Alcohol Abuse and Chemical Dependencies

What is alcoholism?

Alcoholism is also known as "alcohol dependence." It is a disease that includes alcohol craving and continued drinking despite repeated alcohol-related problems, such as losing a job or getting into trouble with the law. Alcoholism includes four symptoms:

Craving--A strong need, or compulsion, to drink.

Impaired control--The inability to limit one's drinking on any given occasion.

Physical dependence--Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, when alcohol use is stopped after a period of heavy drinking.

Tolerance--The need for increasing amounts of alcohol in order to feel its effects.

Why is alcoholism now considered a disease?

Alcoholism is now accepted as a disease. It is a chronic and often progressive disease. Like many diseases, it has symptoms that include a strong need to drink despite negative consequences, such as serious job or health problems. Like many diseases, it has a generally predictable course and is influenced by both genetic (inherited) and environmental factors.

Is alcoholism inherited?

Yes. Alcoholism tends to run in families and genetic factors partially explain this pattern. The genes that influence the vulnerability to alcoholism are under investigation.

Is alcoholism an environmental disease?

Yes. A person's environment, such as the influence of friends, stress levels, and the ease of obtaining alcohol, may influence their drinking and the development of alcoholism. Still other factors, such as social support, may help to protect even high-risk people from alcohol problems.

Can I have 100% (or zero) risk for alcoholism?

Risk is not destiny. A child of an alcoholic parent will not automatically develop alcoholism. A person with no family history of alcoholism can become alcohol dependent.

If alcoholism is a disease, can it be cured?

Not yet. Alcoholism is a treatable disease, and medication has also become available to help prevent relapse, but a cure has not yet been found. This means that even if an alcoholic has been sober for a long time and has regained health, he or she may relapse and must continue to avoid all alcoholic beverages.

What medications are there for alcoholism?

Two different types of medications are commonly used to treat alcoholism. The first are tranquilizers called benzodiazepines (e.g., Valium and Librium), which are used only during the first few days of treatment to help patients safely withdraw from alcohol.

A second type of medication is used to help people remain sober. A recently approved medicine for this purpose is naltrexone (ReVia TM). When used together with counseling, this medication lessens the craving for alcohol in many people and helps prevent a return to heavy drinking. Another, older medication is disulfiram (Antabuse), which discourages drinking by causing nausea, vomiting, and other unpleasant physical reactions when alcohol is used.

Does alcoholism treatment work?

Treatment is effective in many, but by no means all, cases of alcoholism. Studies show that a minority of alcoholics remain sober 1 year after treatment, while others have periods of sobriety alternating with relapses. Still others are unable to stop drinking for any length of time. Treatment outcomes for alcoholism compare favorably with outcomes for many other chronic medical conditions. The longer a person abstains from alcohol, the more likely that person is to remain sober.

What if there is a relapse?

It is important to remember that many people relapse once or several times before achieving long-term sobriety. Relapses are common and do not mean that a person has failed or cannot eventually recover from alcoholism. If a relapse occurs, it is important to try to stop drinking again and to get whatever help is needed to abstain from alcohol. Ongoing support from family members and others can be important in recovery.

Does someone have to be alcoholic to have problems from alcohol?

No. Even if you are not alcoholic, abusing alcohol can have negative results, such as the failure to meet major work, school, or family responsibilities because of drinking, alcohol-related legal trouble, automobile crashes due to drinking, and a variety of alcohol-related medical problems. Under some circumstances, even moderate drinking can cause problems--for example, when driving, during pregnancy, or when taking certain medicines.

How common is alcoholism in the U.S.?

It is estimated that 14 million people in the United States -- 1 in every 13 adults -- abuse alcohol or are alcoholic.

Are certain groups of people more likely to develop alcohol problems than others?

More men than women are alcohol dependent or experience alcohol- related problems. Rates of alcohol problems are also highest among young adults ages 18-29 and lowest among adults 65 years and older. Among major U.S. ethnic groups, rates of alcoholism and alcohol- related problems vary.

How can you tell whether you (or someone close to you) has an alcohol problem?

A good first step is to answer the brief questionnaire below. (To help remember these questions, note that the first letter of a key word in each question spells "CAGE"):
Have you ever felt you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

One "yes" answer suggests a possible alcohol problem. More than one "yes" answer means it is highly likely that a problem exists.

If I have trouble with drinking, can I simply reduce my alcohol use without stopping altogether?

That depends. If you are diagnosed as an alcoholic, the answer is "no." Studies show that nearly all alcoholics who try to merely cut down on drinking are unable to do so indefinitely. Instead, cutting out alcohol (that is, abstaining) is nearly always necessary for successful recovery. However, if studies show that you are not alcoholic but have had alcohol-related problems, you may be able to limit the amount you drink. If you cannot always stay within your limit, you will need to stop drinking altogether.

If an alcoholic is unwilling to seek help, is there any way to get him or her into treatment?

This can be a challenging situation. An alcoholic cannot be forced to get help except under certain circumstances, such as when a violent incident results in police being called or following a medical emergency. This doesn't mean, however, that you have to wait for a crisis to make an impact. Based on clinical experience, many alcoholism treatment specialists recommend the following steps to help an alcoholic accept treatment:

Stop all rescue missions. Family members often try to protect an alcoholic from the results of his or her behavior by making excuses to others about his or her drinking and by getting him or her out of alcohol-related jams. It is important to stop all such rescue attempts immediately, so that the alcoholic will fully experience the harmful effects of his or her drinking--and thereby become more motivated to stop.

Time your intervention. Plan to talk with the drinker shortly after an alcohol-related problem has occurred--for example, a serious family argument in which drinking played a part or an alcohol- related accident. Also choose a time when he or she is sober, when both of you are in a calm frame of mind, and when you can speak privately.

Be specific. Tell the family member that you are concerned about his or her drinking and want to be supportive in getting help. Back up your concern with examples of the ways in which his or her drinking has caused problems for both of you, including the most recent incident. State the consequences. Tell the family member that until he or she gets help, you will carry out consequences--not to punish the drinker, but to protect yourself from the harmful effects of the drinking. These may range from refusing to go with the person to any alcohol-related social activities to moving out of the house. Do not make any threats you are not prepared to carry out.

Be ready to help. Gather information in advance about local treatment options. If the person is willing to seek help, call immediately for an appointment with a treatment program counselor. Offer to go with the family member on the first visit to a treatment program and/or AA meeting.

Call on a friend. If the family member still refuses to get help, ask a friend to talk with him or her, using the steps described above. A friend who is a recovering alcoholic may be particularly persuasive, but any caring, nonjudgmental friend may be able to make a difference. The intervention of more than one person, more than one time, is often necessary to persuade an alcoholic person to seek help.

Find strength in numbers. With the help of a professional therapist, some families join with other relatives and friends to confront an alcoholic as a group. While this approach may be effective, it should only be attempted under the guidance of a therapist who is experienced in this kind of group intervention.

Get support. Whether or not the alcoholic family member seeks help, you may benefit from the encouragement and support of other people in your situation. Support groups offered in most communities include Al-Anon, which holds regular meetings for spouses and other significant adults in an alcoholic's life, and Alateen, for children of alcoholics. These groups help family members understand that they are not responsible for an alcoholic's drinking and that they need to take steps to take care of themselves, regardless of whether the alcoholic family member chooses to get help.

What is a safe level of drinking?

Most adults can drink moderate amounts of alcohol -- up to two drinks per day for men and one drink per day for women and older people -- and avoid alcohol-related problems. (One drink equals one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits.)

Who should not drink at all?

Certain people should not drink at all. They include women who are pregnant or trying to become pregnant; people who plan to drive or engage in other activities requiring alertness and skill; people taking certain medications, including certain over-the-counter medicines; people with medical conditions that can be worsened by drinking; recovering alcoholics; and people under the age of 21.

Is it safe to drink during pregnancy?

No. Drinking during pregnancy can have a number of harmful effects on the newborn, ranging from mental retardation, organ abnormalities, to hyperactivity and learning and behavioral problems. Moreover, many of these disorders last into adulthood. While we don't yet know exactly how much alcohol is required to cause these problems, we do know that they are 100% preventable if a woman does not drink at all during pregnancy. Therefore, for women who are pregnant or are trying to become pregnant, the safest course at present is to abstain from alcohol.

As people get older, does alcohol affect their bodies differently?

Yes. As a person ages, certain mental and physical functions tend to decline, including vision, hearing, and reaction time. Moreover, other physical changes associated with aging can make older people feel "high" after drinking fairly small amounts of alcohol. These combined factors make older people more likely to have alcohol- related falls, automobile crashes, and other kinds of accidents. In addition, older people tend to take more medicines than younger persons, and mixing alcohol with many over-the-counter and prescription drugs can be dangerous, even fatal. Further, many medical conditions common to older people, including high blood pressure and ulcers, can be worsened by drinking. Even if there is no medical reason to avoid alcohol, older men and women should limit their intake to one drink per day.

Does alcohol affect a woman's body differently from a man's body?

Yes. Women become more intoxicated than men after drinking the same amount of alcohol, even when differences in body weight are taken into account. This is because women's bodies have proportionately less water than men's bodies. Because alcohol mixes with body water, a given amount of alcohol becomes more highly concentrated in a woman's body than in a man's. That is why the recommended drinking limit for women is lower than for men.

In addition, chronic alcohol abuse takes a heavier physical toll on women than on men. Alcohol dependence and related medical problems, such as brain and liver damage, progress more rapidly in women than in men.

Is alcohol good for your heart. Is this true?

Several studies have reported that moderate drinkers -- those who have one or two drinks per day -- are less likely to develop heart disease than people who do not drink any alcohol or who drink larger amounts. Small amounts of alcohol may help protect against coronary heart disease by raising levels of "good" HDL cholesterol and by reducing the risk of blood clots in the coronary arteries.

If you are a nondrinker, you should not start drinking only to benefit your heart. Protection against coronary heart disease may be obtained through regular physical activity and a low-fat diet. And if you are pregnant, planning to become pregnant, have been diagnosed as alcoholic, or have any medical condition that could make alcohol use harmful, you should not drink.

For those who can drink safely and choose to do so, moderation is the key. Heavy drinking can actually increase the risk of heart failure, stroke, and high blood pressure, as well as cause many other medical problems, such as liver cirrhosis.

If I am taking over-the-counter or prescription medication, do I have to stop drinking?

Possibly. More than 100 medications interact with alcohol, leading to increased risk of illness, injury and, in some cases, death. The effects of alcohol are increased by medicines that slow down the central nervous system, such as sleeping pills, antihistamines, antidepressants, anti-anxiety drugs, and some painkillers. In addition, medicines for certain disorders, including diabetes and heart disease, can be dangerous if used with alcohol. If you are taking any over-the-counter or prescription medications, ask your doctor or pharmacist whether you can safely drink alcohol.

This article incorporates information provided by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), one of 18 institutes that comprise the National Institutes of Health (NIH), the principal biomedical research agency of the U.S. Government.

Alcohol Fact's

• Alcohol is a depressant: It slows the body's processes.
• Alcohol is the most abused drug in the world.
• The average age for people to start drinking in the United States is 12.9 years.
• Drunk-driver crashes are the #1 cause of death for 15-24 year olds in the U.S.
• 80.7% of high school seniors have used alcohol.
• 52.5% of high school seniors have been drunk in their lifetime.
• 1 in 4 eighth graders have been drunk in their lifetime.
• 1 in 4 high school students drinks in quantities and with a frequency that indicates a problem.
• 1 in 4 children in every classroom lives in a home where someone is chemically dependent.
• Almost half of all high school seniors (48%) have used illicit drugs in their lifetime.

Alcohol Abuse and Alcoholism At A Glance
Alcoholism is a very common disease.
Alcohol abuse affects 1 in 13 U.S. adults.
Alcoholism involves physical dependence.
Alcoholism is a treatable, but not a curable disease.

Alcohol abuse and alcohol dependence are not only adult problems, they also affect a significant number of adolescents and young adults between the ages of 12 and 20, even though drinking under the age of 21 is illegal.

The average age when youth first try alcohol is 11 years for boys and 13 years for girls. According to research by the National Institute on Alcohol Abuse and Alcoholism, adolescents who begin drinking before age 15 are four times more likely to develop alcohol dependence than those who begin drinking at age 21.

It has been estimated that over three million teenagers are out-and-out alcoholics. Several million more have a serious drinking problem that they cannot manage on their own. The three leading causes of death for 15 to 24 year-olds are automobile crashes, homicides and suicides alcohol is a leading factor in all three. Dependence on alcohol and other drugs are also associated with psychiatric problems such as depression, anxiety, oppositional defiant disorder, or antisocial personality disorder. Teenagers and drugs and alcohol will be discussed more in detail later in this training.

The most common and effective way for an individual to combat his or her addictive behaviors is through a self-help support group, with advice and support from a health care professional. Treatment should also involve family members because family history may play a role in the origins of the problem and successful treatment cannot take place in isolation.

Alcohol Dependency
Alcohol is a potent nonprescription drug sold to anyone over the national legal drinking age. This drug is a tranquilizer and a member of the family of sedative-hypnotic drugs. Temperate and occasional users of alcohol who are in normal health do not appear to suffer negative effects from use of alcohol.

Consumed in substantial amounts, alcohol's toxicity may be because it acts as a foreign substance in the body's metabolism. The short-term expression of this toxicity is felt as a hangover. The long-term toxicity may develop into alcoholism and alcohol-related diseases such as cirrhosis. Unlike carbohydrates, fats, and proteins, which can be manufactured by the body, alcohol is an introduced substance that is not synthesized within the body. It is a food because it supplies a concentrated number of calories, but it is not nourishing and does not supply a significant amount of needed nutrients, vitamins, or minerals-these are empty calories.

Most foods are prepared for digestion by the stomach so that their nutrients can be absorbed by the large intestine, but 95 percent of alcohol is absorbed directly through the stomach wall or the walls of the duodenum and the small intestine.

The drinker's physical and emotional state (fatigue, stress) and individual body chemistry unpredictably affect absorption. Alcohol moves from the bloodstream into every part of the body that contains water, including major organs like the brain, lungs, kidneys, and heart, and distributes itself equally both inside and outside of cells. Only 5 percent of alcohol is reduced from the body through the breath, urine, or sweat; a larger portion is oxidized or broken down in the liver.

Drinking while Pregnant
Many women quit using alcohol when they find out they are pregnant, even if they are heavy or problem drinkers. This is especially true if they find out they're pregnant in their first trimester. This is often a "teachable moment". If we say the right things in the right way to women at this moment, we can really increase the numbers who will quit drinking. And for those who don't make changes at the teachable moment, it is nevertheless important to engage them as early as possible and take advantage of opportunities later on in their pregnancies to quit or reduce use. There are many ways to do this, so it's important not to feel hopeless or helpless.

Women need accurate information. Many women are given incorrect information about the effects of alcohol and other drugs. This misinformation can come from anywhere - physicians, other helping professionals, friends, or family. For example, many women will say that their friends or families told them it was OK to drink beer during pregnancy because it helps with breastfeeding later on. And their friends have the proof of their own healthy babies to show for it. It's important to understand this, because it helps service providers to adopt a more non-judgmental attitude. It helps to understand that pregnant women aren't necessarily using alcohol because they're irresponsible, but because they might not have accurate information.

Many factors can lead to negative birth outcomes, including poverty, malnutrition, domestic violence, and other negative life events. Pregnant drinkers want to be treated within the context of their whole lives, not just as a pregnant person. It is important to be conscious of the precarious situations in which many pregnant women find themselves and try to address as many of these concerns as possible. The main barriers to seeking treatment reported by pregnant women with substance use issues are: shame, fear of prejudicial treatment, feelings of depression and low self-esteem, the belief or hope that they could change without treatment, not having enough information about available treatment services, waiting lists at treatment agencies, and fear of child welfare services. Where these barriers are in place, it's not surprising that the consequences are often lies to service providers and physicians, avoidance of prenatal care, avoidance of addiction treatment, and apprehension of children.

On the other hand, the top support systems reported by pregnant women with substance use issues are: supportive professionals, supportive family members, supportive friends/recovery group members, children as motivators to get help, and health problems as motivators. Women also say that they appreciate approaches that are holistic, that don't assume that the woman has the sole responsibility for the health of her child, and that address the contextual issues (such as poverty or violence) that make a pregnant woman's life more challenging. The challenges for good practice, then, are to ensure a holistic approach, to provide safety within addictions treatment, and to eliminate barriers to treatment.

It is not necessary to be an addictions expert to help women with substance use problems. Fear prevents many service providers from asking questions about alcohol or other substance use. You might be afraid that you're not an expert in addictions so you don't have the skills to ask. However, substance use counseling is exactly like any other kind of counseling - good, motivational counselors are empathic, non-judgmental, good listeners, and able to give neutral advice. Unfortunately, there has been an historic perspective in addictions counseling that has not supported these basic counseling skills and until the last decade, harmful, confrontational styles have dominated the field. However, research and practice have shown that it is empathic, basic counseling skills - skills you already possess - that are the most effective ones in helping people with substance use issues.

You might also be afraid to ask questions because you think the woman will be angry with you. However, if you ask questions about alcohol use in a completely matter-of-fact way, you are very unlikely to get this response. Your attitude will usually dictate a woman's reaction. If she perceives you to be a fair and open person, the chances are much better that she will be open with you.

You may also be reluctant to ask questions about substance use because you don't know what you would do if you got a positive response: the importance of two things can't be over-emphasized; don't over-react and don't feel overwhelmed. Anyone can suggest some small steps a pregnant woman can take and sometimes these small steps are all that's required. This section provides a number of ideas to support you.

Provide basic FAS (Fetal Alcohol Syndrome) education and information about the prenatal risks of alcohol and drug use to all program participants.

Use client-focused women-centered approaches and principles as the framework or organizing factor for client identification, assessment, counseling, and education.

Provide counselors with basic practical addiction counseling training.

Involve Clients in Program Planning, Implementation and Evaluation

Policies with respect to "client confidentiality" and "sharing of information" should be clear, understood by the counselor, and communicated to the client.

Each of these points will be discussed in more detail below.

The Program will effectively engage and identify prenatal substance-using women by:

Provide basic FAS (Fetal Alcohol Syndrome) education and information about the prenatal risks of alcohol and drug use to all program participants.

Clients will be engaged in education and discussion about Fetal Alcohol Syndrome, alcohol and drug-related birth defects, use of alcohol and other drugs during pregnancy. Whenever possible the client's partner or significant others will be included. Posters will be displayed and used as teaching tools, and low literacy culturally sensitive pamphlets will be provided.

Use client-focused women-centered approaches and principles as the framework or organizing factor for client identification, assessment, counseling, and education.

Provide counselors with basic practical addiction counseling training

This training can be found in different ways in different communities. Developing formal partnerships with the alcohol and drug program providers in your community will be a definite asset in terms of accessing training opportunities. Once you have established a formal relationship, ask to have your counselors included in their training. They will often provide "in-kind" training to other "allied" outreach workers and professionals in the community. Or, invite an alcohol and drug counselor from your community to provide in-house staff training for your counseling team. In return you can offer training to their staff in areas of expertise from your agency.

Involve Clients in Program Planning, Implementation and Evaluation

Whenever possible create opportunities for participants involved in program activities to participate in the planning, implementation and evaluation of activities. Hold client focus sessions to brainstorm ways of improving service delivery. Make it fun (pizza party) and acknowledge the importance of their feedback. Respond by realigning the program to meet the needs that participants express.

Collect individual client feedback. Ask for clients' response as to what they like about the program and what they would like the program to do differently. Provide index cards and a box to ensure anonymity. For each entry have participants fill out an entry to a draw for some kind of incentive (or points) to acknowledge their contribution.

Encourage clients to participate in the program by volunteering. Provide opportunities for them to gain confidence and skills. Ask participants who show leadership in a cooking club to prepare recipes, food, or shop for a session. Encourage clients to lead a peer support group session, make phone calls to participants, or to bring a snack from home.

Mentor women who have been active and shown leadership and growth in support groups by inviting them to attend community workshops to further their knowledge and skills. Provide opportunities and support them in telling their story to other individuals or groups of women or front-line workers in the community.

In all cases ensure that participants are compensated in formal ways, recognized for their contribution, acknowledged and honored. This is a powerful achievement for them and equally important in grounding and sustaining growth of communities to meet the needs of women and families.

Policies with respect to "client confidentiality" and "sharing of information" should be clear, understood by the counselor, and communicated to the client. It is important for the counselor to be honest and open with the client. Records should be written with the expectation that the client will read them. The client should be advised during her intake interview that information she provides will be shared with other agencies only for the purpose of continuity of care when there is a reasonable and direct connection between the services. She should be told which agencies she could expect the information to be shared with and all reasonable efforts should be made to have her release the information herself or to obtain her consent before releasing the information.

Having the client sign a consent to exchange information provides the counselor with a formal opportunity to answer questions about how the information will be used. At this time, the client can be involved in her care by providing the contact names of others who could be active in collaborative case management (client's partner/parent, mental health therapist, teacher, home support worker).

Policies must be consistent with the acts and codes of state and national governing policies. Protect client records by keeping them in locked cabinets or drawers.

Program goals should include specific objectives addressing substance use during pregnancy. For example: To decrease the number of alcoholic drinks consumed by pregnant women who drink, to decrease the incidence of binge drinking, to maintain the decrease throughout the pregnancy and to encourage and support abstinence. To reduce drug use to only those drugs approved by a physician.

All clients should be screened with a questionnaire or interview to identify women at risk for alcohol and drug abuse problems. To gather further information from those women considered at risk or potential risk based on screening, by undertaking a comprehensive holistic assessment for planning and management.

Good Practice: Accepting that women may not be able to quit but can reduce harm. A harm reduction approach involves supporting people in making whatever change is possible in their use of alcohol and/or other drugs, and/or changes in behaviors related to their use, so that harm to themselves and to others is reduced.

In this context it has definite applicability in the prevention of FAS. Since we do not know a safe level of alcohol use in pregnancy, it has always been recommended that women not drink before or during this period and while breast-feeding. However, with an abstinence approach, we may "drive away", "turn off" or otherwise not reach many of the women at highest risk of having a child affected by FAS - women who are still using alcohol and other drugs, who have significant problems with their use and have difficult lives. Such women will respond best to flexible support when it is not conditional on abstinence.

Alcohol Effects on a Fetus

What effect does alcohol have on a fetus? Alcohol use during pregnancy may damage a developing fetus. The possibility, extent, and type of damage depends on the amount of alcohol use; the frequency of use; and the fetus's genetic susceptibility and stage of development. Heavy alcohol use (5 or more drinks on one occasion) during pregnancy can cause a child to have growth retardation, facial abnormalities, birth defects, mental retardation, or behavior and learning problems. Lesser amounts of alcohol use during pregnancy may cause any combination of these effects to a milder degree.

Heavy alcohol use during pregnancy can also lead to miscarriage, premature delivery, or stillbirth.

What is the range of alcohol effects?

Children with the most severe effects are said to have fetal alcohol syndrome (FAS) or fetal alcohol abuse syndrome (FAAS). These children have characteristic facial features (a small face, narrow eye openings, a short upturned nose, a flattened groove between the nose and the upper lip, and a thin upper lip), growth retardation, and mental and behavioral problems (central nervous system effects). They may also have birth defects that involve the eyes, ears, heart, urinary tract, or bones. Children with less severe effects from alcohol exposure during fetal development may have one or a combination of these characteristics to a milder degree.

Some experts use the term fetal alcohol spectrum disorder (FASD) to include all categories of alcohol effects on a fetus.

How does alcohol cause these effects?

When a pregnant woman drinks alcohol, the alcohol passes from her blood into the fetus. Large amounts of alcohol may damage fetal cells, especially those of the central nervous system. The exact way alcohol causes the damage is not known. From magnetic resonance imaging (MRI) and computed tomography (CT) scans of babies with alcohol effects, it appears that alcohol may target specific areas of the developing brain (Mattson, Schoenfeld, Riley).

If I drink during pregnancy, will my child have effects from alcohol? Not all fetuses exposed to alcohol have permanent effects from it. In the United States, about 1 to 2 babies out of 1,000 have fetal alcohol syndrome.

The possible effects on the fetus depend on the amount and frequency of drinking, and the fetus's genetic susceptibility and stage of development. For example, the first 3 months of pregnancy are a critical time for physical development of the fetus. Alcohol use during this time can lead to abnormal facial features and birth defects.

Smoking, poor health and nutrition, use of other drugs, and having had several pregnancies also increase the chances that use of alcohol will affect the fetus.

How much alcohol is safe to drink during pregnancy?

No amount of alcohol is considered safe to drink during pregnancy. An amount of alcohol or a specific time during pregnancy when it is safe to drink has not been identified.

When are alcohol effects on a fetus diagnosed?

A baby with severe alcohol effects (fetal alcohol syndrome) may be diagnosed at birth. Children with lesser alcohol effects may not be diagnosed until behavior or learning problems develop.

Can alcohol effects on a fetus be prevented? Alcohol effects on a fetus can be prevented by not drinking during pregnancy. Even one heavy drinking episode (5 or more drinks) during this time may harm your baby.

What is the treatment for my child with alcohol effects?

Treatment may include educational support, social skills training, vocational training, and counseling. Early identification, even if the alcohol effects are mild, gives each child the best opportunity to reach his or her full potential in life. Early diagnosis may help prevent school difficulties, legal problems, and mental health problems, such as alcohol or other substance abuse, depression, or anxiety.

The harm reduction approach emphasizes:

• Women's right to non-judgmental services
• Belief in the competency of women to make choices and changes in their lives and their substance use Reducing the harm arising from use, rather than focusing on the drug itself -- whether legal or illegal
• Involving the women and their communities in jointly coming up with strategies that will work
• Modifying our attitudes towards women who use, so we can truly provide non-judgmental caring assistance
• Getting over our urgency that she stop her use
• Providing advocacy and services to address her needs within a social context e.g., housing, child-care, transportation
• Staying hopeful

HARM REDUCTION

Range of Options/Approaches
"Using" <---------- Continuum ----------> "Non-using"

Harm reduction support to pregnant women includes:
To reduce (if they can't stop) their use of alcohol
To stop, or reduce the use of any or all other drugs being used with alcohol
To access good prenatal care and health care overall
To eat well during pregnancy
To reduce their stress and/or stabilize their living situation.

Caution: For pregnant women who are tolerant and dependent on alcohol, opiates and benzodiazepines, abrupt reduction or cessation of use is not recommended. Any reduction or cessation by a pregnant woman of use of alcohol, opiates or benzodiazepines should be done under the supervision of a physician familiar with withdrawal management.

Client-focused, women-centered approaches are based on principles that emphasize clients' strengths and empowerment. Each woman is the best expert on how to bring about change in her life. Focusing on their strengths helps clients see how they have managed to cope in difficult circumstances and how they might apply those strategies to other situations. A women-centered approach helps to create strategies and solutions that are appropriate to the lives of each woman. Clients are encouraged to work toward small changes that are realistic within the context of their everyday lives. It is as important (if not more important) to focus on the woman's process of positive change as it is to deliver education and support around reduction and cessation. Clients possess strengths that are sources of empowerment. Small goals are framed in a positive light by focusing on actions that clients can start doing rather than on what they should stop doing.

Empowering clients means "helping people discover the considerable power within themselves." (Saleebey, 1992)

Saleebey's empowerment "strengths perspective" is based on the following assumptions:
Despite life's struggles, all persons possess strengths to be marshaled to improve the quality of clients' lives.
Counselors must respect these strengths and the directions in which clients wish to apply them.
Client motivation is increased by a consistent emphasis on strengths as the client defines them.
Discovering strengths requires a process of cooperative exploration between clients and helpers.
Focusing on strengths turns counselors away from the temptation to judge or blame clients for their difficulties and toward discovering how clients have managed in the most difficult of circumstances.

Create a supportive environment
Establish the tone and setting for the client to feel comfortable in talking about her pregnancy and other personal issues. Women are generally relieved to be able to talk about personal issues when they feel safe, understood, and non-judged. "Normalizing" alcohol and drug use and the fears and anxieties of pregnant women is key to creating an open trusting relationship with a client.

Display information (poster and pamphlets) on alcohol and other drug use in your office
Have resources at your fingertips
Establish a comfortable and safe private physical environment where you may talk with the client
Be sensitive to culture and literacy issues
Explain openly to the client why you are asking particular questions and why the information is needed
Listen and respond to what the client is saying by reflecting back what you heard her say to see if that is what she meant
Focus on her strengths and what has helped her make changes in the past
Emphasize her power and freedom to make choices
Motivational Counseling; Key Elements
Demystify counseling; it is simply a respectful and sensitive way of talking.

The counselor and the client are partners in the process. This is a shift from "doing for" clients toward believing that clients are their own experts. Counselors work with clients in a partnership to establish goals that focus on coping, rather than attempting to "cure" clients' problems. It gives counselors a new level of confidence for addressing the overwhelmingly complex range of problems that clients often face. It is satisfying to work with a client and contribute to her growing self-awareness and empowerment.

Client-focused approaches of interviewing and talking with women allow for substance use issues to be addressed from a holistic perspective. Thus, the focus of support and intervention is not solely on substance use, but rather on a wide range of issues influencing her substance use including social, health, economic, and personal issues.

Key aspects of a motivational counseling approach:
responds to client resistance with reflection rather than confrontation;
promotes greater client awareness of and responsibility for problems with alcohol and works toward a commitment to change;
emphasizes personal choice regarding use and personal
control over decisions; avoids imposing the counselors' conclusions on the client;
supports client choices by removing barriers to change (such as, providing child care, transportation, and any other accessibility issues a woman might face);
avoids labels such as "alcoholic"; and,
accepts relapse as part of the process of change.

Benefits of using client-focused, women-centered approaches in discussing alcohol and drug use include:
Alcohol and drug use can be discussed in highly individualized ways.
A realistic harm reduction focus can be maintained within the context of women's lives.
Increased client self-awareness and small behavioral changes are considered successes.
Clients' life circumstances and behavioral changes are considered successes.
Increased confidence and skill levels for counselors in talking with women about alcohol and drug use and other complex personal issues facing clients.

Motivational Counseling: Skills and Techniques:

• Exploring for Exceptions
• Complimenting
• Coping Questions and What's Different?
• Reframing Language to the Positive

Exploring for Exceptions
This involves asking the client to think of a situation in which she expected to use alcohol/drugs, but for some reason she did not. Or, listening to the client talk about small changes she has made with respect to her use and helping her to recognize the significance of the small changes she has made and her potential for dealing effectively with difficult circumstances. Together you and the client then explore ways in which the client could try to repeat the behaviors, activities, feelings or thinking associated with the exceptions. These small exceptions often form the basis of strategies and solutions that have the potential to help the client reduce her alcohol use.

Complimenting
Complimenting the client affirms and recognizes the respect and confidence that you have for a client to make positive changes in her life. It is usually unexpected, as clients often don't perceive positive change until you bring it to their attention and awareness. They are overwhelmed by the full nature of the problem instead of recognizing small changes and successes.

Coping Questions and What's Different?
Used in follow-up with a client; ask her to describe what has been different with respect to her coping related to the issues you discussed last time. The question is purposely phrased in this way so that she is encouraged to focus on how she coped with difficult situations in the broader context of her life, rather than focusing on substance use. When she discusses her experiences, listen for unrecognized strengths and resources used by the client and reveal them to her. Compliment her. These thoughts, feelings and activities can then be explored further with a view to repeating them or applying them in different situations.

Reframing Language to the Positive
Using "positive reframing" - every attempt is made to assure that positive meanings are found and applied to what might be perceived as negative situations.

Examples of positive language?
"bumps along the road " ? instead of relapse
In terms of approach it is very important to alter one's thinking about relapse. Relapse in the traditional sense inferred a backward step and had negative connotations. Refer to a slip as a "hiccup" or a "bump on the road". Bumps are expected on any journey that you are on and they are not negative. "When you hit a bump, notice what is happening. You will learn something about yourself to help you carry on your journey." "rediscovery" ? instead of recovery

"signs of recovery" - refer to "signs of your body becoming drug-free or alcohol-free", instead of "withdrawal symptoms" from substance use.

Integrateing Client-Focused Counseling into Practice
Scenario:
Stacey is 26 years old. She has two children, six and three years old. She is a repeat client who was involved with the program during her last pregnancy. She is currently taking a full college course load; exams are pending and she is doing a student work experience.

She has just learned that on top of all this, she is pregnant, about seven weeks gestation. She describes the overwhelming stress and emotional conflict that she is experiencing. She has been in and out of a relationship for years with the same partner, though they have never really lived together. She says, "He is good to the kids, but we just can't live together." She has considered her options and has made a decision to carry on with the pregnancy. Stacey admits to having a long history of drinking alcohol daily. She states that "few people know about this? I guess you could say that I am a closet drinker." Additionally Stacey says she smokes 20 cigarettes a day. She noted, "I know I need to quit drinking and cigarettes now that I'm pregnant? I've done it before? I know I can do it ? but I've got a lot more on my plate this time!"

Stacey has volunteered her goal. "I know I can quit." She is also providing information that she is motivated to quit, "I know I can do it." And she has provided an exception, "I've quit before." Now the counselor's task is to work in partnership with Stacey. Compliment her. Use her own language in your discussions with her. Encourage her. Acknowledge her strength in sharing that she is a closet drinker and her worries about smoking and drinking during her pregnancy. Listen for exceptions that will tell you how she quit before and under what circumstances. Help her to rediscover those strengths and strategies by exploring solutions together.

Counselor
First, I admire your strength in telling me that you are a daily drinker when few people know about it. I'm really impressed by everything you have been telling me. You have made recent remarkable changes in your life. You left a relationship. You have returned to school. I admire your courage in setting yet another challenge for yourself to quit smoking and drinking. You say that you've quit before. Tell me more about that. What did you do in the past that you found helpful?

Stacey
During my first pregnancy I referred myself for Treatment. I knew I couldn't do it myself. But when I found out I was pregnant the second time I quit right away, cold turkey! But I didn't have near the stress then that I have now.

Counselor
Wow, so pregnancy is a really motivating time for you! What did you learn about in Treatment that you were able to quit cold turkey the last time you were pregnant?

Stacey
Well, I learned that I just needed to change my routine in the evenings. I would invite a friend over or go out for awhile. Then, if I was still tempted to drink, I would go to bed early.

Counselor
So, visiting with a friend and going out made a difference. How was that helpful to you?

Stacey
I guess it helped me keep my mind off drinking. At first it was really hard, but I knew I could never live with myself if my drinking harmed the baby in any way. After awhile I could even sit at home for an evening by myself and not miss it. I can remember how that surprised me!

Counselor
Tell me more about how it surprised you?

Stacey
I don't know. Maybe I was afraid that I wouldn't be able to do it on my own.

Counselor
It sounds like you've learned a lot about yourself and what you are capable of doing when you put your mind to it. What do you need to do now to get back on track?

Stacey
Well, I really messed up by getting back into my old patterns. Sometimes I don't even fix the kids and me a decent meal when I get home from school. Now that I'm pregnant I need to look after myself better again.

Counselor
What will you be doing differently when you are looking after yourself again?

Stacey
Well, for starters, I need to think about making a shopping list and buying food to have in the house to make proper meals for me and the kids.

Counselor
And how will that make a difference to you?

Stacey
Shopping and making a meal will keep me busy and I'll feel better by having something to eat? right now half the time I eat a bag of chips, study, drink a few beers and go to bed. I 'll stop at the grocery store on my way home today.

Counselor
It sounds like you know what you need to do to get back on track. This week watch for times when things are going better for you and take notice of what you are doing that is helpful. I'll see you next week.

Follow up session with Stacey one week later:

Counselor
Good to see you again. What's been happening differently with respect to your goal to get back on track by looking after yourself again?

Stacey
I quit drinking right after we talked a week ago and I haven't had a cigarette for the past two days.

Counselor
Wow, you really respond to personal challenges! When you left here last time you seemed really motivated to get back on track! Tell me what you have been doing differently since I saw you last?

Stacey
Well, I asked my work experience supervisor at school if I could lead the evening recreation programs at my children's school in the evenings to get work experience credit. So, I'm at programs 3 evenings a week. Monday is floor hockey, Wednesday is social club, and Friday is mixed gym night. It's been a little crazy arranging for the kids' Dad to come over to look after the kids, but it's been worth it. The other nights I made supper, cleaned up, studied and one night I went to bed at 8:30.

Counselor
Wow, you have been really creative in thinking of different ways of coping. You've made so many changes in such a short time. Tell me about how it has been for you? How have these changes made a difference to you?

Stacey
Well, the desire to quit has been there a long time. I want my kids to be proud of me. I felt guilty about my drinking and it isn't easy to smoke and work any more. Thinking about the health of the baby is the big motivator, but I want to stay quit after the baby this time! I want to get a good job and I need to keep healthy to balance the kids and working.

Counselor
I know it hasn't been easy for you. You show a lot of courage and strength. In the past week what have you done when confronted with situations where you had to fight the urge to drink or smoke?

Stacey
Actually, I did notice that it bothered me when my friends smoked around me outside at the college. I found myself leaving? (deep in thought)... I didn't realize it till now, but maybe I've been avoiding my friend. I thought about inviting her over to watch a video, but I changed my mind because she smokes.

Counselor
It's really helpful to notice situations like the one you have just described and notice what you do that is helpful. You may hit bumps along the road. That's only natural. Use the bumps to become aware of what you are doing that works and keep doing more of what is working for you. In the next weeks continue to notice what you are doing that is helping you look after yourself. I look forward to talking to you again next week to see how you are coping. Keep up the good work.

How do you ask about Substance Use?
Drinking and other drug use is common and is a normal part of many people's lifestyles. Routinely asking about alcohol and other drug use within the context of a client's prenatal health gives a woman permission to talk about a topic that she may find difficult or awkward to talk about with others. Asking a woman about her alcohol and drug use suggests that you believe substance use is a normal part of everyday life. By displaying this attitude you are "normalizing" the situation and it makes it easier for women who may have a problem to talk about it with you.

Explain that the questions you ask about substance-use are routine and asked of all clients.

You can ask substance use questions:
As part of your routine prenatal intake or assessment,
As part of a follow-up interview you have with the client,
When talking with a woman about life issues and how she copes with them.

Here are some approaches for asking questions. Substance use questions are best framed within the context of overall health. So in addition to asking about sleeping patterns and eating habits, it is quite appropriate to ask about consumption in this context. Open-ended questions are always better than closed ones. This means you will not ask "do you drink?" Rather, you would ask "how much do you drink?" From this simple beginning, you can get a wealth of information. If her response indicates that she does drink, then you can ask further probing questions such as "how much do you use daily or weekly?", "how long have you been doing this?", and "when did you have your last drink?"

Also, explore with the woman what she has heard about substance use during pregnancy. Remember that many women are given inaccurate information, either from professionals or from friends. A conversation about her experience can be very helpful in determining if she has received inaccurate information and correcting it. It would be helpful to be able to refer to good factual written information at this point. Sit down with the woman and review the relevant information and if possible, leave it with the woman. It takes time to digest new information and she will be able to review the facts in private and in her own time.

A "Timeline Followback" (see below) is a tool to explore past substance use that may be helpful in this circumstance. In a Timeline Followback, people simply review their substance use (amount and frequency) over a given period of time - say, in this case, since the woman found out she was pregnant - with the use of a calendar. People have remarkably accurate recall and it helps to identify patterns of use that can be linked to events in the woman's life or the progress of the pregnancy.

Alcohol Timeline Followback (TLFB)

The Alcohol TLFB is a drinking assessment method that obtains estimates of daily drinking and has been evaluated with clinical and non-clinical populations. Using a calendar, people provide retrospective estimates of their daily drinking over a specified time period, which can vary up to 12 months from the interview date. Several memory aids can be used to enhance recall (e.g., calendar- key date's serve as anchors for reporting drinking; standard drink conversion).

The Alcohol TLFB has been shown to have good psychometric characteristics with a variety of drinker groups and can generate variables that provide a wide range of information about an individual's drinking (e.g., pattern, variability, and magnitude of drinking). The method is recommended for use when relatively precise estimates of drinking are necessary, especially when a complete picture of drinking days (i.e., high and low risk days) is needed (evaluating drinking pre-post treatment). Although timeline summary data have been found to be generally reliable, as with all drinking assessment methods, exact day-by-day precision cannot be assumed or necessarily expected. Overall, the Alcohol TLFB method provides a relatively accurate portrayal of drinking and has both clinical and research utility

Sometimes helping professionals fall into the trap of asking questions about substance use only once. Then they heave a big sigh of relief and think "thank goodness, that's over with, I don't have to do that again." In fact, every interaction with a pregnant woman (regardless of whether or not she initially admitted use) should include questions about substance use - again in a matter-of-fact way - again framed within the overall context of her health. This is especially important for women who may have originally minimized their substance use: they need to know you are always able to hear about her substance use, if she decides to disclose later on in her pregnancy.

Remember the barriers to care - guilt, fear of being judged, and fear of losing the infant - but also remember that service providers are in a unique position to facilitate change. In fact, practitioner characteristics are one of the strongest motivators to change characteristics.

A screening instrument can be used alone, embedded in a general intake or as a part of a more comprehensive assessment of alcohol and drug use.

The TWEAK and T-ACE (see below) are two screening tools commonly used to identify risk of alcohol use during pregnancy.

Scenario:
Counselor:
"How many times did you drink alcohol on average every week before you knew that you were pregnant?"

Client:
"Generally, two times a week on the weekend at a party or in the bar with friends."

Counselor:
"At this point during your pregnancy, on average how many times do you drink alcohol each week?"

Client:
In almost every instance, the client will tell you that she is drinking less or on fewer occasions. The client is anticipating a lecture about the harm of drinking alcohol during pregnancy at this point. Instead, compliment her - "Wow, that's remarkable that you've made that much of a change in your drinking already! How have you done that?" She will be pleasantly surprised by this response. It is not how people traditionally approach it. Instead of judging her you are telling her how wonderful it is that she has made positive changes and listening carefully with respect to how she has made the changes. You are acknowledging that she is the expert in her life and that she knows what works for her. As quickly as the rapport will allow, you are focusing on solutions and positives rather than problems.

While she is talking, listen continually for positives and magnify them for her, bringing them to her awareness. Encourage her to practice doing more of what is working.

Follow up
In follow up, the next time you make contact with her, it is important not to refer exactly to the goals the client set for herself the last time you talked. You could be setting her up for immediate failure if she hasn't met any of her goals or put her on the defensive depending on your approach. Instead, what works well is to ask her to describe any situations where she was tempted to drink or when she drank alcohol since the last time you talked. For example:

Counselor:
"What's it been like coping with your goal to reduce drinking alcohol this past week? What have been your social supports?"

This will usually begin a dialogue that lets you better understand who and what is important to her, what is happening when she is drinking and with whom she drinks. You will get snapshots of her life, within her social context, providing useful information with which to develop creative individually tailored interventions for the client.
If she replies,

Client:
"Well, I haven't been able to cut down yet, but I know I have to for the sake of the baby."

Then the counselor can respond by acknowledging,

Counselor:
"I understand that it will take hard work and courage on your part to make changes with respect to your drinking. However, I sense that you are motivated to start thinking about ways that you can take some positive steps in the right direction. Have there been times in the past when you have cut back or quit drinking alcohol? What was that like for you? What were you doing differently during those times? What worked for you?"

This approach will build her sense of dignity and respect gives value to her efforts.

Client Focused Counseling
Skills Practice Guidelines

GUIDELINE	KEY WORDS	SAMPLE QUESTIONS
In the positive. Instead?	"Instead"	"What do you want?"
In a process form. This?	"How"	"How will you be doing this?"
In the here-and-now	"On track"	"As you leave here and you are on track, what will you be doing or saying differently that will tell you that you are on track?"
In specific terms.	"Specifically" "Helpful" "Better" "Differently"	"How specifically will you be doing this?" "What do you find helpful" "How will you know when things are getting better?" "What have you been doing differently to cope with the changes you've made?"
In client's control	"You"	"What will you be doing differently?'
In the client's language	(Use the client's language)

• What will you be doing instead of (smoking, drinking, using drugs)?
• How will you be doing this?
• How specifically will you be doing this?
• What will you be doing differently that will tell you that you are on track?
• What do you find is helpful?
• How will you be thinking differently?

Brief Screening tool: TWEAK TEST

This screening instrument is to be administered by the counselor as part of a general screening.

T	Tolerance: How many drinks does it take to make you feel high? (Record number of drinks) Score 2 points if she reports 3 or more drinks to feel the effects of alcohol. Score:____	No. of drinks ____
W	Worry: Have close friends or relatives worried or complained about your drinking in the past year? Score 2 points for a positive "yes". Score:____	____Yes ____ No
E	Eye-Opener: Do you sometimes have a drink in the morning when you first get up? Score 1 point for a positive "yes". Score:____	____Yes ____ No
A	Amnesia (Blackouts): Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? Score 1 point for a positive "yes". Score:____	____Yes ____ No
K(C)	Cut Down: Do you sometimes feel the need to cut down on your drinking? Score 1 point for a positive "yes". Score:____	____Yes ____ No
	Total Score = _____ A total score of 2 or more points indicates a likely drinking problem.

To score the test, a 7-point scale is used. The Tolerance and Worry questions each contribute 2 points, and the other three items contribute 1 point each. As indicated above, only one of the two Tolerance questions is asked. The Tolerance-high question scores 2 points if it is reported that three or more drinks are needed to feel high. The Tolerance-hold question scores 2 points if a respondent reports being able to hold six or more drinks.

A total score of 2 or more indicates that obstetric patients were likely to be risk drinkers (Russell et al. 1994). However, preliminary studies suggest that cut-points of 3 or 4 are better than 2 for identifying harmful drinking or alcoholism (Chan et al. 1993).

Source: Russel, Marcia, Martier, Susan S., Sokol, Rober J., Mudar, Pamela, Bottoms, Sidney, Jacobsen, Sandra & Jacobsen, Joseph (1994). Screening for Pregnancy Risk-Drinking. Alcoholism: Clinical and Experimental Research, 18 (5): 1156-1161.

Brief Screening tool: T-ACE

T-ACE is a measurement tool of four questions that are significant identifiers of risk drinking (i.e., alcohol intake sufficient to potentially damage the embryo/fetus).

The T-ACE is completed at intake. The T-ACE score has a range of 0-5. The value of each answer to the four questions is totaled to determine the final T-ACE score.

Note:
1 Drink
= 12 oz beer
= 12 oz cooler
= 5 oz wine
= 1 mixed drink (1.5 oz. hard liquor)

Binge (drinking) = consuming 5 or more alcoholic drinks on an occasion

A total score of 2 or greater indicates potential risk for the purposes of Pregnancy Outreach Program identification of prenatal risk.

1. How many drinks does it take to make you feel high? less than or equal to 2 drinks more than 2 drinks	Tolerance
2. Have people annoyed you by criticizing your drinking? No Yes	Annoyance
3. Have you felt you ought to cut down on your drinking? No Yes	Cut Down
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? No Yes	Eye Opener
Total Score = _____

Source:
Sokol, Robert J., "Finding the Risk Drinker in Your Clinical Practice" in G. Robinson and R. Armstrong (eds), Alcohol and Child/Family Health: Proceedings of a Conference with Particular Reference to the Prevention of Alcohol-Related Birth Defects. Vancouver, BC., December, 1988.

Alcohol and Drug Assessment Questionnaire

Caffeine How much of each of the following substances do you consume in a day? (greater than 400 mg/day = potential prenatal risk)

Substance	Pre-pregnancy	At intake
Coffee: - Perc - Drip - Instant	Daily consumption in cups ___ cups x 110 mgs = _____ mgs ___ cups x 145 mgs = _____ mgs ___ cups x 75 mgs = _____ mgs	Daily consumption in cups ___ cups x 110 mgs = _____ mgs ___ cups x 145 mgs = _____ mgs ___ cups x 75 mgs = _____ mgs
Tea - Regular - Herbal	Daily consumption in cups ___ cups x 65 mgs = _____ mgs ___ cups x 0 mgs = __0__ mgs	Daily consumption in cups ___ cups x 65 mgs = _____ mgs ___ cups x 0 mgs = __0__ mgs
Cola	___ cans x 35 mgs = _____ mgs	___ cans x 35 mgs = _____ mgs

Smoking

When was the last time you smoked cigarettes, if ever?
___ Never smoked
___ Within the last 2 weeks
___ Within the last month
___ Within the last 3 months
___ Within the last 6 months
___ Within the last year
___ Over 1 year ago

Before you were pregnant, how many cigarettes, on average, did you smoke in a week? _____
How many cigarettes, on average, did you smoke last week? (at prenatal intake) _____

Alcohol

When was the last time you drank alcohol, if ever?
___ Never drank alcohol
___ Within the last 2 weeks
___ Within the last month
___ Within the last 3 months
___ Within the last 6 months
___ Within the last year
___ Over 1 year ago

Before you were pregnant, how many times (occasions) did you drink alcohol each week? ____; each month? ____
On average, how many drinks did you have on an occasion? _____

Is there any history of abuse of alcohol by any of the following family members?
___ Biological mother
___ Biological father
___ Spouse/partner
___ Brother/sister
___ None apply

Have you had any treatment for alcohol use?
___ Yes: Where? _________________________________________
___ NO: When? ________________

What is your understanding of the possible effects that drinking alcohol may have during pregnancy? (Fetal Alcohol Syndrome)?

Drugs

When was the last time you used drugs, if ever?
___ Never used drugs
___ Within the last 2 weeks
___ Within the last month
___ Within the last 3 months
___ Within the last 6 months
___ Within the last year
___ Over 1 year ago

Before you were pregnant, how many times (occasions), on average, did you use drugs each week? ____; each month? ____

In the past week, how many times did you use drugs? ____ (at intake)

Have you had any treatment for drug use?
___ Yes: Where? _________________________________________ ___ No: When? ___________________________________________

Drugs Used (check all that apply)

Drug	Within 2 weeks	Within 1 month	Within 6 months	Within 1 year	Over 1 year ago
Marijuana/THC
Crack/Cocaine
Cocaine (IV)
LSD/Acid
Heroin (IV)
Heroin (other)
Tylenol/Codeine (T 3's)
Barbiturates and other tranquillizers
Other tranquillizers
Inhalants
Other (specify): ________________ ________________

Prenatal Alcohol Screening - Follow-up

If the client does not have an alcohol use problem, no further action is needed with respect to alcohol use. She may not use alcohol at all or seldom and drinks only one or two drinks on an occasion. Screening for drug use is recommended. Take the opportunity to reinforce her current practices for safe or low-risk drinking and discuss her ways of coping and risks of second-hand cigarette or marijuana smoke during pregnancy.

Provide basic FAS Education to every client
Give basic information about FAS and fetal alcohol and drug-related birth defects. If she says, "I don't need to know about this because I'll never drink when I'm pregnant", ask her to be an ambassador and supportive to other women in the community by sharing the information with friends and family.

Ask clients about their understanding of Fetal Alcohol Syndrome, or alcohol and drug-related birth defects. Dispel any myths. Most women will name learning disabilities, health problems; mention that there is something different about the facial appearance of those affected by FAS. Often they will tell you a story about someone they know who is fetal alcohol affected. Rarely do they identify "brain damage" as a consequence. This presents an opportunity for dialogue about the life-long effects and irreversible nature. A teaching resource that has real impact is a photograph of a "normal fetus brain compared to a fetus brain affected by alcohol exposure". A picture is worth a thousand words. Display pictures and other FAS posters - refer to them when you discuss FAS with a client. The client will often ask to show the picture to a family member at a future visit presenting an opportunity for further education. You may also provide a FAS Information Handout that can be taken away with them.

If the client is at low-risk for alcohol use, continue to monitor her alcohol use with her. Screen for other drug use. You may decide to proceed with further assessment specific to her alcohol and drug use as well as of other relevant areas of her life. This will leave an open door for her to bring up concerns related to her use later or her struggles to avoid use.

If the client is at risk for alcohol use, proceed with a holistic, comprehensive assessment of the client's substance use, including drugs and other relevant areas of her life (i.e., social and economic influences, physical and psychological health).

The purpose of doing an assessment is to: obtain background information about a woman's life situation, develop a personal action plan together with the client, make the best plans/referrals possible.

Looking at the many factors in a woman's life helps place her substance use within a broader context. It also helps you to discuss and make her aware of how her substance use is closely connected to things that have gone on or are going on in her life.

General prenatal and postnatal client data and information form important background information to an alcohol and drug assessment.

It is important to ask about all aspects of her life and not just about her substance use. This enables both of you to become aware of issues that may have contributed to her substance use and may present barriers to making changes.

Ask about her family's use of substance use
Other people's substance use can also affect a pregnant woman and the fetus. Asking a question about any history of abuse of alcohol by their mother, father, sibling, spouse or partner may reveal useful information in forming a plan of care. She may live with someone whose alcohol or other drug use creates additional stress for her and may increase the chance that she will use substances. This would also have an influence on their financial situation and the money they would have available for food and other necessities if they have a low fixed income. A history of abuse of alcohol by her biological mother or father opens discussion about family patterns of drinking and what meaning that has for her. In some cases, the woman may even disclose that she herself is affected by her mother's alcohol and drug use during pregnancy and the successes and challenges that presents for her.

In all cases remember to respect a woman's comfort level. It is better to have less information than to have her not come back because she felt she had to tell you things she really didn't want to reveal or she feels ashamed about what she has already told you.

Drug and Alcohol Assessment
Using Client-focused Counseling
For best results, incorporate alcohol and drug assessment questions into the client data collection at client intake.
A sample Alcohol and Drug Assessment Questionnaire is provided as an interview guide. For each substance (caffeine, tobacco, alcohol and other drugs) formulate the questions purposefully to discuss substance use prior to intake..

In almost every case, this will set the stage for the client to reveal those times in her life when she has made positive steps toward change. Examples of change might include thinking about reducing or quitting or times when he/she has reduced or quit using a substance for short or long periods.

Sometimes a client is unable to describe how change has happened. Such is often the case when a client may not be consciously making a positive change. For example: a client may tell you that she has cut down his/her smoking due to feeling ill inferring it has nothing to do with her. You can respond with a question, "During these times when you are feeling ill what are you doing instead of smoking?" This response enables her to explore what she is doing differently that contributes to positive change. This encourages her to become more aware of some of the things she is doing and ways of repeating the experience. Amplifying any solutions the client offers is very useful in countering any sense of powerlessness, which a client may be experiencing.

Once she has described what she is doing to contribute to the change, you can proceed to explore with her the inner resources and strengths the client is using. Asking the client what she has tried so far and reflecting back to her the strengths and resources she is using tells the client that you know she is competent and has the capacity to make good things happen and be successful in the goals she sets for herself.

This creates an opportunity for the counselor to immediately respond with compliments or positive feedback with respect to these changes in behaviors or exceptions. The compliments should punctuate what a client is already doing that is useful, based on information she has revealed. Focus on complimenting her with respect to what she needs to continue to do differently and more of to effectively reach her goal.

This is an example of how to formulate questions to ask about alcohol use. This format, along with the client-focused counseling approach, will solicit client responses that focus on solutions, positives and possibilities in the desired direction.

In the Stages of Change model developed by James Prochaska and Carlo DiClemente, change is seen not as a sudden event, but instead as something that happens in stages or cycles. The model identifies six stages that may take place during a process of behavior change: pre-contemplation, contemplation, preparation, action, maintenance, and termination.

Pre-contemplation
Women in this stage are not concerned about their substance use and are not considering changing their behavior, even when there are serious negative consequences of their use. This is different from "denial"; pre-contemplators do not perceive that they have a problem. It may or may not be apparent to others that a problem exists. However, during pregnancy a woman may begin to have some questions or concerns about her drinking. The motivator for contact is not necessarily related to her drinking, but may be part of the reason for why she is there.

Examples of statements by a pregnant woman in the pre-contemplation stage of change are: "My partner told me that if I don't come and see you he/she will leave".

"I think I may be pregnant, I have not had a period in a few months".

"I was told by my Children's Social worker that if I don't come in to see you that I will lose this baby just like I did my first baby".

"My family told me that I have a drinking problem. They are a problem, not my drinking. If everyone got off my back I would be just fine."

Counselor strategies for women in the pre-contemplation stage of change are to:
establish a trusting relationship maintain an empathic accepting, non-judgmental approach to the woman's perception of her situation; help the woman see the discrepancy between her current behavior and her future goals for herself and for her baby;
meet resistance with reflection - do not confront. Counselor strategies for women in the Your goal is to help the woman move to the stage of contemplation (not to action, yet). To do this, you can use the following motivational strategies: Counselor strategies for women in the commend the woman for attending your program, group or session; Counselor strategies for women in the women who are pregnant may feel guilt about harming themselves and their babies - it is important, then, not to increase guilt; instead, provide factual information about the risk of alcohol use in pregnancy in a non-judgmental, non-shaming way, non-blaming way;

provide information about other non-judgment services that can provide accurate, research-based information on her pregnancy;

talk about both the mother and the baby,

talk about both alcohol use and pregnancy concerns: help her make a connection to her infant and let her know that both she and the baby are important;

if she feels coerced, talk about the feelings she has about being forced to attend your session;

explore why other people say she has a problem; ask "how much alcohol do you use" rather than "do you use alcohol" - if the response to use is positive, then ask "how much? how long ? and when did you last use?.";

women who are using alcohol may perceive many positive aspects to their use (such as, stress management, support in social interactions, self-medication of trauma or abuse issues).

It is important to acknowledge the positive as well as the negative role that alcohol use plays in women's lives; use a calendar (or Timeline Followback) to assist in gathering information on alcohol use and work backwards; allow the woman to compare how much alcohol she uses with typical consumption patterns. Talk about sources of distress such as threat of apprehension of her expected infant/other children, relationship loss, job loss, legal problems, and so on; ask questions about her life in a direct but non-threatening way; for example, rather than ask "does anyone abuse you?", ask "is there anyone in your life who hits you, shouts at you, or punches you?" follow the woman's agenda; encourage any and all small changes that reduce high-risk behaviors; express concern and keep your door open - you want her to return to talk to you again

Women in this stage are ambivalent about change. They begin to see the positive aspects of change, but are reluctant to give up their use of alcohol. Many will volunteer at least a few tentative concerns about their alcohol use, often qualifying them with "buts". In this stage of change, a pregnant woman may have concerns about her alcohol use and her pregnancy.

How the counselor responds to the woman's initial concerns will determine whether the woman will risk exploring further concerns. If the counselor responds in a judgmental way or presents concerns as evidence of alcoholism, additional disclosures may not be forthcoming. If, on the other hand, the woman's concern statements are met with understanding and respect, the client may be more inclined to explore these and other concerns.

Examples of statements by a pregnant woman in the contemplation stage of change are:

"Sometimes I worry about the effect this will have on my baby but my sister drinks daily and her kids were fine".

"I only drink on the weekends but sometimes I think about it all week. I want to stop but I really enjoy it".

"Yes? I go out to the bar on a Friday night and maybe I drink too much".

Counselor strategies for women in the contemplation stage of change are to:

tip the scale - reflect both sides of the woman's ambivalence, but place greater stress on the perceived problems:

"So on the one hand you don't think of yourself as an alcoholic but on the other hand you can see that your drinking is having some scary effects on you and you worry that you may be doing serious damage to yourself and your baby".

The goal is to tip the balance in favor of the positive aspects of change; go slowly and resist the urge to make action plans for the woman; follow her lead, making only gentle suggestions; pay attention to the details, especially if a referral needs to be made: at this stage she trusts you, but she may not trust someone else - facilitate and follow up with any referrals you make for her. Your goal is to help the woman move to the stage of preparation (still not to action). To do this, you can use the following motivational strategies:
continue to explore from the woman's perspective what is good about the her drinking and what is not so good - you can use a pros and cons chart (sometimes called a decisional balance chart); continue to encourage any small reduction of high-risk behaviors; emphasize and reinforce the small steps that the woman is able to make towards change; do not alarm the woman about her use, but provide factual information about the continuum of effects alcohol can have on the fetus; promote the woman's belief in her ability to change

In this stage, the woman is actively considering change and begins to consider what alternatives might be available. A tip in the balance toward change characterizes this stage. The transition in client speech is from

"There may be a problem" to "What can I do?".

It is upsetting to begin to see personal risk and problems. Therefore, in this stage, a woman may become more anxious, depressed, agitated, sad, or angry. This is an uncomfortable stage (which is one reason why it is motivating).

The woman may deal with her discomfort either by: changing her behavior and making a plan to stop her alcohol use or; minimizing the risk and returning to the contemplation stage.

Two things make the difference in which approach a woman will choose. One is the counselor's ability to help the woman maintain a level of anxiety that is neither overwhelming nor being minimized. The other is the woman's belief that there is an effective and realistic change strategy available and that she is capable of carrying it out.

Examples of statements by a pregnant woman in the preparation stage who has chosen to move to the action stage are:

"I have really thought about it and I know I have to do something about my drinking problem. I just don't know where to begin".

"I've decided to stop for my baby".

"I have to stop drinking but it's going to be really hard".

Counselor strategies for women in the preparation stage of change are to:
assist in making a change plan, by providing as many options for change as possible, then allowing the woman to select those that she perceives as the most helpful; assure the woman there are available, effective, acceptable and realistic avenues for change and provide her with the alternatives; describe the options available and, together, work through which alternatives make most sense to start.

Your goal is now to help the woman move to the action stage of change.

To do this, you can use the following motivational strategies:
encourage the woman's belief in her ability to make changes; assist with making and writing out the change plan; make the plan S.M.A.R.T. - specific, measurable, attainable, realistic, and timely; consider a contract but be sensitive to the possibility that some women may have had with poor experiences with contracts; continue to go slowly and follow the woman's lead with respect to timing; know the risks of withdrawal for the mother and the fetus; depending on her consumption levels, a medically supervised withdrawal may be required; if the plan includes detox or treatment, make a referral for services:
talk about the things that could get in the way of the success of the plan (such as, friends and family who use alcohol, high-risk situations for alcohol use, and stressful events).

Action
This stage is characterized by implementing the plan that was made in the preparation stage. Other barriers and issues may arise once the woman has begun to implement changes, for example family members and others may not trust the changes or may be threatened by them and so they may try to sabotage efforts, and a woman's underlying issues, such as trauma, abuse, depression, or anxiety, may surface. While some counselors may feel that the positive change process means that a woman may not require the same level of support, in reality she may require increased supports at this time. It is a period of losses as well as gains: loss of friends/family who are unsupportive, loss of a neighborhood or community, loss of the positive aspects of the alcohol use - and the rituals associated with the use. Examples of statements by a pregnant woman in the action stage are:

"This is really hard. I wasn't hung over the other day and that was new for me".

"Sometimes I wonder if I can keep this up - it's so weird".

"My family aren't being supportive. I guess they've seen this all before".

"I have to do something about my partner who is hitting me".

Counselor strategies for women in the action stage of change are to: mediate and support change; set small, achievable goals; refrain from any negative comments or actions if she has a relapse; provide a lot of positive feedback.

Your goal is help the woman maintain the change. To do this, you can use the following motivational strategies:
reach for the positives; acknowledge the small steps and provide positive feedback; reflect with empathy; for example "you were hopeful that your family; would be really pleased, but they seem unable to trust that this is for real."

Look at the goals that were set - are they working or are they too ambitious?; acknowledge and reassure that relapse is a normal part of recovery - and can be learned from; if any other issues surface during this period, assist her in making arrangements for support.

Maintenance
This stage is characterized by more than the original behavior not being present. Major changes and shifts in thinking occur. Many women will think of painful issues from the past that may lead to feelings of guilt and remorse. For example, women may reflect on the impact their alcohol use has had on their children.

Examples of statements by a pregnant woman in the maintenance stage are:

"I was thinking about when I used to drink and how that must have been really hard for my family".

"I feel so guilty that I have been able to stop drinking for this baby, but I didn't for my other kids".

"My son is having problems at school. I went to see his teacher and she said he is really angry with me. He told her that I was never around and now I want to set all kinds of rules. I was really hurt. I feel terrible about what's happened".

Counselor strategies for women in the maintenance stage of change are to: assist in relapse prevention; provide support around other issues that may arise, either directly or by referral.

Depending on your orientation to alcohol problems, your goal is to help the woman maintain or to terminate the cycle of change.

To do this, you can use the following motivational strategies: make linkages with other community service providers who could provide relapse prevention services; facilitate referrals for counseling around other issues that may arise (such as grief and loss, trauma and abuse, depression and anxiety); recognize that relapse can occur at this stage and be sure to be non-judgmental in response - counselors must monitor their own responses to a woman's relapse (for example, disappointment, frustration, anger, or grief) and maintain appropriate boundaries and expectations.

Termination
Some people reach this stage and others do not; the latter stay in the maintenance stage. However, for those who reach termination, this stage indicates that the drinking behavior is no longer part of the way the woman defines herself. She no longer requires treatment or support around this issue. She has exited the stages of change cycle.

Case Management

Good practice:
Supporting the client as she increasingly takes the lead in her own case management.

Principles

Be honest and up front with the client at all times, "no hidden agendas".

Support your client in learning how to identify her own strengths and needs, how to advocate for herself and her children, and to be in charge of her own case management.

Help her to understand that asking for help, when she needs it, is a strength, not a weakness.

Scenario: (Anticipating child protection concerns)
Be up front and open with your moms. What I find works well is to explain to the client:

"It's much better if you phone a social worker and ask for help instead of waiting for her to come knocking on your door. Tell the social worker what you need to be a successful parent. Ask for plans to be put in place before you deliver. Now you are in the driver's seat." I often use the example: "You can consider a policeman to be a good guy or a bad guy. If you're on the right side of the law and you go up to a policeman and say 'I need your help', they're going to be there for you. And it's the same with social workers."

Multidisciplinary Team
When counselors are part of a multidisciplinary team, it is essential that everyone have a common philosophy and approach. Clients have reported in evaluations, "One thing I like about coming here is that there isn't one person you talk to about your addiction and another person you talk to about nutrition." Clients don't have to see different counselors for different needs. Clients have stated "there is a feeling of safety ... no one knows whether I am talking to a counselor about prenatal vitamins or a personal issue (e.g., marijuana use, abusive partner)". All members of the team have developed capacities to respond to the diverse needs of clients; however, they consult with one another in case management.

Many women don't feel comfortable accessing traditional alcohol and drug services, especially when they are pregnant. Be creative in working with the client to find harm reduction interventions that work for her! "Anything is possible"! Ask your clients to identify alcohol and drug front-line workers who they have found to be helpful.
Develop relationships with community alcohol and drug counselors at your "detox", alcohol and drug clinic, treatment center, needle exchange, or with others such as street workers to be involved in creative individually tailored case management.

Negotiating treatment alternatives
In working with women to develop and implement treatment plans, you will find it helpful to know the front-line workers in your community involved in the alcohol and drug systems of care.

Ask women what they have learned about themselves in the past that works in reducing or abstaining from alcohol and/or drugs.

Women will often "detox" at home with the support of family, go to a safe house, or live temporarily with another family member. What often works is for a woman to find someone to be with who respects and understands her and provides her a place where she can feel safe and safely detoxify from drugs and/or alcohol.

Scenario:
Susan admitted to daily drinking at her intake interview. Now that she is pregnant she says, "I know that I need to quit drinking. I want to have a healthy baby. Every morning when I get up I tell myself that I'm not going to drink, but one drink leads to another. If I could just go for one day without drinking I know I could quit." When the counselor asked her what has worked for her in the past, she stated that she "needs to get out of the house and find something to do to keep really busy for a few days." Together they explored some possibilities. They discussed what she likes to do when she isn't drinking. She said that "I really like to cook and bake, but I don't have any groceries." The counselor invited her to volunteer by preparing and cooking food for our groups held at the center (this may not be possible for all therapists to offer this as an option). For two days she made banana bread, casseroles and soups for our group activities. She came in for two days and cooked. She was given some of the food she prepared to take home with her. The third day she came in and cleaned up the clothing exchange and she watched a video. By the fourth day she felt in control of her temptation to drink and, in fact, remained sober the remainder of her pregnancy.

Common Understanding
Scenario:
It is a balancing act to play the role of client advocate for pregnant and parenting women using substances and to ensure protection of the children. Being candid and honest with women is the key. Work with women to develop strategies for harm reduction that will keep their children safe. Discuss a plan to prepare for times when they may return to using alcohol and/or drugs. Encourage them to arrange for safe child-care alternatives or other respite.

For many women who have themselves not had the experience of feeling protected and safe in their families, they may not have developed models, resources or capacities to provide a protective and safe environment for their children. In speaking with women about child protection, it is important to explain that when they are not safe, this is an indicator that they need additional support to ensure that their children are safe.

Good Practice: Incorporating a peer support component as part of the model.

There is recognition that in a group setting, women benefit from learning from and with other women. Although making changes in reducing or abstaining from alcohol and drugs is, in many ways, an individual journey, it is also an experience that can be made easier and more enjoyable with the support and wisdom of others traveling along the same path. They learn that they are not alone in these issues and can take strength from each other.

Support groups should offer time, space and privacy for women to explore the whole of their lives in a safe manner. Women receive positive feedback, talk about common problems, and know others genuinely care about them and what is happening in their lives. Through getting and giving information, listening and being listened to, and learning new ways of coping, clients report a sense of self-worth and dignity.

The struggle is seldom just about alcohol and drugs. It's a way of coping with relationship, violence, poverty and other complex issues. Through sharing experiences and stories with others, women find support and a collective strength for making change. Recognize that people learn in different ways. Through group discussions, skill development exercises, art, relaxation, journal writing and others.

Women's substance abuse has evolved as a way of coping with lost power, choices and abilities. Support women's discovery or rediscovery of power, choices and abilities. Each woman's journey is an individual one done at her own pace. Recognize that there are "many roads, one journey".

It is important to recognize:
the links between women's issues: depression, violence, and substance abuse;

that recovery must take place through many levels: mind, body and spirit;

that women learn in different ways: verbal presentations, group discussion, skill development exercises, art, meditation and relaxation, music, etc.

Create a comfortable environment
Use creative ideas to make the group room comfortable, private and special for sessions. Our surroundings influence how we feel and behave. For example, low lighting, candles and music create a soothing environment to help participants feel calm and relaxed. Involve participants in choosing symbolic objects, pictures and music to create a space that reinforces participants' values and who they are.

Sit in a circle format
Try to find comfortable chairs. Arrange the chairs in a circle. This is comfortable for discussions. A Center for the Circle
Set a coffee table in the center of the circle to create a focal point.

Cover the table with a cloth and on it place a plant, dried flower arrangement, candle, potpourri burner, dream catcher, or other objects contributed by participants.

Sight, Sound and Smell Listening to music before sessions and during relaxation exercises or breaks sets the tone to help participants collectively unwind and becomes a joining ritual. A pleasant-smelling room created by burning scented candles and aromatherapy can create a warm inviting atmosphere.

Encourage self-care
Collect self-care items in a basket. Samples of cosmetic products, candles, bath beads, herbal teas, and other items can easily be obtained as donations or with a small budget. Participants can choose one item weekly or names can be drawn on a weekly basis to choose a self-care item.

Involve Participants in planning, implementation, and evaluation Together have the group develop: Group expectations Example: To learn more effective coping skills. To better understand why we use alcohol and/or drugs.

Group Guidelines
- Confidentiality - "What is said here, remains here."
-To be treated with respect - tolerate differences,
-No attendance if under the influence of drugs.

The Name of the Group
The name of the group matters. Involve participants in naming the group. The following names have arisen in recent groups: "discovery and empowerment group" and "women's retreat", instead of the traditional "alcohol and drug support group."

Experiential learning and sharing approaches through group process
Check-ins/outs
At the start of each session, each participant is given a few minutes to share how she is feeling or what the day or week has been like for her. The group witnesses and validates each woman's experience and recognizes similarities and differences. It is an effective way of making everyone aware of information or feelings that may influence the tone and direction of the session. Through collectively exploring what common patterns and differences there are in their experiences, the group can make decisions on what issues they would like to discuss or learn more about in depth. For example, if negative relationships are a commonality, they can ask the group leader/facilitator to help them examine this topic in more depth.

Speaking stone, feather or stick These are helpful tools to use in a round of check-in or check-out in groups. The group chooses a symbolic item. A participant holds the item when she is speaking. When she is done speaking she passes it to the next participant. As long as a participant is holding the item, she has the group's attention, without interruption - even if she is not speaking. It helps to define who is speaking and when the speaker is finished, and is useful for structuring the activity.

Address barriers to women's participation.

• Food
• Sharing food is a wonderful way to socialize and get to know people.
• Serve tasty nutritious snacks and beverages when participants arrive or at a break.
• This ensures that no one is hungry and that participants will be better able to focus on the group experiences.

Childcare
Discuss and consider ways to enable women with children to attend. Offer childcare (if possible) on site or explore child-care subsidy and other options.

Transportation
Consider providing bus tokens, arranging car-pooling, shuttle service or other options.

Adolescents & Alcohol-Other-Drug Issues

Adolescents are not little adults, they are adolescents. They live somewhere between childhood and adulthood with specific needs different from the needs of children and adults. They often look like adults, but their behavior often looks childlike. They carry difficult and varied issues. Each brings varying experience and maturity to the day. Some are growing up "normally" and some suffer impaired or disordered development. Introduce alcohol-and-other-drugs into their lives and it becomes difficult to tell the normal from the disordered. To help kids change and grow in healthy ways we need to understand who are struggling through normal development and who need help to work through issues that impede normal development. If kids are using alcohol-and-other-drugs, their use distorts their lives and how they are perceived by those who strive to help them grow healthy and strong. To help kids change and grow in healthy ways we need to help youth who are using alcohol-and-other-drugs to eliminate them from the their lives.

Basic Terms, Concepts, and Definitions:
Addiction (also, dependency, chemical dependency): If the use of alcohol or other drugs is interfering with any area of a person's life, whether social (legal, school, family, friends) or personal (physical, mental, emotional, spiritual, financial) and s/he cannot stop using alcohol-and-other-drugs without help, then s/he is addicted. Help, in this definition, means treatment and/or twelve-step program.

Blackout: Total or partial memory loss for an undetermined period of time due to the effects of alcohol on the brain; alcohol induced amnesia. People in blackouts may appear to be functioning normally to those around them. Passing out or unconsciousness may or may not be part of a blackout. Blackouts are abnormal, an indication of a problem, or developing problem with alcohol.

Denial: Inability to or deciding not to recognize a problem as a problem. Denial functions to protect self-worth. Individuals, families, and institutions, such as schools and school systems, are capable of denial.

Enabling: A system comprising ideas, feelings, attitudes, and behaviors that unwittingly allow and/or encourage problems to get worse by preventing individuals from experiencing consequences.

Progression: Predictable stages of alcohol-and-other-drugs; all individuals do not pass through all stages, but each stage represent a qualitatively different and increasingly destructive relationship with alcohol-and-other-drugs. Indications that individuals are in harmful stages include loss of control, frequency and seriousness of harmful consequences, and heightened emotional pain.

Tolerance: The body's ability to adjust to the continuing, frequent presence of alcohol or other drugs resulting in the need to increase dosage in order to attain the sought-for change of feelings or high. High tolerance, e.g., ability to drink a large quantity of alcohol without showing signs of impairment, is an indication of a problem or developing problem with the drug.

Reinforcement: The property of a mind altering drug that reinforces continued use by essentially telling the brain that as long as the drug is present in the body, everything is okay. An example of reinforcement at work is the individual who is convinced he drives better after a few drinks, convinced, even, with no alcohol present in his system. Reinforcement hinders the individual's ability to link consequences to alcohol-and-other-drugs use. For example, the employee who says, "You'd drink, too, if you worked for this SOB," fails to see that difficulty at work and with the boss may be caused by her drinking.

Progressive Stages of Adolescent Alcohol-Other-Drug Use
Kids don't start drinking or using other drugs with the intention of becoming addicted. About 10% of kids who begin using drugs become alcohol and drug dependent. However, non-addicted and addicted kids begin and continue to use alcohol and drugs for any number and combination of reasons, including:

• to experiment;
• to socialize;
• to test limits;
• to belong to a peer group;
• because of societal and media influence;
• due to genetic influence;
• to deal with their troubled families and other painful experiences;
• lack of meaningful contribution to their and others' lives;
• because adolescence is no picnic.

All kids progress through predictable stages of use, but all kids do not progress through all stages. While any adolescent alcohol and drugs use is potentially harmful and illegal, many find that they can control their use and avoid harmful consequences. However, we don't know which youth will be able to remain free from harm and which will not. Therefore, we need to prevent use and intervene as early as possible with those who are using.

There are many descriptions of adolescent alcohol and drugs progression; each is more or less consistent with the others, but each uses different terminology and describes the stages a bit differently.

Stages of Drug and Alcohol Abuse

Stage 1: Experimentation
Experimentation is the first stage and comprises the first few episodes of alcohol and drugs use, a brief time when kids discover drugs and their effects. Contrary to common perception, experimentation is not automatic and does not need to happen. If kids never experiment, they can't develop alcohol and drugs problems. Preventing or delaying experimentation starts with adults' refusal to accept that all kids will experiment.

Experimentation is typically done in secret with others, using gateway drugs (see below) obtained from older siblings or friends; alcohol may be stolen from parents' liquor cabinet. Parents and school are usually unaware of kids' experimentation. Some kids never progress past the experimentation phase because of unpleasant experiences involving undesirable effects. Youth in their late elementary and early middle school years typically comprise the group involved in experimentation.

Stage 2: Recreational and Social Use
As a result of what they discover during experimentation, some adolescents will progress to more regular use in recreational and social settings. We need to underscore that recreational and social use means just that and does not condone alcohol and drugs use, nor imply that it is expected and acceptable behavior.

During stage two adolescents typically use gateway drugs 2 or 3 times monthly with friends at parties on weekends. Kids use according to rules involving how much, when, and where they will use. The social event, not alcohol and drugs use, is the focus and use is not deemed necessary to have fun. Alcohol and drugs use does not usually result in intoxication, but an occasional episode might occur. Parents and school are usually unaware of kids' use during this stage; if parents suspect use and confront their child, s/he will often lie about alcohol and drugs use. Middle and high school aged youth make up the group in stage two.

Possible Lessons Learned During Stages 1 & 2
Their experience with alcohol and drugs during the experimentation and recreational/social stages has a direct influence on adolescents' future use. They may learn that alcohol and drugs use provides any one or combination of the below lessons. Their use may teach them that alcohol-and-other-drugs:

• produce reliable, predictable, and pleasurable feelings;
• relieve pressure, tension, and painful feelings, at least for a while;
• is what they've been looking for in life-the answer;
• are not for them;
• are no big deal-they can take them or leave them. (At first glance this lesson may look favorable; however, it is insidiously dangerous with harmful, long-term implications.)

Prevention and Intervention Strategies During Stages 1 & 2
Prevention includes K-12 health education, K-12 prevention programs, parent education, staff in-service regarding alcohol and drugs issues, and fostering resiliency and bonding in all children and youth.

Intervention is most effective during these stages and involves confrontation when drug use occurs and strict, appropriate consequences for violations of family rules/norms and school policy.

Stage 3: Seeking
During stage three, youth seek opportunities to use and seek the high that alcohol and drugs use provides.
A serious pattern of alcohol and drug involvement is indicated and clear, harmful and destructive characteristics of adolescent alcohol and drugs use begin to emerge at this stage.

• Rules begin to break down-frequency and amount of use rises;
• Solitary use begins;
• Other drugs become more available and are tried;
• alcohol and drugs use is the focus at parties, not the socialization with friends-kids intentionally get drunk or wasted;
• alcohol and drugs are used to escape problems and cope with pressure;
• Dishonesty about use becomes more frequent;
• Peer groups may change;
• Efforts at school become inconsistent and erratic;
• Tolerance increases, along with pride in being able to "handle it;"
• Kids may arrive at school or school events under the influence.

Stages 4 & 5: Harmfully Involved & Dependent/Addicted
It takes a professional addictions counselor to assess and determine whether an adolescent is harmfully involved or dependent. Educators-Student Assistance Teams-need only to determine that alcohol and drug use is causing significant problems and is, therefore, the problem that must be addressed. An indistinct line separates these two stages and their indicators.

Stage 4: Harmfully Involved
During stage 4 teens will progressively use alcohol and drugs more regularly during the week; use in greater quantities and use alone. alcohol and drugs becomes part of their life-style; they own and use their own paraphernalia. They use heavier drugs-at this stage teens have typically tried four or five different drugs. They attempt to justify alcohol and drug use and believe it helps them cope with pressure, stress, and problems and use for these reasons regularly. Powerful negative emotions, including guilt, fear, and shame, cause the adolescent to use alcohol and drugs to self-medicate away the pain.

Parents and school know something is wrong, but tend to deny what they know and see They often blame one another and may enable use to avoid confrontation. Parents try to control their child's use with strict rules and punishment.

Stage 5: Dependent/Addicted
During this stage, adolescents use daily and need to repeat getting high. They use at home and at school. They are obsessed with alcohol and drugs and turn to harder drugs and heavier use. Dependent adolescents have tried four to six different drugs and use three or four on a regular basis. They use any means to get money for drugs and hide and protect their supply. Solitary use increases resulting in intense loneliness. Peer groups comprise only drug-users.

Physical deterioration, paranoia, self-hatred, rage, depression and suicidal ideation are common during this stage.

Problems at home, school, work and in the community increase in number and degree. Parents and school may simply give up, feel out of control, and relieved if the teen moves out or leaves school.

Intervention During Stages 3 - 5
Behaviors of concern become more visible during these stages as alcohol and drug use becomes more frequent and regular. Interventions include staff consistently addressing "party-talk," effective administration of policy, staff in-service regarding alcohol and drugs and student assistance referral procedures, parent education and involvement, a vigilant student assistance team that supports vigorous identification and referral of students exhibiting behaviors of concern, alcohol and drug assessment, contracts, alcohol and drugs focused insight class, and outside assessment referral.

Here are the 10 critical components of a good drug and alcohol prevention program:

Research based, theory driven. Of special importance are the theories about why people become addicted and the research on risk factors.

Effective programs offer developmentally appropriate information. Teens tend to be more interested in the "here and now" than in potential future effects of drug use. Information about short-term negative social consequences of use should be a primary ingredient in any program. The most effective programs teach social resistance skills. (How to say "No.") Especially at the junior high level, these programs offer teens ways to learn to resist peer pressure. (See Learning to Say No in this issue.)

Normative education. Teach teens that most people do not use drugs and alcohol. (See Most People Don't Use Drugs in this issue.)

Personal and social skills training. Teens need to learn problem- solving skills as well as goal-setting, stress management, and communication skills. Building these skills actually leads to reductions in drug and alcohol use among teens.

Interactive teaching techniques. Programs that teach through role-playing, discussion, and small group activities are more successful than traditional lecture-based ones.

Teacher training and support. The major emphasis of this training should be on using interactive teaching strategies in addition to covering the facts about drugs and alcohol. In-depth interventions and "booster sessions." A one-shot program has little likelihood of success.

Culturally sensitive. The heterogeneous nature of American schools makes this an interesting challenge. One way to deal with this issue is to provide customizable materials to teachers and let them make the experience appropriate to the students.

Outreach. To be totally successful, prevention programs need to reach out into the community and into the homes of the students.

GATEWAY DRUGS
Gateway drugs are drugs that serve as the "gate" or path that almost always precedes the use of illicit drugs such as marijuana, cocaine, heroin, and LSD. These gateway drugs serve as almost essential precursors to the use of other drugs, and often lead to adoption of the drug-using lifestyle. Gateway drugs, or drugs-of-entry, serve to initiate a novice user to the drug-using world. Heroin addicts rarely, if ever, begin their drug use with heroin -- they start with gateway drugs, such as tobacco, and then progress (or regress) to heroin. While not all users of gateway drugs progress to heroin or cocaine, many do, and it is not possible to predict which users will progress to heroin and which will not.

The common gateway drugs include: tobacco, alcohol, inhalants, and anabolic steroids. Use of these drugs is statistically linked with later progression to other drugs. The linkage is not biochemical, however. Despite the fact that tobacco smoke contains hundreds of toxic chemicals, none of them cause smokers to try marijuana or cocaine. The gateway drugs serve as social and psychological precursors to the use of other drugs. The decisions to use tobacco or other gateway drugs set up patterns of behavior that make it easier for a user to go on to the other drugs. It is the series of decisions made by the smoker that make decisions to use other drugs easier. Social psychologists refer to this phenomenon as a "developmental progression." Children who decide to accept the risks of smoking later find it much easier to accept the risks of using other drugs.

On the other hand, children who make conscious decisions to avoid smoking tobacco because of the health risks are very unlikely to later make a decision to smoke marijuana, because accepting the health risks of smoking marijuana would be psychologically inconsistent with the values and beliefs of a non-tobacco smoker.

While the link is not biochemical, it is powerful nonetheless. How powerful is the influence of tobacco use on future use of illegal drugs? In 1987, a research team from the University of Michigan's Institute for Social Research found that among high-school seniors, daily smokers were 10 times more likely to use cocaine regularly than were seniors who never had smoked regularly. Students who never smoked were much less likely to experiment with controlled substances such as heroin and LSD, and very unlikely to use them regularly. However, nearly one-fourth of the seniors who smoked cigarettes daily had used cocaine in the month before the survey.

The Michigan study examined five different levels of smoking history and use of 15 different drugs. The evidence was overwhelming that cigarette-smoking high school seniors were much more likely to use every class of controlled substance (but only slightly more likely to use alcohol) than were non-smoking students. The link is dose related, the more cigarettes a student smoked, the more likely he or she was to use marijuana and cocaine. For example, while less than 4 percent of the high school seniors who never had smoked tried cocaine one or more times during their senior year of high school, more than 40 percent of the seniors who smoked a pack a day or more had tried cocaine during the year. Only 7.2 percent of the non-smoking seniors used marijuana during the month before the survey, as compared with 59 percent of the pack a day smokers. (Reference: Johnston, O'Malley, and Bachman, 1987.)

The role of alcohol as a gateway drug is a little more complex. The statistical link between alcohol use and use of illicit drugs is age and dose related. Alcohol use by children and young adolescents serves as a precursor to and predictor of future use of illicit drugs, while alcohol use that begins after the age of 16 does not appear to be linked directly with use of other illicit drugs. The child who begins using alcohol in the late elementary grades or during junior high school is much more likely to later use such drugs as cocaine, marijuana, and LSD, while the person who begins drinking later in adolescence is no more likely than non-drinkers to use other illicit drugs. Those who drink heavily, or who regularly "binge drink" (drink to the point of intoxication at least once every two weeks) are more likely to use controlled substances than are non-drinkers or moderate drinkers.

Inhalants are drugs whose fumes or vapors are inhaled for their intoxicating effect. They include such substances as gasoline, lighter fluid, tool-cleaning solvents, model airplane glue, typewriter correction fluid, and even fumes from permanent magic markers. Particularly in the Midwest, inhalants often are the first drug used by children to produce an intoxicating effect. In some communities, as many as one-fourth of all late elementary grades students regularly use inhalants to get high. Statistically, those children who use inhalants are much more likely to use other illicit drugs than are non-inhalant users.

Recently, the use of Anabolic Steroids by some students has been shown to produce the gateway drug effect. Steroids are used to build muscle bulk. Often, steroid users combine a regimen of pills and injectable forms of the drug. Some steroid users learn to accept the risks of using injectable drugs and of regularly taking pills. The psychological conditioning that accompanies acceptance of these risks can lead to accepting the risks associated with other drug use.

Some social scientists believe that the gateway drug phenomenon is simply an example of practice conditioning that leads to the development of a learned behavior. Children who experiment with and later use gateway drugs are, in effect, practicing the wrong social skills and learning the wrong behaviors. They then apply these conditioned behaviors to other, more sinister drugs.

One of the problems with this approach is the possible minimization of the risks associated with the gateway drugs themselves. Tobacco and alcohol themselves cause nearly one-third of all deaths from all causes in the United States. More people die from tobacco and alcohol use each month than die in an entire year from use of all other illicit drugs combined.

From a public policy standpoint, tobacco and alcohol prevention programs are essential in their own right. They help mitigate the adverse impact that the two deadliest drugs have on our society. But tobacco and alcohol prevention programs also are important as a means of preventing use of other drugs. Prevention of cocaine and heroin use begins with preventing tobacco use. If children learn to make good decisions not to use gateway drugs, they are very unlikely to begin using controlled substances.

ALCOHOL IMPAIRMENT CHART
Copyright 1997 ?
FEMALES

APPROXIMATE BLOOD ALCOHOL PERCENTAGE
DRINKS*	BODY WEIGHT IN POUNDS									EFFECT ON PERSON
	90	100	120	140	160	180	200	220	240
0	.00	.00	.00	.00	.00	.00	.00	.00	.00	ONLY SAFE DRIVING LIMIT
1	.05	.05	.04	.03	.03	.03	.02	.02	.02	IMPAIRMENT BEGINS.
2	.10	.09	.08	.07	.06	.05	.05	.04	.04	DRIVING SKILLS SIGNIFICANTLY AFFECTED. POSSIBLE CRIMINAL PENALTIES
3	.15	.14	.11	.10	.09	.08	.07	.06	.06
4	.20	.18	.15	.13	.11	.10	.09	.08	.08
5	.25	.23	.19	.16	.14	.13	.11	.10	.09
6	.30	.27	.23	.19	.17	.15	.14	.12	.11	LEGALLY INTOXICATED. CRIMINAL PENALTIES IMPOSED.
7	.35	.32	.27	.23	.20	.18	.16	.14	.13
8	.40	.36	.30	.26	.23	.20	.18	.17	.15
9	.45	.41	.34	.29	.26	.23	.20	.19	.17
10	.51	.45	.38	.32	.28	.25	.23	.21	.19

Subtract .01% for each 40 minutes of drinking.
" One drink is equal to 1? oz. of 80 proof liquor, 12 oz. of beer, or 4 oz. of table wine. ALCOHOL IMPAIRMENT CHART
MALES

APPROXIMATE BLOOD ALCOHOL PERCENTAGE
DRINKS*	BODY WEIGHT IN POUNDS									EFFECT ON PERSON
	100	120	140	160	180	200	220	240
0	.00	.00	.00	.00	.00	.00	.00	.00	ONLY SAFE DRIVING LIMIT
1	.04	.03	.03	.02	.02	.02	.02	.02	IMPAIRMENT BEGINS.
2	.08	.06	.05	.05	.04	.04	.03	.03	DRIVING SKILLS SIGNIFICANTLY AFFECTED. POSSIBLE CRIMINAL PENALTIES
3	.11	.09	.08	.07	.06	.06	.05	.05
4	.15	.12	.11	.09	.08	.08	.07	.06
5	.19	.16	.13	.12	.11	.09	.09	.08
6	.23	.19	.16	.14	.13	.11	.10	.09
7	.16	.22	.19	.16	.15	.13	.12	.11	LEGALLY INTOXICATED. CRIMINAL PENALTIES IMPOSED.
8	.30	.25	.21	.19	.17	.15	.14	.13
9	.34	.28	.24	.21	.19	.17	.15	.14
10	.38	.31	.27	.23	.21	.19	.17	.16

Subtract .01% for each 40 minutes of drinking. * One drink is equal to 1? oz. of 80 proof liquor, 12 oz. of beer, or 4 oz. of table wine.

Tips for Teens: The Truth About Alcohol

Slang--Booze, Sauce, Brews, Brewskis, Hooch, Hard Stuff, Juice

How to relate with your teenage clients regarding alcohol and drugs

Alcohol affects your brain.
Drinking alcohol leads to a loss of coordination, poor judgment, slowed reflexes, distorted vision, memory lapses, and even blackouts.

Alcohol affects your body.
Alcohol can damage every organ in your body. It is absorbed directly into your bloodstream and can increase your risk for a variety of life-threatening diseases, including cancer.

Alcohol affects your self-control.
Alcohol depresses your central nervous system, lowers your inhibitions, and impairs your judgment. Drinking can lead to risky behaviors, including having unprotected sex. This may expose you to HIV/AIDS and other sexually transmitted diseases or cause unwanted pregnancy.

Alcohol can kill you.
Drinking large amounts of alcohol can lead to coma or even death. Also, in 1998, 35.8 percent of traffic deaths of 15- to 20-year-olds were alcohol-related.

Alcohol can hurt you--even if you're not the one drinking. If you're around people who are drinking, you have an increased risk of being seriously injured, involved in car crashes, or affected by violence. At the very least, you may have to deal with people who are sick, out of control, or unable to take care of themselves.

Know the law.
It is illegal to buy or possess alcohol if you are under 21.

Get the facts.
One drink can make you fail a breath test. In some states, people under the age of 21 who are found to have any amount of alcohol in their systems can lose their driver's license, be subject to a heavy fine, or have their car permanently taken away.

Stay informed.
"Binge" drinking means having five or more drinks on one occasion. About 15 percent of teens are binge drinkers in any given month.

Know the risks.
Mixing alcohol with medications or illicit drugs is extremely dangerous and can lead to accidental death. For example, alcohol-medication interactions may be a factor in at least 25 percent of emergency room admissions.

Keep your edge.
Alcohol can make you gain weight and give you bad breath.

Look around you.
Most teens aren't drinking alcohol. Research shows that 70 percent of people 12-20 haven't had a drink in the past month. Teenagers may be involved with alcohol and legal or illegal drugs in various ways. Experimentation with alcohol and drugs during adolescence is common. Unfortunately, teenagers often don't see the link between their actions today and the consequences tomorrow. They also have a tendency to feel indestructible and immune to the problems that others experience. Using alcohol and tobacco at a young age increases the risk of using other drugs later. Some teens will experiment and stop, or continue to use occasionally, without significant problems. Others will develop a dependency, moving on to more dangerous drugs and causing significant harm to themselves and possibly others.

Adolescence is a time for trying new things. Teens use alcohol and other drugs for many reasons, including curiosity, because it feels good, to reduce stress, to feel grown up or to fit in. It is difficult to know which teens will experiment and stop and which will develop serious problems. Teenagers at risk for developing serious alcohol and drug problems include those:

• with a family history of substance abuse
• who are depressed
• who have low self-esteem, and
• who feel like they don't fit in or are out of the mainstream

Teenagers abuse a variety of drugs, both legal and illegal. Legally available drugs include alcohol, prescribed medications, inhalants (fumes from glues, aerosols, and solvents) and over-the-counter cough, cold, sleep, and diet medications. The most commonly used illegal drugs are marijuana (pot), stimulants (cocaine, crack, and speed), LSD, PCP, opiates, heroin, and designer drugs (Ecstasy). The use of illegal drugs is increasing, especially among young teens. The average age of first marijuana use is 14, and alcohol use can start before age 12. The use of marijuana and alcohol in high school has become common.

Drug use is associated with a variety of negative consequences, including increased risk of serious drug use later in life, school failure, and poor judgment which may put teens at risk for accidents, violence, unplanned and unsafe sex, and suicide. Parents can help through early education about drugs, open communication, good role modeling, and early recognition if problems are developing.

Warning signs of teenage alcohol and drug abuse may include:
Physical Fatigue, repeated health complaints, red and glazed eyes, and a lasting cough.
Emotional personality change, sudden mood changes, irritability, irresponsible behavior, low self-esteem, poor judgment, depression, and a general lack of interest.
Family starting arguments, breaking rules, or withdrawing from the family.
School decreased interest, negative attitude, drop in grades, many absences, truancy, and discipline problems.
Social problems new friends who are less interested in standard home and school activities, problems with the law, and changes to less conventional styles in dress and music.

Some of the warning signs listed above can also be signs of other problems. Parents may recognize signs of trouble but should not be expected to make the diagnosis. An effective way for parents to show care and concern is to openly discuss the use and possible abuse of alcohol and other drugs with their teenager.

Consulting a physician to rule out physical causes of the warning signs is a good first step. This should be followed or accompanied by a comprehensive evaluation by a therapist.

Commonly asked questions
Q. Aren't beer and wine "safer" than liquor?
A. No. One 12-ounce beer has about as much alcohol as a 1.5-ounce shot of liquor, a 5-ounce glass of wine, or a wine cooler.

Q. Why can't teens drink if their parents can?
A. Teens' bodies are still developing and alcohol has a greater impact on their physical and mental well-being. For example, people who begin drinking before age 15 are four times more likely to develop alcoholism than those who begin at age 21.

Q. How can I say no to alcohol? I'm afraid I won't fit in.
A. Remember, you're in good company. The majority of teens don't drink alcohol. Also, it's not as hard to refuse as you might think. Try: "No thanks," "I don't drink," or "I'm not interested." Drugs and Alcohol: effects, dangers and addiction

Alcohol
The oldest and most widely used drug in the world, alcohol is a depressant that alters perceptions, emotions, and senses.

Effects & Dangers:
Alcohol first acts as a stimulant, and then it makes people feel relaxed and a bit sleepy. High doses of alcohol seriously affect people's judgment and coordination. Drinkers may have slurred speech, confusion, depression, short-term memory loss, and slow reaction times. Large volumes of alcohol drunk in a short period of time may cause alcohol poisoning. Addictiveness: Teens who use alcohol can become psychologically dependent upon it to feel good, deal with life, or handle stress. In addition, their bodies may demand more and more to achieve the same kind of high experienced in the beginning. Some teens are also at risk of becoming physically addicted to alcohol. Withdrawal from alcohol can be painful and even life-threatening. Symptoms range from shaking, sweating, nausea, anxiety, and depression to hallucinations, fever, and convulsions. Amphetamines
Amphetamines are stimulants that accelerate functions in the brain and body. They come in pills or tablets.

Prescription diet pills also fall into this category of drugs. Street Names: speed, uppers, dexies, bennies

How they're used: Amphetamines are swallowed, inhaled, or injected.

Effects & Dangers:
Swallowed or snorted, these drugs hit the user with a fast high, making them feel powerful, alert, and energized. Uppers pump up heart rate, breathing, and blood pressure, and they can also cause sweating, shaking, headaches, sleeplessness, and blurred vision. Prolonged use may cause hallucinations and intense paranoia. Addictiveness: Amphetamines are psychologically addictive. Users who stop report that they experience various mood problems such as aggression and anxiety and intense cravings for the drugs. Cocaine and Crack
Cocaine is a white crystalline powder made from the dried leaves of the coca plant. Crack, named for its crackle when heated, is made from cocaine. It looks like white or tan pellets.

Street Names for Cocaine: coke, snow, blow, nose candy, white, big C

Street Names for Crack: freebase, rock

How it's used: Cocaine is inhaled through the nose or injected. Crack is smoked.

Effects & Dangers:
Cocaine is a stimulant that rocks the central nervous system, giving users a quick, intense feeling of power and energy. Snorting highs last between 15 and 30 minutes; smoking highs last between 5 and 10 minutes. Cocaine also elevates heart rate, breathing rate, blood pressure, and body temperature.

Injecting cocaine can give you hepatitis or AIDS if you share needles with other users. Snorting can also put a hole inside the lining of your nose.

First-time users - even teens - of both cocaine and crack can stop breathing or have fatal heart attacks. Using either of these drugs even one time can kill you.

Addictiveness: These drugs are highly addictive, and as a result, the drug, not the user, calls the shots. Even after one use, cocaine and crack can create both physical and psychological cravings that make it very, very difficult for users to stop.

Depressants
Depressants, such as tranquilizers and barbiturates, calm nerves and relax muscles. Many are legally available by prescription (such as Valium and Xanax) and look like bright-colored capsules or tablets.

Street Names: downers, goof balls, barbs, ludes

How they're used: Depressants are swallowed.

Effects & Dangers:
When used as prescribed by a doctor and taken at the correct dosage, depressants can help people feel calm and reduce angry feelings. Larger doses can cause confusion, slurred speech, lack of coordination, and tremors. Very large doses can cause a person to stop breathing and result in death. Depressants and alcohol should never be mixed - this combination greatly increases the risk of overdose and death. Addictiveness: Depressants can cause both psychological and physical dependence. Ecstasy (MDMA)
This is a designer drug created by underground chemists. It comes in powder, tablet, or capsule form. Ecstasy is a popular club drug among teens because it is widely available at raves, dance clubs, and concerts.

Street Names: XTC, X, Adam, E, Roll

How It's Used: Ecstasy is swallowed or sometimes snorted.

Effects & Dangers:
This drug combines a hallucinogenic with a stimulant effect, making all emotions, both negative and positive, much more intense.

Users feel a tingly skin sensation and an increased heart rate.

Ecstasy can also cause dry mouth, cramps, blurred vision, chills, sweating, and nausea.

Many users also experience depression, paranoia, anxiety, and confusion.

Addictiveness: Although the physical addictiveness of Ecstasy is unknown, teens who use it can become psychologically dependent upon it to feel good, deal with life, or handle stress.

GHB
GHB, which stands for gamma-hydroxybutyrate, is often made in home basement labs, usually in the form of a liquid with no odor or color. It has gained popularity at dance clubs and raves and is a popular alternative to Ecstasy for some teens and young adults. The number of people brought to emergency rooms because of GHB side effects is quickly rising in the United States. And according to the U.S. Drug Enforcement Agency (DEA), since 1995 GHB has killed more users than Ecstasy.

Street Names: Liquid Ecstasy, G, Georgia Home Boy

How It's Used: When in liquid or powder form (mixed in water), GHB is drunk; in tablet form it is swallowed.

Effects & Dangers:
GHB is a depressant drug that can cause both euphoric (high) and hallucinogenic effects.

The drug has several dangerous side effects, including severe nausea, breathing problems, decreased heart rate, and seizures.

GHB has been used for date rape because it is colorless and odorless and easy to slip into drinks.

At high doses, users can lose consciousness within minutes. Overdosing GHB requires emergency care in a hospital right away. Within an hour GHB overdose can cause coma and stop someone's breathing, resulting in death.

GHB (even at lower doses) mixed with alcohol is very dangerous - using it even once can kill you.

Addictiveness: When users come off GHB they may have withdrawal symptoms such as insomnia and anxiety. Teens may also become dependent upon it to feel good, deal with life, or handle stress.

Heroin Heroin comes from the dried milk of the opium poppy, which is also used to create the class of painkillers called narcotics - medicines like codeine and morphine. Heroin can range from a white to dark brown powder to a sticky, tar-like substance.

Street Names: horse, smack, Big H, junk

How it's used: Heroin is injected, smoked, or inhaled (if it is pure).

Effects & Dangers:
Heroin gives you a burst of euphoric (high) feelings, especially if it's injected. This high is often followed by drowsiness, nausea, stomach cramps, and vomiting. Users feel the need to take more heroin as soon as possible just to feel good again.

With long-term use, heroin ravages the body. It is associated with chronic constipation, dry skin, scarred veins, and breathing problems.

Users who inject heroin often have collapsed veins and put themselves at risk of getting deadly infections such as HIV, hepatitis B or C, and bacterial endocarditis (inflammation of the lining of the heart) if they share needles with other users.

Addictiveness: Heroin is extremely addictive and easy to overdose on (which can cause death). Withdrawal is intense and symptoms include insomnia, vomiting, and muscle pain.

Inhalants
Inhalants are substances that are sniffed or "huffed" to give the user an immediate rush or high. They include household products like glues, paint thinners, dry cleaning fluids, gasoline, felt-tip marker fluid, correction fluid, hair spray, aerosol deodorants, and spray paint.

How it's used: Inhalants are breathed in directly from the original container (sniffing or snorting), from a plastic bag (bagging), or by holding an inhalant-soaked rag in the mouth (huffing).

Effects & Dangers:
Inhalants make you feel giddy and confused, as if you were drunk. Long-time users get headaches, nosebleeds, and may suffer loss of hearing and sense of smell.

Inhalants are the most likely of abused substances to cause severe toxic reaction and death. Using inhalants, even one time, can kill you.

Addictiveness: Inhalants can be very addictive. Teens who use inhalants can become psychologically dependent upon them to feel good, deal with life, or handle stress.

LSD
LSD (which stands for Lysergic Acid Diethylamide) is a lab-brewed hallucinogen and mood-changing chemical. LSD is odorless, colorless, and tasteless.

Street N

ames: acid, blotter, doses, microdots How it's used: LSD is licked or sucked off small squares of blotting paper. Capsules and liquid forms are swallowed. Paper squares containing acid may be decorated with cute cartoon characters or colorful designs.

Effects & Dangers:
Hallucinations occur within 30 to 90 minutes of dropping acid. People say their senses are intensified and distorted - they see colors or hear sounds with other delusions such as melting walls and a loss of any sense of time. But effects are unpredictable, depending on how much LSD is taken and the user.

Once you go on an acid trip, you can't get off until the drug is finished with you - at times up to about 12 hours or even longer!

Bad trips may cause panic attacks, confusion, depression, and frightening delusions.

Physical risks include sleeplessness, mangled speech, convulsions, increased heart rate, and coma.

Users often have flashbacks in which they feel some of the effects of LSD at a later time without having used the drug again.

Addictiveness: Teens who use it can become psychologically dependent upon it to feel good, deal with life, or handle stress.

Marijuana
The most widely used illegal drug in the United States, marijuana resembles green, brown, or gray dried parsley with stems or seeds. A stronger form of marijuana called hashish (hash) looks like brown or black cakes or balls.

Marijuana is often called a gateway drug because frequent use often leads to the use of stronger drugs.

Street Names: pot, weed, blunts, chronic, grass, reefer, herb, ganja How It's Used: Marijuana is typically smoked in cigarette (joints), hollowed-out cigars (blunts), pipes (bowls), or water pipes (bongs). Some people mix it into foods or brew it as a tea.

Effects & Dangers:
Marijuana can affect mood and coordination. Users may experience mood swings that range from stimulated or happy to drowsy or depressed.

Marijuana also elevates heart rate and blood pressure. Some people get red eyes and feel very sleepy or hungry. The drug can also make some people paranoid or cause them to hallucinate.

Marijuana is as tough on the lungs as cigarettes - steady smokers suffer coughs, wheezing, and frequent colds.

Addictiveness: Teens who use marijuana can become psychologically dependent upon it to feel good, deal with life, or handle stress. In addition, their bodies may demand more and more marijuana to achieve the same kind of high experienced in the beginning.

Methamphetamine
Methampetamine is a powerful stimulant.

Street Names: crank, meth, speed, crystal, chalk, fire, glass, crypto

How it's used: It can be swallowed, snorted, injected, or smoked.

Effects & Dangers:
Users feel a euphoric rush from methamphetamine, particularly if it is smoked or shot up. But they can develop tolerance quickly - and will use more meth for longer periods of time, resulting in sleeplessness, paranoia, and hallucinations.

Users sometimes have intense delusions such as believing that there are insects crawling under their skin. Prolonged use may result in violent, aggressive behavior, psychosis, and brain damage.

Addictiveness: Methamphetamine is highly addictive.

Nicotine
Nicotine is a highly addictive stimulant found in tobacco. This drug is quickly absorbed into the bloodstream when smoked.

How it's used: Nicotine is typically smoked in cigarettes or cigars. Some people put a pinch of tobacco (called chewing or smokeless tobacco) into their mouths and absorb nicotine through the lining of their mouths.

Effects & Dangers:
Physical effects include rapid heartbeat, increased blood pressure, shortness of breath, and a greater likelihood of colds and flu.

Nicotine users have an increased risk for lung and heart disease and stroke. Smokers also have bad breath and yellowed teeth. Chewing tobacco users may suffer from cancers of the mouth and neck.

Withdrawal symptoms include anxiety, anger, restlessness, and insomnia.

Addictiveness: Nicotine is as addictive as heroin or cocaine, which makes it extremely difficult to quit. Those who start smoking before the age of 21 have the hardest time breaking the habit.

What Are Abuse and Addiction?
Telling the difference between abuse and addiction is hard. Addiction begins as abuse, or usage of a substance like marijuana or cocaine. You can abuse a drug without having an addiction. For example, just because Sara smoked weed a few times doesn't mean that she has an addiction, but it does mean that she's abusing a drug - and that could lead to an addiction.

Addiction means having no control over whether to use a drug. A person who's addicted to cocaine has grown so used to the drug that he has to have it. Addiction can be physical, psychological, or both.

Physical addiction is when a person's body actually becomes dependent on a drug. It also means that a person builds tolerance to a drug, which means he needs a larger dose of that drug to get the same effects. When a person who is physically addicted stops using drugs, he may experience withdrawal symptoms. Withdrawal can be like having the flu - common symptoms are diarrhea, shaking, and generally feeling awful.

Psychological addiction may happen along with physical addiction or on its own. In this case, the cravings for a drug are psychological, or mental. People who are psychologically addicted feel overcome by the desire to have a drug. They may lie or steal to get it. An addicted person - whether it's a physical or psychological addiction or both - no longer has a choice.

An addiction is not just measured by how many times a person uses a drug. Some drugs, like crack or heroin, are so addictive that they may only be used once or twice before the user loses control. A person crosses the line between abuse and addiction when he's no longer trying the drug to have fun or get high, but because he's come to depend on it. His whole life centers around the need for the drug.

Signs of Addiction:
The basic sign of an addiction is a need to have the drug or substance. However, there are many other symptoms that can suggest a possible addiction. The important thing to remember is that drastic physical or mental changes in someone represent a big problem.

Common signs and symptoms of addiction may actually be caused by other conditions, too, such as depression or eating disorders. That's why it's so important to get help, no matter what the problem is.

Warning Signs:
Psychological symptoms:
Do you see drugs as the solution to problems?
Do you spend a lot of time figuring out how you can get drugs?
Do you steal money or sell belongings to be able to afford drugs?
Have you been withdrawing from your relationships with your friends or family?
Have you lost interest in school, sports, or hobbies that used to be important to you? Have your grades slipped?
Are you experiencing anxiety or depression?
Are you keeping secrets from your friends or family?
Do you only hang out with friends who use drugs?
Have you tried to stop using drugs but can't?
Do you feel like you can't control your moods? Have friends or family members expressed concern about your mood swings?

Physical symptoms:
Have your sleeping habits changed?
Has your physical health been affected by drugs?
Do you feel shaky or sick when you try to stop using drugs?
Do you keep needing to take more of the drug to get the same effect?
Have your eating habits changed? Have you lost or gained weight for no apparent reason?

Friends have a big influence on teenagers overall, but girls are particularly susceptible to peer pressure when it comes to drinking. Adolescent girls are more likely than boys to drink to fit in with their friends, while boys drink largely for other reasons and then join a group that also drinks.

Girls often are introduced to alcohol by their boyfriends, who may be older and more likely to drink. Additionally, depression has been found to be higher in teenage girls than in boys. One study found symptoms of depression among one in four girls.

Why do Males and Females Respond Differently to Alcohol?
Females process alcohol differently than males; smaller amounts of alcohol are more intoxicating for females regardless of their size.

Three physiological differences may explain this:
Females have less body water than males. When people drink, alcohol spreads into the water in their bodies. Because females have smaller amounts of body water to dilute the alcohol, they have higher concentrations of alcohol in their blood than males have after drinking identical amounts of alcohol.

An enzyme that is important in metabolizing or processing alcohol works differently in females than in males. In males, the enzyme - called alcohol dehydrogenase - breaks down much of the alcohol in the stomach so that less of it enters the circulatory system. In females, the enzyme is less active.

Changing hormone levels during the menstrual cycle may affect the rate of alcohol metabolism in females.

Activities: For Teens
Lesson Objectives:
Students will be able to say "no" using several different approaches.
Grade Level and Subject Area:
9-12
Materials:
"How to Say No" idea sheet

Activities and Strategies:
Have students read the "How to Say No" idea sheet. Have students write a situation in which they would feel pressured to say "Yes" on a slip of paper. While they do this, you should make slips of paper for each strategy listed on the "How to Say No" sheet. Fold them and put them in a "Strategies" container. Have students fold their scenarios and place them in a container marked "Scenarios." Have students volunteer to act out the scenarios or break them into smaller groups so they will all have turns to practice. Each student actor will pick a slip from the "Strategies" container as well as one from the "Scenarios" container. A variation on this would be to have the student who draws the scenario and strategy read them and choose the cast to play out the scene.

Adapted from Substance Abuse Prevention Activities for Secondary Students. By Patricia J. Gerne and Timothy A. Gerne. Published by Prentice Hall in 1991.

"How to Say No" Idea Sheet

Strategy (Say no...)	Explanation (A)/Example(B)
with Directness	A. Be confident, look them in the eye B. "No, thanks!" (You don't need to offer an explanation!) "Nope, I'm not interested!" "Not tonight"
with Humor	A. Use a quick, witty comment that ends the conversation. B. When asked if you want to smoke say, "No thanks, I'm not a chimney!"
with a Friend	A. Plan with a friend beforehand what each of you will or will not do and stick together. B. "I'll pass" (you know your friend will also pass - this also creates peer pressure back to the other person NOT to do whatever they wanted you to do!)
with an Exit	A. Plan ways to physically relocate in case of an uncomfortable situation. B. Go to the bathroom, the next room, out on a walk, or home.
with an Excuse	A. Pass the responsibility off on someone else. B. "I'm going to the dentist and I don't want my breath to smell like cigarettes." "No thanks. The coach won't let me play if I do."
with an Invitation	A. Leave the door open for future activities. B. "I can't stay now, but how about if we go to a movie later."
with Imagination	A. Think of ways to totally change the focus. B. Change the topic; give a compliment; ask an unrelated question; etc.

Lesson Objectives:
Students will be able to identify the aspects of peer pressure to which they may be most susceptible.
Grade Level and Subject Area:
9-12: Health Education.
Materials:
Masking tape

Activities and Strategies: Make a long line on the floor out of masking tape. Put a sign on one end that says "10: Feel strongly for the issue" and a sign on the opposite end saying, "1: Feel strongly against the issue." You may also want to put a sign with "5" on it in the middle of the line. Explain to the class the sometimes it takes a strong will and a lot of courage to go against one's peers. Ask for a volunteer to "take a stand" on a controversial issue.

For example:
"The school should allow students to leave during lunch."
"A woman should be able to hold down ANY job a man can hold down in the work place."
"This school should have uniforms."
"Teens shouldn't need their parents permission to buy CD's with explicit lyrics on them."
Have the volunteer stand at the point on the line that indicates his/her position on the issue.
Have the rest of the class try to pressure the volunteer into moving by making compelling arguments for or against the issue.
Encourage them to be persistent. Let them make promises, etc.

After a few minutes, stop the class and discuss the activity.
How did the volunteer change his/her mind?
How did it feel to be under so much pressure?
How did it feel to give the pressure?
What arguments would convince you to move? Why?
This activity should be followed by information about decision-making and coping skills.

Lesson Objectives:
Students will be able to discuss people's opinions about drug use. Students will be able to see how many people use drugs or alcohol at their school.
Grade Level and Subject Area:
6-7/Health Education
Materials:
Completed and tallied drug use survey (from ALL 6th and 7th graders)
Four signs posted on different walls in the classroom - one with each of the following:
Agree
Strongly agree
Disagree
Strongly disagree

Preparation:
Have the students complete a drug use survey before the class period when you will do this activity. Then, tally the numbers for each category to have as statistical information to present to the class. (Note: If the results of the survey look inaccurate, use these national averages: 24.6% of 8th graders have used alcohol in the past thirty days, 8.5% have been drunk in the past 30 days.) Write the percentages for each category on the board so students can see them when they enter the room. Its most effective to remind students that numbers such as 20% equal 1 in 5 students.

Activities:
Discuss the results of the drug survey. Remind students that ALL 6th and 7th graders responded. Explain that the following activity will help the student learn to discuss people's feelings about drug use. Point out the four signs and explain that you will read a statement and the students will go to the sign that reflects their opinion. Tell the students that they can choose to stand under any sign, but they need to be able to explain why they chose the sign they did.

Read one of the following statements:

People should not drink and drive.
Most people your age at this school drink alcohol frequently (at least once a month)
Smoking cigarettes will make a kid very popular.
It's cool to get drunk.
It's okay to get drunk at weddings.
I would prefer to have friends who didn't smoke marijuana.
People my age who drink know how to enjoy life more.

Have students move to the sign that reflects their opinion. Discuss the statement and the students' opinions. Here are some sample questions for discussion:

What is your opinion of this statement? Why do you feel this way? Ask another student, "Do you agree with what that person said?" Why or why not? There are few people (or no one) standing under the "disagree" (OR other appropriate sign), why do you think this is the case? Are you standing under the sign because it is how you really feel or did you think that is where I wanted you to stand? For those of you who agree with this statement, who remembers the actual number of people your age who drink (OR smoke, etc.) at least once a month? Review the statistics if necessary make sure it is clear that most people do not drink. Do you think our school is the same as other schools regarding alcohol/tobacco/drug use? Why or why not? What could you say to someone who tried to tell you that smoking/drinking/using drugs would help you fit in? Look around the room at where everybody is standing. What does that tell you about the people in this class? Think of your best friend. If he or she told you that its cool to get drunk, would you agree? What would you think of your friend?

Read more statements and discuss them as time permits.
When time is up, have student return to their seats. Compliment them for standing up for their opinions and listening to others' opinions. Pose the following question to the students and have them discuss:

Suppose a new kid just moved into your neighborhood and wanted to know how you, as a class, felt about alcohol and drug use. What would you tell him or her?

Review the main points of this exercise: Most students do not use drugs Students don't need to fall for peer pressure because they know that, in fact, most people do not use drugs

Drug Use Survey
Instructions: Answer the following questions as honestly as possible. Your answers will be tallied and used in class as part of a future lesson.

1. Have you had any alcohol to drink in the last 30 days?
    YES - just a few sips    YES - more than a few sips    NO

2. Have you smoked one or more cigarettes in the last 30 days?
    YES    NO

3. Have you smoked one or more marijuana cigarettes in the last 30 days?
    YES    NO

4. Have you been drunk or felt drunk from drinking alcohol in the past 30 days?
    YES    NO

5. Do you think you might drink at least some alcohol every month two years from now?
    YES    NO

6. Do you think you might try smoking cigarettes two years from now?
    YES    NO

7. Do you think you might try smoking marijuana two years form now?
    YES    NO

What is A.A.?
Alcoholics Anonymous is a voluntary, worldwide fellowship of men and women from all walks of life who meet together to attain and maintain sobriety. The only requirement for membership is a desire to stop drinking. There are no dues or fees for A.A. membership.

Current Membership
It is estimated that there are more than 100,000 groups and over 2,000,000 members in 150 countries.

Relations With Outside Agencies
The Fellowship has adopted a policy of ?cooperation but not affiliation? with other organizations concerned with the problem of alcoholism. We have no opinion on issues outside A.A. and neither endorse nor oppose any causes.

How A.A. Is Supported
Over the years, Alcoholics Anonymous has affirmed and strengthened a tradition of being fully self-supporting and of neither seeking nor accepting contributions from nonmembers. Within the Fellowship, the amount that may be contributed by any individual member is limited to $2,000 a year.

How A.A. Members Maintain Sobriety
A.A. is a program of total abstinence. Members simply stay away from one drink, one day at a time. Sobriety is maintained through sharing experience, strength and hope at group meetings and through the suggested Twelve Steps for recovery from alcoholism.

Why Alcoholics Anonymous Is "Anonymous"
Anonymity is the spiritual foundation of A.A. It disciplines the Fellowship to govern itself by principles rather than personalities. We are a society of peers. We strive to make known our program of recovery, not individuals who participate in the program. Anonymity in the public media is assurance to all A.A.s, especially to newcomers, that their A.A. membership will not be disclosed.

Anyone May Attend A.A. Open Meetings
Anyone may attend open meetings of A.A. These usually consist of talks by a leader and two or three speakers who share experience as it relates to their alcoholism and their recovery in A.A. Some meetings are held for the specific purpose of informing the nonalcoholic public about A.A. Doctors, members of the clergy, and public officials are invited. Closed discussion meetings are for alcoholics only.

How A.A. Started
A.A. was started in 1935 by a New York stockbroker and an Ohio surgeon (both now deceased), who had been hopeless drunks. They founded A.A. in an effort to help others who suffered from the disease of alcoholism and to stay sober themselves. A.A. grew with the formation of autonomous groups, first in the United States and then around the world.

How You Can Find A.A. In Your Town
Look for Alcoholics Anonymous in any telephone directory. In most urban areas, a central A.A. office, or intergroup, staffed mainly by volunteer A.A.s, will be happy to answer your questions and/or put you in touch with those who can.

What A.A. Does Not Do
A.A. does not: Keep membership records or case histories, engage in or support research, join councils or social agencies (although A.A. members, groups and service offices frequently cooperate with them), follow up or try to control its members, make medical or psychiatric prognoses or dispense medicines or psychiatric advise, provide drying-out or nursing services or sanitariums, offer religious services, provide housing, food, clothing, jobs, money, or other welfare or social services, provide domestic or vocational counseling, provide letters of reference to parole boards, lawyers, court officials, social agencies, employers, etc.

The Recovery Program
Upon attending only a few meetings, the newcomer is sure to hear references to such things as "the Twelve Steps, "the Twelve Traditions, " "slips, " "the Big Book, and other expressions characteristic of A.A. The following Paragraphs describe these factors and suggest why they are mentioned frequently by A.A. speakers.

What are the 'Twelve Steps'?
The "Twelve Steps" are the core of the A.A. program of personal recovery from alcoholism. They are not abstract theories; they are based on the trial-and-error experience of early members of A.A. They describe the attitudes and activities that these early members believe were important in helping them to achieve sobriety. Acceptance of the "Twelve Steps" is not mandatory in any sense.

Experience suggests, however, that members who make an earnest effort to follow these Steps and to apply them in daily living seem to get far more out of A.A. than do those members who seem to regard the Steps casually. It has been said that it is virtually impossible to follow all the Steps literally, day in and day out. While this may be true, in the sense that the Twelve Steps represent an approach to living that is totally new for most alcoholics, many A.A. members feel that the Steps are a practical necessity if they are to maintain their sobriety.

Here is the text of the Twelve Steps, which first appeared in Alcoholics Anonymous, the A.A. book of experience:

1. We admitted we were powerless over alcohol - that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our short-comings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

What are the 'Twelve Traditions'?
The "Twelve Traditions" of A.A. are suggested principles to insure the survival and growth of the thousands of groups that make up the Fellowship. They are based on the experience of the groups themselves during the critical early years of the movement.

The Traditions are important to both old-timers and newcomers as reminders of the true foundations of A.A. as a society of men and women whose primary concern is to maintain their own sobriety and help others to achieve sobriety:

1. Our common welfare should come first; personal recovery depends upon A.A. unity.
2. For our group purpose there is but one ultimate authority a loving God as He may express Himself in our group conscience. Our leaders are but trusted servants; they do not govern.
3. The only requirement for A.A. membership is a desire to stop drinking.
4. Each group should be autonomous except in matters affecting other groups or A.A. as a whole.
5. Each group has but one primary purpose - to carry its message to the alcoholic who still suffers.
6. An A.A. group ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.
7. Every A.A. group ought to be fully self-supporting, declining outside contributions.
8. Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers.
9. A.A., as such, ought never be organized; but we may create service boards or committees directly responsible to those they serve.
10. Alcoholics Anonymous has no opinion on outside issues; hence the A.A. name ought never be drawn into public controversy.
11. Our public relations policy is based on attraction rather than promotion; we need always maintain personal anonymity at the level of press, radio, and films.
12. Anonymity is the spiritual foundation of all our traditions, ever reminding us to place principles before personalities.

What are 'slips'?
Occasionally a man or women who has been sober through A.A. will get drunk. In A.A. a relapse of this type is commonly known as a "slip." It may occur during the first few weeks or months of sobriety or after the alcoholic has been dry a number of years.

Nearly all A.A.s who have been through this experience say that slips can be traced to specific causes. They deliberately forgot that they had admitted they were alcoholics and got overconfident about their ability to handle alcohol. Or they stayed away from A.A. meetings or from informal association with other A.A.s. Or they let themselves become too involved with business or social affairs to remember the importance of being sober. Or they let themselves become tired and were caught with their mental and emotional defenses down. In other words, most "slips" don't just happen.

Does A.A. have a basic 'textbook'?
The Fellowship has four books that are generally accepted as "textbooks." The first is Alcoholics Anonymous, also known as "the Big Book," originally published in 1939, revised in 1955 and 1976. It records the personal stories of 42 representative problem drinkers who achieved stable sobriety for the first time through A.A. It also records the suggested steps and principles that early members believed were responsible for their ability to overcome the compulsion to drink.

The second book is Twelve Steps and Twelve Traditions, published in 1953. It is an interpretation, by Bill W., a co-founder, of the principles that have thus far assured the continuing survival of individuals and groups within A.A.

A third book, Alcoholics Anonymous Comes of Age, published in 1957, is a brief history of the first two decades of the Fellowship.

The fourth is As Bill Sees It (formerly titled The A.A. Way of Life, a reader by Bill). This is a selection of Bill W.'s writings.

These books may be purchased through local A.A. groups or ordered direct from Alcoholics Anonymous, Box 459, Grand Central Station, New York, NY 10163.

What is 'the 24-hour program'?
"The 24-hour program" is a phrase used to describe a basic A.A. approach to the problem of staying sober. A.A.s never swear off alcohol for life, never take pledges committing themselves not to take a drink "tomorrow." By the time they turned to A.A. for help, they had discovered that, no matter how sincere they may have been in promising themselves to abstain from alcohol "in the future," somehow they forgot the pledge and got drunk. The compulsion to drink proved more powerful than the best intentions not to drink. The A.A. member recognizes that the biggest problem is to stay sober now! The current 24 hours is the only period the A.A. can do anything about as far as drinking is concerned. Yesterday is gone. Tomorrow never comes. "But today," the A.A. says, "today, I will not take a drink. I may be tempted to take a drink tomorrow - and perhaps I will. But tomorrow is something to worry about when it comes. My big problem is not to take a drink during this 24 hours. Along with the 24-hour program, A.A. emphasizes the importance of three slogans that have probably been heard many times by the newcomer before joining A.A. These slogans are: "Easy Does It," "Live and Let Live," and "First Things First." By making these slogans a basic part of the attitude toward problems of daily living, the average A.A. is usually helped substantially in the attempt to live successfully without alcohol.

What is the A.A. Grapevine?
The Grapevine is a monthly pocket-size magazine published for members and friends who seek further sharing of A.A. experience. The only international journal of the Society, the Grapevine is edited by a staff made up entirely of A.A.s.. Single copies of the magazine are usually available each month at meetings of local groups, but most readers prefer to receive their copies on a regular subscription basis. In the U.S. the cost of annual subscription is $15.00, slightly more - in Canada; single copies are $1.50.

Why doesn't A.A. seem to work
for some people?
The answer is that A.A. will work only for those who admit that they are alcoholics, who honestly want to stop drinking and who are able to keep those facts uppermost in their minds at all times.

A.A. usually will not work for the man or woman who has reservations about whether or not he or she is an alcoholic, or who clings to the hope of being able to drink normally again.

Most medical authorities say no one who is an alcoholic can ever drink normally again. The alcoholic must admit and accept this cardinal fact. Coupled with this admission and acceptance must be the desire to stop drinking.

After they have been sober a while in A.A., some people tend to forget that they are alcoholics, with all that this diagnosis implies. Their sobriety makes them overconfident, and they decide to experiment with alcohol again. The results of such experiments are, for the alcoholic, completely predictable. Their drinking invariably becomes progressively worse.

A.A. is Not a religious organization (taken from the Alcoholics Anonymous website) Perhaps the alcoholic in your life thinks that A.A. is an evangelical organization, heavy on religion and preaching. Again, the facts are different. A.A. has been described as, basically, a spiritual program. To be sure, it does not offer any material help, as a welfare department would. But A.A. is certainly not a religious organization. It does not ask its members to hold to any formal creed or perform any ritual or even to believe in God. Its members belong to all kinds of churches. Many belong to none. A.A. asks only that newcomers keep an open mind and respect the beliefs of others. A.A. holds that alcoholism, in addition to being a physical and emotional illness, is also a spiritual disorder to some degree. Because most alcoholics have been unable to manage things on their own, they seem to find effective therapy in the decision to turn their destiny over to a power greater than themselves. Many A.A.s refer to this power as "God." Others consider the A.A. group as the power to be relied upon. The word "spiritual" in A.A. may be interpreted as broadly as one wants. Certainly, one feels a certain spirit of togetherness at all A.A. meetings.

Here are 16 Steps for Discovery and Empowerment

1. We affirm we have the power to take charge of our lives and stop being dependent on substances or other people for our self-esteem and security. Alternative: We admit/acknowledge we are out of control with/powerless over ________________, yet have the power to take charge of our lives and stop being dependent on substances or other people for our self-esteem and security.
2. We come to believe that God/Goddess/Universe/Great Spirit/Higher Power awakens the healing wisdom within us when we open ourselves to that power.
3. We make a decision to become our authentic selves and trust in the healing power of the truth.
4. We examine our beliefs, addictions, and dependent behavior in the context of living in a hierarch1cal, patriarchal culture.
5. We share with another person and the universe all those things inside of us for which we feel shame and guilt.
6. We affirm and enjoy our intelligence, strengths, and creativity, remembering not to hide these qualities from ourselves and others.
7. We become willing to let go of shame, guilt, and any behavior that prevents us from loving ourselves and others.
8. We make a list of people we have harmed and people who have harmed us, and take steps to clear out negative energy by making amends and sharing our grievances in a respectful way.
9. We express love and gratitude to others and increasingly appreciate the wonder of life and the blessings we do have.
10. We learn to trust our reality and daily affirm that we see what we see, we know what we know and we feel what we feel.
11. We promptly admit to mistakes and make amends when appropriate, but we do not say we are sorry for things we have not done and we do not cover up, analyze or take responsibility for the shortcomings of others.
12. We seek out situations, jobs, and people that affirm our intelligence, perceptions, and self-worth and avoid situations or people who are hurtful, harmful, or demeaning to us.
13. We take steps to heal our physical bodies, organize our lives, reduce stress, and have fun.
14. We seek to find our inward calling, and develop the will and wisdom to follow it.
15. We accept the ups and downs of life as natural events that can be used as lessons for our growth.
16. We grow in awareness that we are sacred beings, interrelated with all living things, and we contribute to restoring peace and balance on the planet.

You are free to make copies of these steps as long as credit is given to:
Charlotte Kasl, 1991, Many Roads, One Journey: Moving Beyond the 12 Steps.
Charlotte Kasl, P.0. Box 1302, Lolo MT 59847

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