Pubdate: Tue, 16 Aug 2005
Source: New York Times (NY)
Section: Health
Page: F6
Copyright: 2005 The New York Times Company
Author: Sally Satel, M.D.
Note: Sally Satel is a psychiatrist and resident scholar at the 
American Enterprise Institute and a co-author of "One Nation Under Therapy."
Bookmark: (Opinion)
Bookmark: (Treatment)
Bookmark: (Marijuana)
Bookmark: (Cocaine)
Bookmark: (Heroin)
Bookmark: (Methadone)
Bookmark: (Methamphetamine)
Bookmark: (Oxycontin/Oxycodone)


Patients arrive broke, busted or abandoned at our methadone clinic in 
a raw section of Northeast Washington. They are opiate addicts, 
primarily dependent on heroin, though some take vast doses of 
street-bought painkillers like OxyContin.

Drinking the pink methadone solution every day prevents withdrawal sickness.

About half of our patients have also spent years on crack or alcohol. 
Not all have stopped, but at least they have cut back. We see almost 
no methamphetamine users, but that is a simple accident of geography 
- - the corrosive drug hasn't yet reached epidemic proportions in this 
part of the country.

The personal ravages of hard-core addiction are enormous, and they 
translate into enormous social costs - crime, violence, 
incarceration, homelessness, unemployment, hepatitis C, H.I.V./AIDS.

Such an immense burden makes me wonder about the wisdom of federal priorities.

Why is marijuana, of all drugs, the main target of the White House 
Office of National Drug Control Policy?

Answer: the gateway theory of addiction. Start with marijuana, the 
idea is, and progress to methamphetamine or heroin or cocaine.

To me, the "gateway" assumption, which took root in the 1950's, has a 
nostalgic, "Reefer Madness" feel. But it is still driving federal 
policy. The drug czar's office made that clear last month in response 
to a call from the National Association of Counties "to put the same 
kind of emphasis on methamphetamine abuse as they have on marijuana." 
The association had just announced that its 500 members were reeling 
from methamphetamine-related crime, incarceration and child-neglect.

The Office of National Drug Control Policy defended its 
prioritization. Addressing "early marijuana use is an effective way 
of heading off and preventing subsequent movement into other drug 
use," said a spokesman for the drug czar on National Public Radio.

Is this true? Is the gateway argument a valid justification for 
marijuana policy?

No reasonable person disputes that most users of cocaine and heroin 
have smoked marijuana earlier in life. Likewise, the more frequently 
people consume marijuana the more likely they are to try hard drugs.

But what is the nature of the linkage? Is it actual cause and effect, 
as the drug czar's office implied, or a correlation based on a common 
factor that predisposes youth to drug use in general? And how 
frequently do we observe such a progression?

One theory is that teenagers who smoke marijuana without incident are 
emboldened by the experience to try other more risky and exotic 
drugs. And perhaps buying marijuana brings them in contact with 
dealers of stronger drugs.

Or possibly cocaine and heroin abusers would have developed their 
drug problems no matter what. As RAND researchers reported in a 2002 
article, "Reassessing the Marijuana Gateway Effect," "Marijuana use 
precedes hard drug use simply because opportunities to use marijuana 
come earlier in life than opportunities to use hard drugs."

A relatively newer theory suggests that marijuana sets up the user's 
brain to be more receptive to harder drugs. A much-publicized 1997 
study from the Scripps Research Institute reported that cannabis 
activates the same reward circuitry in the brain as cocaine, heroin, 
tobacco and alcohol. But this has dubious relevance to future 
addiction. After all, almost any normal pleasurable activity, like 
eating or sex, also stimulates those pathways.

In any event, a brain activation effect couldn't be too powerful, as 
most casual marijuana smokers do not graduate to the abuse of hard 
drugs. Only about 3 percent of monthly cannabis users go on to try a 
hard drug in the same year, according to data from the National 
Survey on Drug Use and Health. And roughly one-fifth of those who try 
cocaine eventually become addicted; perhaps one-third of heroin 
experimenters do.

Social scientists have found that adolescents who progress to hard 
drugs are already quite troubled to begin with. Truancy, failing in 
school, fighting, stealing and drinking often come before heroin or 
cocaine involvement. Marijuana use before age 15 is also a red flag 
indicating psychological turmoil and social instability.

By contrast, older teenagers who experiment with marijuana generally 
function as well as nonusers with respect to school and mental well-being.

These observations are consistent with my own clinical experience.

As staff psychiatrist for the clinic, I have taken over 500 detailed 
histories of adults with opiate addictions. Marijuana was the least 
of their problems when they were young. More often, they were 
staggering under the weight of a chaotic home life and had dropped 
out school, committed petty crimes and battled depression. These 
problems, not marijuana, led them to hard drugs.

Efforts to prevent new generations of addicts are noble, but they 
should be rational too. It's hard to say whether any one policy a 
drug czar could devise would have derailed the early trajectories of 
my patients' lives. But it is clear that such a large investment in 
the gateway theory has been of little help. 
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MAP posted-by: Richard Lake