cigarettes can be bought in any convenience store, t thmedil problems relad to its use are, in the words of one expert, "astronomical." smoking is the largest cause of both emphysem and lung cancer and a significant factor in heart disease, high blood pressure, strokes, and bladder cancer. smoking nicotine may be legal, but as d alexander glassman it is still drug use. what people feel is that it's a behavior. you know that, it i't just 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 iur vein and you get an antibiotic, that's a drug. with cigarettes, there's a lot of activity that people may like or get used to.

it there's a ritual.ug. that's true with otherrugs of abuse, too. people get used to anything. people get inthabits. there's something about lding something in your hand. people get used to anything. it makeshem re comfortable. bill smoke2 1/2 packs a y. i started oking when i was in my midteens, like 15 or 16,/2 packs a y. at summer camp in new hash it wld just be niceto have o since i'm 5o now, that was 35 years ag boer with this i'm in politics. 2o or 4oi raise moy. i just did a b campaign lastovember. that last month relection day, i was upofour packs aay. i was never without cigarett enou give 1oo ople alcohol, about 5% of people will find it very hard to stop, and they lose control of the drug.

so... drugs are not addicting for everybody. with nicotine, it's rlly much more addicting than alcohol. if youive everybody cigarettes for a significant period otime-- not f 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, whher you're anxious or angry or depressed or bored, when you light u a cigarette, the nitine makes ita lile bit b. th's terrific drug. and for some pple, those effects are very marked. d any time, en years aftethey've stopped, if they get very ups, they have the thght that, "if i'ght a cigarette, it would make it better." that's real. it's not imagined. it slows you down, having to light up,

having to find th ashtray, in periods of hi,high strs, to just constantly be going forhe cigarette and smokg it. just wastes so muchof your e. i uld loveo rid ll that. the year i didn't smoke was an incredible year. all those cliches are . i smelled thingsetr. tasted for the first te. my head was clearer at all times. i so rret going back, i cannot tell you. bill is seing help for his smokinproblem at smokenders, one of many prrams bill is seing help nicoti sstutes,is,ion. manf and old-faiod willpor. they ran me through,i woul, 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 would see some things relating to the drug thing-- i looked in the box, and it upset m 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 noti out there in the public consciousness that it isn't because they see so many people who get into trement and then later see thelapse. ths the nature a chronic disease. it's completely unrealistic to expect someone to go into trement and be cured the way a person who has pneumonia can get an antibiotic anbe cured.

so as with man psychogical disorders, experts talk treatment, not cure. the most common situion is first,o get the drug out of the person's stem. next is a rehabilitation prram, and finally, a maintenance period that for some, may last a lifetime. the rehabitation 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, sociocultural treatments, such as grou like alcoholics anonymous and narcotics anonymous and drug-free halfway houses. ofn, treatment involves either an in or outpatient package including all three kinds of care. if a patient comes in with a depressn, including all three kinds of care. and you only offer a self-helgroup but don't address that depression directly,

you may be missi part of your effectiveness. similarl if he has no drug-free network of friends, everybody he 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 set of problems, and then match your interventions to his problems. dr. childress is talking about a recent development called treatment matching. what our research shs, anthe research of many other pele, is that sutance abusers are very diffent. shs, we'rnot just talking about heroin addicts or alholics. we're talking about differt kinds oflcoholics and heroin addts. they need to be assessed individually and a determation must be made the treatment programhas tod they have.

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 whe we h been having dinnewith 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 storyf meredi and his struggle to stop using alcohol. meredith is a 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 father, who was a presbyterian minister, who abused me by whipping me beuse i feared my father, who was a presbyterian minister, with anythin he could get his hands on. he blamed me for something i didn't do. i started drinng to cope with that fear that i had for him. the late 197os, meredith anowledged that he had a inking pblem. after numero trtment progra heinly fou hp where clients partipean in oneo-e seoard and support groups that build on their shared cultural beliefs. this is acmplished 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 than yourself and accept yourself as you are--

with the concept of the american indian medine wheel. the medicine wheel symbolizes the cycles and changes in life om birth to death. the medicine wheel is both spiritual and physical. it usually takes the form of a circle, representing understanding of s anharmon with the universe. alcoholism or drug abuse can disrupt the harmony of the circle. it's only by reestablishing a correct balance that heang-- recove from substance abuse-- can ocr. in this support group, leader wally morse, a recovering alcoholic, th from within andutsi thinantyh and os, 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, d spiritual. with the use of the medicine wheel, it also covers the socioculture

of how you're going to start fitting back in your ly situation.. what see to be clear is that the 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 that more standard forms amongst the native americans.rs. it represents unity. the medicine wheel involves the spiritual, the physical, the emotional, and the alcoholism part, you know? and we identify that in our native way, whh is very sacred. and when youook that at this inner circle, it stopped the u. and when youook that aand one of the feelings 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 when you first got into treatment? ea night went to bed, when yi went through got into 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 houor 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 for my higher power, and i couldn't find it. i had to go by traditional w 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 dicine wheel offers a chance to think about a spiritual healing and integrating that belief system to the treatment process itself. dr. walker, who himself is a cherokee, knows om experience thatapping into tradition makes good treatment sense. the first steps that 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 treatment upon thoseues. for indian people, that becomes kind of obvious. ere's a very speci culture identification in what the tribe believes.

and if you can work upon the positives of that belief system, the treatment process isasier to understand for the peop who are committeto it. i ve never held a medicine wheel in my hands yet. it is very sacd. i reecit. when i once hold that, i better continue it on... without the use of alcohol or drugs. any use of drugs or alcohol 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 a fst drink, "you'll trger the addictprocess, and you won't be ableto con" problem is 7o%-8o% of the pple

are gog to experiee a lae. we know is based o 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 do other than give in return tohe meetings. we're saying that's not necessarily the case because we've found people who view it differtly. this means, instead, they've made mistake in their recovery process. they need make a course correction relapse prevention wasreated l get back on tck. 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. next is anticipating high-risk situations for relap.al. 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 w. 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 therugs or substances as a w 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. besidehelping substance abusers deal with the ups and downs of recovery, dr. marlatt and his team focus on prevention with special attentiono the crucial rmative year of college, where it ibelieved that ung pele may develop lifelong abusive drinking patterns. i believe st teachers on ts campus would tell you that classes on friday art dely attended because everybody's hung over. but alcohoabuse may begin even earlier. in one study, 2/3 of high-school senio alcohol is a known contributor were foundto violence, su as date re and ndalm, as well as driving accidents. in this young age oup, and college students in particular, we sewe'vlooked atn drng peoplerom high schl that have just entered the university of washgton.

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 youlives the kinds of problems that college students get into with drinking. you know the kind othings i'm talking about? what's an example of a problem you've heard about related to drinking? yes? slipping of grades and not going to class as a result of hangovers. ok. so that would be a negative consequence. yes? just becoming dependent on i 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 eience,

their physical reactions toto drinkg. all right, folks. i want to interrupt you for a moment. you've all had the opportunity to be drinking now for about 2o minutes are you feeling any of the effts, the early effes of alcohol intoxication that you spo abouearlier? a little bit because everyone'sore talkative. 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 the way you're thinking? is ai'm gettingcing anytreally glaug..body ok. i feel a little bit 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 them to see firsthand the power that expectations have on physical reactions. a t of the things we expt alcohol to do the power that expectations have onmay be duethactions. or various thingswed all our live it's called the myth of the magic elixir. lots of research over the years has shown would the drug itself, at three iornt this in anyrug effe the setting inhich 's admtered, and your beliefs about how the drug will affect you. wh they're testing a new drug,eo and your beliefs about how the drug will affect you. to test for these belief factors. th alcohol, if people think wilmake them relaxed, it doeeven when there'no alcohol. thbar lais to shake people up about this. one young man, after we told him no alcohol, he was feeling pretty loaded, he said, "do you think i'm doing this to myself?" he put himself in the setng,

thought he was having a real drink. he created the elements that accompany the drug experience. for cocaine, as with alcohol, relapse is problem. afteare is essential. ...after this more intensive phase treatnt, the person has some sort of maintenance care-- involvement in perhaps self-help groups again or support groups or individual therapy 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-- thers a disoer that tends to improve for a while, and if youe not careful, will get worse again-- to keep that maintenance phase in place is important. dr. childress beeves one of the major reasons patients relap

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 it. for example,as people beco, peripheral skin temperature drops, producing co and sweaty hands. the patient also handlesdra using a substance that looks, smells, and taes like cocaine, but isn't. es in environment haveeen pair with this d for a veryong time, thousands of times probably over the course of theears,

and w, after he's been detoxified or in a rehabilitation center, the patient goes back to his natural environment and describe seeing these cues-- places that phe's purchased cocne, even paraphernalia lying in the gutter, even news broadcasts of drug raids-- finding these things causing him intense craving. it makes you doubt whether you can ever stay off of it. if i keep running across situions 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 not 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, ch better about it because back then,und, i fei used to wanto...ortable, 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 substance abuse is formidable. how to weave through the puzzle of addicon, dependence, and abuse to find oufirst why some people seem to have a propensity to develop certain addictions 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 caes. in alcoholism, some scientists have discovered a reduin the syste activitye of alcoholics that's highly inherible 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 muiplici of causes. cocaine researchers, too, are looking for a genetic marker, hoping it will lead to effective pharmacological treatments for cocaine addiction. on the treatment front, the new emphasis on treatment matching has led to a variety of efforts including group alternatives to alcoholics anonymous, such as is sos, secular organizations for sobriety, meeting. sos believes in separating religion from recovery. finally, prevention.

mancollege 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 safdrinking, like crses in safe drivi, willome anda fare classrooms across the country. on this subject, most experts do agree it can happen none too soon. just because is free-- there's nothing like being straight, clean... there's thing like this. i'll never be a square. i'll always be... hip. but...there's nothing like beinclean. captioning performed by the national captioning institute, inc. captions copyright 1991 alvin h. perlmutter

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