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 Related pblems 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 use of drugs; and then, of course the Mental Illness that appears to result also from prolonged drug use or even sometimes shortterm drug use. The populations that are most affected are poor populations and minority populations. Narrator 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. Youre trying to get out of yourself and into the plane of not caring, or not having to care, or youre trying to just skip out on life. And thats 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 counterintuitive. It appears that people are doing things that are producing bad effects for themselves. Thats one of the very confusing things about trying to understand addictions. Why do people appear to be engaging in selfdestructive 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 isnt clear. But when we look more closely at the behavioral pharmacology or the biology of addiction, we see that theres 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 brains pleasure chemical. Its 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 dont 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 theyre 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 thats being transmitted genetically from family to family. When you look at certain family complexes, you see these multigenerational, multiaffected 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 nonalcoholics. 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 cotwin is more likely to be a heavy drinker. And that suggests that its the same genes that are involved in smoking and alcohol drinking just being expressed differently in different people. So this cooccurrence may represent a general vulnerability factor that may be reflected in personality characteristics that are genetically determined. People with family histories, people with comorbid psychiatric disorders are at higher risk. Psychological distress, another emotional illness, depression anxiety are highly associated with drug use. Ive never met anybody who is abusing anything, and doesnt have some small, underlining Mental Health issue. Because before you picked up the first drink, you probably didnt feel good about yourself, or before you tooted or even smoked the first cigarette. Low selfesteem takes you low, you dont feel good about yourself you feel different. And thats one of the characteristics of most addicts. Narrator environment is also an important element in determining the risk for addiction. Dr. Mccaul because its not like other geneticallyaffected illnesses that will express, to some extent independently of the persons 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 dont expose themselves to the agent at risk, to the alcohol or to the drug, theyll 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 ive seen this also in the california mexicanamerican, texas theres 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 nondrugs. But theres 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. Thats the equivalent of two or three sodas, or maybe one or two cups of coffee. Because the drug is so readily available, it doesnt produce a big problem. So its an example of a well tolerated, widespread drug of dependence thats 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 doesnt 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 happens when you disturb this receptor by smoking marijuana. Its 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. Thats harder to tease out if that was marijuana or some other factor. Narrator comped t, are more obvious, acss all popations 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. Theyll feel energized, awake, alert, excited. Theyll 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 im 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 wasnt 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 theyre very acute. They come on rapidly, and, depending on how you administer it, theyll 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. Weve 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 peoples 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 its 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 its injected, theres 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 selfadministering it in sterile ways. So theyre very highrisk of infection. Narrator people who are not caught in the web of addiction have a hard time understanding its power and depth. Its 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, dont stop this drug. We can recognize that, because in Animal Studies animals will tend to selfadminister the same drugs that humans selfadminister and abuse. So we dont need to think that theres 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. Youre trying to get out of yourself and into the plane of not caring or not having to care or youre trying to just skip out on life. You dont want to do it this way anymore. Lets just get high. It takes a lot of intervention to get you off that plane. Narrator one reason its 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 cant 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 drugfree existence. To ask people to taper from their drug of choice or substance of choice isnt successful, because if they could do that, they certainly wouldnt need medical treatment. So what we ask them, is can we give you a substance similar or crosstolerant, 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 theyre 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. Theyre very, very effective. Because of what is often a pharmaceutical focus upon the development of treatments, its 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. Thats a combination of several therapies, but we help treat people or help teach people what. The triggers are, what leads them to crave. And its 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 dealers house, i have no clue how, theres some brain chemistry evidence that thats the case, that the anticipation is creating a state of reward; they dont 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 thoughtstopping . Stop those thoughts. How do you learn internal states . And for many people, those are subtle things that they dont even appreciate that drive their drug use. So relapse prevention is an important tool. Even if we wanted to get better, and say dont even have alcohol near where people cannot drink responsibly, you can leave outreachs front door and across the street is a liquor store. So its really that hard job of making people get secure enough to be able to survive in an area thats 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, theres literature suggesting that people who try to quit smoking, after they try about seven to ten times, theyre more likely to succeed. So something happens in the process where they learn what its going to take to really abstain from cigarettes. You cannot beat up people because they relapsed. I dont like that word. Relapsed to us, means that you returned to drug use. Oops, you slipped. Oh, you know, he had a relapse. Its all so negative. Why dont we say, no, he just hasnt learned to recover yet. Hell get it. Hell get it. Come on, we can start over. Individuals who simply believe theyre going to proceed on willpower and dont anticipate the specific risk theyre going to face, and develop strategies for coping with those risks are much more vulnerable to relapse than individuals whove 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 ive seen that in other people, and ive seen that in myself. Narrator often overlooked is the role families play in the cycle of addiction. There are definitely dos and donts for families. Those dos and donts are often difficult to see when theyre in the middle of coping with someone with addictive disorder. Thats why i think getting help is so important. Do you not give them any money and they threaten theyll go out and live on the street, or worse, kill themselves . Do you give them money and chances are, theyll use it for drugs or alcohol . Its easy to say, oh, that familys 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 o