not going to be able to breathe well enough. so it's not only a matter of dying of lung cancer when you're 75," i said, "you're going to have a lousy quality of life for the last 20 years." dean hamer: almost 50% of people try to stop every year but simply aren't able to do so. we've been very interested in whether or not there is a genetic basis for why some people find it easy to stop smoking,

and other people find it very difficult. if we could find that, we might be even able to develop new therapies or new drugs which would help the most recalcitrant people to quit their smoking addiction. we have actually found two genes that seem to be involved. one is involved in dopamine metabolism. it's the gene for the dopamine transporter. it's a very interesting finding because one of the new drugs for smoking cessation affects this same transporter. that's a drug called zyban, and it affects dopamine metabolism in the brain. the other gene that we found involved is the serotonin transporter gene which is involved in personality traits like depression and impulsitivity and anxiety. people with those traits find it hard to give up smoking because they use the cigarette to self-medicate. karen miotto: because it's such a difficult addiction to recover from or to be in the process of recovery, we recommend a combination. try the patch. try an anti-depressant.

make sure you go to some kind of program to get tools and techniques to identify when you're craving, when you're having high-risk situations, to help prevent the cycle of stopping and starting and stopping and starting. people really need to anticipate these risk situations and practice the behavior of declining, declining the cigarette or getting out of the situation. the individuals who simply believe they're going to proceed on willpower and don't anticipate the specific risk they're going to face and develop strategies for coping with those risks are much more vulnerable to relapse than individuals who've been through these behavioral psychosocial treatments and have anticipated and developed plans for dealing with the risk. so the good treatment programs that combine psychosocial and pharmacological support for smoking cessation probably yield about a 40% long-term cessation rate.

when a smoker quits, at whatever age, the risk of heart disease begins dropping immediately. breathing becomes easier. cancer risks decrease. even though not all damage can be eliminated, the health benefits are immense. of course, avoiding cigarettes from the start is the healthiest course to follow. talk to cigarette smokers 20 years after they've quit smoking and they can describe with wonderful affection how much they liked their cigarettes, how much they would like them again. so the bottom-line message is that prevention and avoidance of drug use is probably the most effective initial step that individuals can have in avoiding problems in this area. we don't know how to make memories or learning go away. we can provide psychosocial support and pharmacological supports to help ople succeed in recovering abstinence once they've developed an addiction, but it's going to be hard. the memories, the learning are always going to be there.

the individual is really permanently changed by an experience of addiction. "the human condition" is a 26-part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: