living alone and no o close to me. then i really knew i was addicted because it didn't bother me about being that way. some addictive drugs, li nicotine, a common, woven into the fabri of o daily life. cigarettes can be bought in any convenience store, in the words of one expert, relate"astronomical."e, 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 blegal, but as dr. alexander glassman it is still drug use. what people feel is that it's a behaor. you know that, it i't jt the-- if you take an antibiotic, you take a pill, stick it in your mouth,

ink 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 i't just the drug. thers a ritual. that's true with otherrugs of abuse, too. people get used to anything. peop get into habits. there'something about holding something in your hand. it makesm moreomfortable. bill smoke2 1/2 cks a y. started smokin when i wasn my midteens, bill smoke2 1/2 cks a y. like 1or6, at summer camp in new hashir t to have to since i'm 5o now, that was 3years ago.it woule boer with is 2o or 4o or 6o tim i'm in politic i rae moy. i just did a campaign lastovember. that last month before election day,

i was up tur packs aay. i was never without cigarette. when you give 1oo ople alcohol, about 5%f 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 thanlcoh. if youive everyby cigarettes for a gnificantperiod o- nof one or two cigarettes-- but for months at a time, at you'll find isabout 3o%e will become addicted to the drug. almost whaver you feel that's d, whetr you're anxious or angry or depressed or bored en y light u a cigarette, e cotine makes ita lile bit. th's aerrific drug. and for some pple, those effects are very marked.

d any time, en yearsafter t, if they gevery ups, ey have the thought that, "if i'light a cigette, it would makit better." that's real.it's not imaned. it slows you down, having to light up, having to find that ashay, in periods of high, high stress, to just constantly going forhe cigarette and smokinit. it just stes 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 st for the fst time. myead was clearer at all times. i so regret going back i cannot tell you. bill is seeking help for s smokinproblem at smokeers, e many p.

manyeople find rief hypnos, nicoti substites, and old-faiowillpo th r me through, i would call it a test, where i saw a film where the people were sming crack, st 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 tngs 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 them relapse. ths the nature a chronic disease. it's completely unalistic to expect soone to go into treatment and beured the way a person who s pneumonia can get an antibioti anbe cured. so awith many psychogical disorders, experts talk treatnt, not cure the mo common siation , first,o get the drug out of the pern's stem. xt is a rehabilitation prram, and finally, a maintenance period 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 agroups like alcoholics anonymous

and narcotics anonymous and drug-free halfway houses. ten, treatment involves ther an in or outpatient packae including all three kinds of care. if a patient comes in with a depression, and you only offer a self-houp but n't address that depression directly, you may be missing part of your effectiveness. silarly, if he has n drug-free neork 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 s of problems, and then match your interventions to his problems. dr. childress is talking about a recent development called treatment mating. what our research shows, we'rnot just talking abouts heroinddicts or alhocs.

we're talking about different kinds of alcoholics and heroinddts. they need to be assessed individually, and a determination 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 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 abusede by whipping with anythghe could get his. he blamed me for something i didn't do. i startedrinng to ce with that fear that i had for him. the late 197os, after numeroustreatmenprra, that he had a inking pblem. heinally foup where clnts partipeindiannprra, that one-to-e seling,blem. 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 americanndian medineheel. 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, reprand harmonstding with the unirse. alcoholism or drug abuse cant the harmony of the circle. it's only by reestlishing a coect balance that heang-- recove from substance abuse-- can ocr. in this support group, leader wally morse, a recovering alcoholic, th from within andutside thinanty,dith and oths, through importanconcepts. 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 situationback 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 alcoholism part, the physyou know? emotnal, and we identify that in our native way, whh is very saed.

when you look 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? ea 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 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 fo higher power, and i couldn't fin. i hato 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 difrent 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 thinkabout a spiritg and integrating that belief system to the treatment process itself. dr. walker, who himself is a cherokee, knows from expience thatapping into tradition makes good treatment sense. the first steps at i've learned thereatment for alcohol/drug problems is to look at the values, the positive things

that a group of people holdost dear, and you hang treatme upon those vues. for indian people, th beces kind of obvious. thers very speci culte identificati in what the tribe belies. and if you can work upon the positives of that belief system, e treatment procs isasier to understand for e peop who are committed to it. i have never held a medicine 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 dgs 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 bebl to conol it. e problem is 7o%-8o% of the pple are gog to experiee a lapse. we know this based on trtmenoutcome studies or people attending aa. if they have a lapse and they believe the disease has taken over, it gives thethe message there's nothing they can do other th give in return to the meetings. we're saying that's not necessarily the case because we've fod peop who ew it differently. this means, instead,they'vee in their recovery process. they need to make a course correction relapse prevention was createl to get back on tck. moreealistically 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 relapwal. we've done many studie onriggers for repse. 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'alwa 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 gative-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 de withhe ups and downs of recovery, dr. marlatand his team focus on prevention with special attentiono those crucial rmative years of college, where it ibelieved that ung pele may develop lifelong abusive drinking patterns. i belthat classes on fridays cau art dely attended becae everybods hung over. but alhoabuse 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 2/3 and ndalm,hool senio as well driving accidents. such as date re 2/3 in this young age oup, and college students in particular, we see an incrcrse in drng and cwe've looked at ipeoplerom high school 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. geor 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 becomin 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 to monitor eiphysical reactions to driing. all right, fks. 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 effects, the early effect of alcohol intoxication th you ske about earlier? a little bit because everyone more talkative. a lot of the anxiety is broken down. we're able to talk toach other. i noticed that you guys were getting louder. orhei'm gettingcing you'really giggly.body laughing.

ok. i feel a little bit wa in e cheeks. is that typical for yo 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 theto see firsthand the power that expectations have on physical reactions. a t of the things we expect cohol to do may be dueth or various thingswer all our ve it's called the myth of the magic ixir. lotsf research over the years has shown that three impornt thing in any drug effect would be the drug self, the setting in which it's admtered, and your beliefs about how the drug will affect you. wh they're testi a new dg,ey alo and your beliefs about how the drug will affect you. to tes for these belief factors. th alcohol, if people think it wilmake them relaxed,

it does ev when the'nolcohol. the bar lais 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 himself 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 essential. .after this more intensive phase of treatment, the person has some sort of maintenance care-- involvement in perhaps lf-help groups again or support groups or individual therapy that would go on for a month-- from anywhere from six mths 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 important. 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 veeen pair with this dru r a very long time, thousands of times probably over the course of theears annow, aer he's been detoxified or in a rehabilitationenter, thpatient goes back to his natural environme andescrisseeing the cues-- people he's used with, places that he's purchased cocai, even paphernalia lying in the gutter, even ns 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 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--

folling that with positive image of how they can be by not aing 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 abt it because back then, i usedo 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 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 toevelopertain addtis while others don't. and second, hoto treat those that do and prevent it in those at risk. as is usually the case the experts aren't all inment ocaes. in alcoholism, some scientists have discovered a reduced level of activity fore in the systems of alcoholics that's hhly inhetable 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 muiplicity of causes. cocaine researchers, t, are looking for a netic marker,hoping d effective phmacologicatreatm for a netic marker,hoping d for cocainaddictn. effeon thereatment front, phmacologicatreatm the new emphasis on treatment matching

effehas led to varietynt, of efforts phmacologicatreatm including group alternatives to alcoholics anonymous, such as is sos, secular organizations for sobriety, meeting. sos believes in separating religion from recovery. finally, prevention. 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 crses in safe dring, willome anda fare in classrooms across the country. on this subject, mo experts do agree in 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. captioningerrmed b thnational ctiing ite, inc. captions copyright 1991 alvin h. perlmutter

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