cigarettes can be bought in any convenience store, t thmedicaprobms relad to its use are, in the words of one expert, "astronomical." smoking is the largest cause of both emphysema and lung cancer and a significant factor in heart disease, high blood pressure, strokes, and bladder cancer. smoking nicotine may be legal, but as dr. alexander glassman remis us, it is still drug use. what people feel is that it's a behaor. you know that, it isn't jt the-- if you take an antibiotic, you take a pill, stick it in your mouth, drink some water, and swallow it, or somody puts a needle iyour vein and you get an antibiotic, that's a drug. with cigarets, there's a lot of activity thateople may like or get used to. it isn't just the drug.

there's a ritual. that's true with other drugs of abuse, to people get used to anything. people get into habits. there'sothing about holding something in your hand. it makes tm more comfortable. bill smokes 2 1/2 packs a y. started smokg when i was in my midteens, bill smokes 2 1/2 packs a y. like 15 or 16, at summer camp in new hashir t to have since i'm 5o now, that was 3years ago.it woule bother with this 2o or 4o or 6o tim a i'm in politic i rae money. i just did aig campaign lastovember. that last month before election day, i was up tofour packs a. i was never without cigarette. when you give 1oo ople alcohol, about 5% of people will find it very hard to stop,

and they lose control ofheso.... drugs are not addicting for everybody. with nicotine, it's rlly much more addicting than alcohol. if youive everybody cigarettes for a gnificantperiod o- nof one or two cigarettes-- but for months at a time, what you'll find is about 3o% of the people will become addicted to the drug. almost whatever you feel that's bad, whether you're anxious or angry or depressed or bored when you light u a cigarette, e nicotine makes ita little. th's a terrific drug. and any time, en yearsafter, those effects are very marked. if they get very upset, they have the thought that, "if i'd light a cigarette, it would makit better." that's real. it's not imagined. it slows you down, having to light up,

having to find that ashtray, in periods of high, high stress, to just constaly going for the cigarette and smokinit. just wastes smuchof your ene. i uld loveo be rid all that. the year i didn't smoke was an incredible year. all those cliches are tr. i smelled things better. i tasted for the first time. my head was clearer at all times. i so regret going back, i cannot tell you. bill is seeking help for his smoking problem aimed at thiaddiction. mans many people find rief hypnosis, nicotine substites, and old-faionewillpor. th ran me through, i would call it a test, where i saw a film

where the people were sming crack, just like i would do-- go sit on the side of the bed. that was all right until they showed me-- had a box there-- and i looked in this box-- and i read that i wod see some things relating to the drug thing-- i looked in the box, and upset me, you kno it really upset me, but it helped me, also, because i said i'm going to beat this. treatment of substance abuse is successful. it's just that there's a notion out there in the public consciousness that it isn't because they see so many people who get into trement and then later see themelapse. ths the nature a chronic disease. it's completely unrealistic to expect soone to go into treatment and be cured the way a person who has pneumonia can get an antibioti anbe cured.

so awith many psychogical disorders, experts talk treatment, not cure the mo common siation is, first,o get the drug out of the pern's system. and finally, a maintenance period next is a rehabilitation prram, that for some, may last a lifetime. the rehabilitation and mainnce progra themselves can involve medication, such as disulfiram or antabuse used for a small percentage of patients, psychological treatment, such as psychotherapy and desensitization, and by far the most widely used, sociocultul treatments, such as groups like alcoholics anonymous and narcotics anonymous and drug-free halfway houses. often, treatment involves ther an in or outpatient package including all three kinds of care. if a patient comes in with a depression, and you only offer a self-heloup but don't address that depression directly,

you may be missing part of your effectiveness. similarly, if he has no drug-free network of friends, everybody knows uses, and you don't refer him to a drug-free network, you may also be missg the boat. look at the patient as an individual with a s of problems, and then match your interventions to his problems. dr. childress is talking aut a recent development called treatment matching. what our research shows, anthe research of many other pele, that substance abusers are very diffent. we'rnot just talking about heroinddicts or alholics. we're talking about different kinds of alcoholics and heroinddts. they need to be assessed individually and a determination must be madets. of what kinds of problems they have. the treatment programhas tod to fit the patient's needs

my husband agreed to see her, see the doctor with me, and we did for maybe, like eight months. i start to come around. i got to the point where things are changing for me, but i'm still drinking. one time he got so drunk that he drove off in my car and left me sort of stranded where we had been having dinner with friends. while one could do a whole program on alcohol trement, we've chosen to look at one prime example of treatment matching with the story of meredi and his struggle to stop using alcohol. meredith is sioux indian who's been drinking since he was a child. there are many factors that seem toe responsible for his problem. most of his life has been spent behind bars. meredith looks to his early years fothe source of his alcohol abuse.

i started drinking at age 12 beuse i feared my faer, who was a presbyterian minister, who abused me by wpping me with anythg he could get his hands on. helamed me for something i didn't do. d i feared him. i startedrinking to ce with that fear that i had for him. the late 197os, meredith acknowledged that he had a inking pblem. after numerotrtment progra he finally found help where clients partipe oneo-oneg health board and support groups that build on their shared cultural beliefs. this is accomplished by combining twelve-step aa philosophy-- which stresses complete abstinence and the idea that you must give up control of the disease to a force larger an yourself and accept yourself as you are--

with the conceptf the american indian medine wheel. the medicine wheel symbolizes the cycles and changes in life from birth to death. the medicine wheel is both spiritual and physical. it usually takes the form of a circle, reprenting understanding of sel and harmon with the universe. alcoholism or drug abuse cant the harmony of the circle. it's only by reestlishing a correct balance that heang-- recove from substance abuse-- can ocr. in this support group, leader wally morse, a recovering alcoholic, both from within andutside thinantyithnd oths, through important concepts. you have to understand your disease attacks you on the four major life areas. the four major life areas are basically physical, ment, emotional, and spiritual. with the use of the medicine wheel, it also covers the socioculture

of how you're going to in yr ly situation..ck what see to be clear is that e medicine wheel's spiritual value works for meredith in much the same way that more standard forms of therapy work for others. [meredith] the medicine wheel is very sacre amongst the native americans. it represents unity. the medicine wheel involves the spiritual, and the alcoholi part, the physyou know? emotional, and we identify that in our native way, whh is very saed. when you look at this inner circle, it stopped the u. and one of the feengs that you'll start having right away is there's a lot of anger that starts to come up. does anybody relate to feeling angry

whenou first got into treatment? each night went to bed, i went through this scenario of who i was going to hurt, who i was going to get even with. once that picture in my mindnd, i was able to sleep. before, i got an hour or two of sleep a night. i was ragged that first week until i realized i was causing the problems. i tried different ways to get rid of my anger, resentments, in searching fomy higher power, and i couldn't find it. i had to go by traditional way to actually know who i am. i had to go to the sacred circle of the sweat lodge for a purification ceremony. like you said, the fourth and fifth step, i found it in the sacred circle. this is where...

i had a spiritual awakening. i tried many different ways, but i couldn't find it. i had to go my own traditional way of the native americans to really find my identity. [dr. walker] the medicine wheel offers a chance to think about a spiritual healing and integrating that belief system to the treatment process itself. dr. waer, who himself is a cherokee, knows from eerience that tapping into traditio makes good treatment sense. the first steps at i've learned in the treatment for alcohol/drug problems is to look at the values, the positive things that a group of people holdost dear, anyou hang treatme upon those vues. for indian people, th becomes kind of obvious. there's very speci culture identification in what the tribe believes.

and if you can work upon the positives ofhat belief system, e treatment process isasier to understand for e peop who are committed to it. i have never held a medici wheel in my hands yet. it is very sacd. i respect it. when i once hold that, i better continue it on... without the use of alcohol or drugs. any use of d or alcoho once a person is in treatmt is considered relapse. many people consider it failure. some experts, however, feel this is a pessimistic notion. the message is, "don't do it because it's a disease. "iyou have fst drink, "you'll trger the addictproces and you won't beble to control it. e problem is 7o%-8o% of the people

are gog to experiee a lapse. we know this based on treatment outcome studies or people attending aa. if they have a lapse and they believe the diseashas ken over, it gives thethe message there's nothing they can d other th give in or return to the meetings. we're saying that's t necessarily the case because we've found peop who ew it differently. this means, instead, they've made a mistake in their recovery process. they need to make a course correction to get back on tck. relapse prevention was createl more realistically with their lapses. we're helping them anticipate what will come up on the road of recovery and how to deal with it at different stages. first stage is dealing with withdrawal. next is anticipating high-risk situations for relap. we've done many studies on triggers for relapse. what causes people to go off the wagon?

some deal with what's going on in the immediate situation when they first go off the won. some are general life style issues. i'always able tostayff drugs for a certain amount of time. i was always good for 3o days, but it was the 31st day that was really a killer. i tried na and aa. as a matter of fact, i did na one time for 4o days, but the 41st day, i just... the high-risk situations-- these are the triggers that throw people off-course-- are negative-feeling states, again anger, anxiety, um...depression, dysphoric states that the person in the past has used the drugs or substances as aay of coping with, are going to be high-risk triggers for relapse. the person's looking for the same old relief

that they got in the past. besides helping substance abusers deal with the ups and downs of recovery, dr. marlatt and his team focus on prevention with special attentiono those crucial rmative year of college, where it ibelieved that ung pele may develop lifelong abusive drinking patterns. i belthat classes on friday on tsart dely attendedl you because everybods hung over. but alcohol abuse may begin even earlier. in one study, 2/3 of high-school senio alcohol is a known contributor were foundto violence,s. such as date re and ndalism, as well driving accidents. in this young age oup, and college students in particular, we sewe've looked atease inr people from high school that have just entered the university of washington.

we've seen a dramatic increase already in the freshman year. in this university of washington course taught by dr. george parks students who are moderate drinkers become more aware of how and why they drink. imagine for me and thinabout in your lives the kinds of problems that college students get into with drinking. you know the kind of things i'm talking abou what's an example of a problem you've heard about related to drinking? s? slipping of grades and not going to class as a resultof hangovers. ok. so that would be a negative consequence. yes? just becoming dependent on it, having to have it before you go to class, before you go out in order to be social. yes. just excessive drinking itself becomes the problem. students also rticipate in the bar lab, a mock bar expience,

in which they're asked toonitor their physical reactions to driing. all right, folks. want to interrupt you for a moment. you've all had the opportunity to be drinking nowfor about 2o . are you feeling any of the effects, the early effects of alcohol ioxication th you spoke about rlier? a little bit because everyone more lkative. a lot of the anxiety is broken down. we're able to talk to each other. i noticed that you guys were getting louder. is anybody noticing anything in their body or ti'm getting you'really giggly. laugng. ok. i feel a little bit wa in the cheeks. is that typical for you when you've had a drink or two? yeah. at the end of the drinking sessns, students find out the beer contains no alcohol.

this helps tm to see firsthand the power that expectations have on physical reactions. a t of the things we expect cohol to do may be due to ths or various thingswed all our ve it's called the myth of the magic elixir. lots of research over the years has shown that three impornt thing in any drug effect would be the drug itself, the setting in which it's admtered, and your beliefs about how the drug will affect you. when they're testing a new drugo and your beliefs about how the drug will affect you. to test for these belief factors. th alcohol, if people think it wilmake them relaxed, it does ev when the'no alcohol. the bar lab is to shake people about this. one young man, after we told him no alcohol, he was feeng pretty loaded, he said, "do you thinki'm doing" no alcohol, he put himlf in the setting,

thought he was having a real drink. he created the elements that accompany the drug experience. for cocaine, as with alcohol, relapse is a problem. aftercare is essential. ...after this more intensive phase of treatment, the person has some sort of maintenance care-- involvement in perhaps self-help groups again or support groups or individuatherapy that would go on for a month-- from anywhere from six months to two years. so that phase can really go indefinitely. the idea there is to maintain the person's gains, recognizing this rehabilitation phase really, also, just the beginning. because this problem tends to be a chronic relapsing problem-- there's a disorder that tends to improve for a while, and if you're not careful, will get worse again-- to keep that maintenance phase in place is portant. dr. childress believes one of the major reasons patients relapse

is that environmental cues-- granulated white sugar, a street where they bought drugs-- can trigger strong cocaine craving that can lead to renewed drug use. dr. childress' study and eatment program at the university of pennsylvania measures the arousal at people feel when doing cocaine-related tasks such as listening to people talk about drugs. you want to check it out? yeah, man. why not? let's check it out. put the whole thing in it. you want the whole thing in one shot. you know how you do it. for example, as people become aroused, peripheral skin temperature drops, producing cold and sweaty hands. the patient also handles drug paraphernalia using a substance that looks, smells, and taes like cocaine, but isn't. es in environment haveeen pair with this dru for a very long time, thousands of times probably over the course of theears

annow, aer he's been detoxified or in a rehabilitation center, the patient goes back to his natural environme and describeseeing the cues- people he's used with, places that he's purchased cocai, even paraphernalia lying in the gutter, even news broadcasts of drug raids-- finding these ings causing him intense craving. it makes you doubt whether you can ever stay off of it. if i keep running across situations like that or either run across people that use, it would put a very big doubt in my mind. as i was in there simulating that, i was saying, "gosh, i wonder, can i ever do this again?" i'll say it like this-- if you ever lose a best friend, and you got a chance to get that best friend back again... then you probably will try to get it back.

[dr. childress] so we took our cue from that and said what we need is some way to weaken this association. we do that by having a patient come into the laboratory and show him cues that will remind him of cocaine over and over again in a protected setting where he can't act on the craving arousal. we're teaching several different strategies. we begin with teaching him a deep relaxation technique to counter the craving and arousal. we also work with them on imagery techniques, having them imagine themselves at their very worst in terms of the bad effects of cocaine-- withered up in a corner without food, money, family-- following that with positive image of how they can be by n acting on this craving. this controlled exposure to cs, designed to be an adjunct to a regular treatment program, is proving effective for some patients like david. i've been here before,

but this time around, i feel much, much comfortable, much better about it because back then, i used to want to... use again, but couldn't use because of people watching me, you know. but now people still watching me, but i don't want to go back through it again because...i don't know. i just don't feel it. before, i wanted to sneak and do it. right now i have no desire. the challenge facing experts in the field of sutance abuse is formidable. how to weave through the puzzle of addiction, dependence, and abuse to find out first why some people seem to have a propensity toevelop certain addtis while others don't. and second, how to treat those that do and prevent it in those at risk.

as is usually the case, the experts aren't all in ament on causes. in alcoholism, some scientists have discovered a reduced level of activity fore in the systems of alcoholics that's highly inheble and that they claim is the product of a single gene. others disagree and lean towards the view that no single gene specific to alcoholism exists and that there are a iplicity of causes cocaine researchers, too, are looking for a netic marker, hoping it will lead effective pharmacologicatreatmen for a netic marker, hfor cocaine addictn. effe thereatment front, pharmacologicatreatmen the new emphasis on treatment matching effehas led to variety, of efforts pharmacologicatreatmen including group alternatives to alcoholics anonymous, such as is sos, secular organizations for sobriety, meeting. sos believes in separating religion from recovery. finally, prevention.

as many college students will eventually die of alcohol-related causes as will receive their master's and doctor's degrees. to counter this reality, experts hope that courses in safe drinking, like courses in safe driving, willecome anda fare classrooms across the country. on this subject, mo experts do agree classrooms it can happen none too soon. ju because is free-- there's nothinlike being stight, clean... there's nothing like this. i'll never be a square. i'll always be... hip. but...there's nothing like being clean. captioningerformed b thnational ctiing itute, inc. captions copyright 1991 alvin h. perlmutter

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