A Conversation About
the Gateway Myth

In March 1999, the Institute of Medicine released its long awaited report on Medical marijuana. This came about as a result of the California voters passing a measure to lgalize medical marijuana. The Drug Czar, Barry McCaffrey first threateded California doctors who might recommend marijuana to their patients, then insisted that medical marijuana use should be based on more scientific research, which he commissioned to make the appropriate findings.

Here is a brief excerpt from the executive summary of the complete IOM report:

Public opinion on the medical value of marijuana has been sharply divided. Some dismiss medical marijuana as a hoax that exploits our natural compassion for the sick; others claim it is a uniquely soothing medicine that has been withheld from patients through regulations based on false claims. In January 1997, the White House Office of National Drug Control Policy (ONDCP) asked the Institute of Medicine to conduct a review of the scientific evidence to assess the potential health benefits and risks of marijuana and its constituent cannabinoids).
The ONDCP request came in the wake of state "medical marijuana" initiatives. In November 1996, voters in California and Arizona passed referenda designed to permit the use of marijuana as medicine. Although Arizona's referendum was invalidated five months later, the referenda galvanized a national response. In November 1998, voters in six states (Alaska, Arizona, Colorado, Nevada, Oregon, and Washington) passed ballot initiatives in support of medical marijuana.

In contrast with the many disagreements bearing on social issues, the study team found substantial consensus among experts in the relevant disciplines on the scientific evidence about potential medical uses of marijuana.

This report summarizes and analyzes what is known about the medical use of marijuana, it emphasizes evidence-based medicine (derived from knowledge and experience informed by rigorous scientific analysis), as opposed to belief-based medicine (derived from judgment, intuition, and beliefs untested by rigorous science).

Among the numerous articles and essays that appeared on the subject in the U.S. press following the release of the report, Joe Califano's opinion piece in the Wall Street Journal on March x, 1999 rushed to defend the infamous Gateway Myth. This essay is included below. A few days later, the Journal published four letters that countered Califano's support for the Gateway Myth. Also included is a very useful perspective on Gateway by Alan Bock.

Califano's Essay

Fri, 26 Mar 1999
Wall Street Journal (NY)


"FEDS GO TO POT" screamed the New York Post headline last week, after the Institute of Medicine released its report "Marijuana and Medicine: Assessing the Science Base." The Associated Press reported that the IOM had found "there was no conclusive evidence that marijuana use leads to harder drugs."

A look at the actual report shows that these press accounts are misleading. Consider these words from the report: "Not surprisingly, most users of other illicit drugs have used marijuana first.  In fact, most drug users begin with alcohol and nicotine before marijuana-usually before they are of legal age. In the sense that marijuana use typically precedes rather than follows initiation of other illicit drug use, it is indeed a 'gateway' drug.  But because underage smoking and alcohol use typically precede marijuana use, marijuana is not the most common and is rarely the first, 'gateway' to illicit drug use."

Those are the words that precede the tentatively worded statement the AP paraphrased: "There is no conclusive evidence that the drug effects of marijuana are causally linked to the subsequent abuse of other illicit drugs." The report notes, however, that "people who enjoy the effects of marijuana are, logically, more likely to be willing to try other mind-altering drugs than are people who are not willing to try marijuana or who dislike its effects.  In other words, many of the factors associated with a willingness to use marijuana are, presumably, the same as those associated with a willingness to use other illicit drugs.  " And the report recognizes "intensity" of marijuana use as increasing the risk of progression to other drugs.

The medical benefits and risks of marijuana-the subjects to which the report devotes most of its attention -are matters for doctors, scientists and the Food and Drug Administration.  The potential of marijuana as a gateway drug is a matter of concern for teenagers, parents and policy makers.

The IOM's brief, three-page discussion of the gateway issue fails to discuss mounting statistical and scientific evidence that children who smoke pot are much likelier than those who don't to use drugs like cocaine, heroin and LSD.  And the press coverage has been dangerously deceptive.

The Institute of Medicine study fails to discuss mounting scientific evidence that children who smoke pot are much likelier to use drugs like cocaine, heroin and LSD.

I have not read or heard in any news report the important finding that "the ...  interpretation .  .  .  that marijuana serves as a gateway to the world of illegal drugs in which youths have greater opportunity and are under greater social pressure to try other illegal drugs ...  is the interpretation most often used in the scientific literature, and is supported by-although not proven by the available data."

The National Center on Addiction and Substance Abuse, which I head, analyzed the data from the Centers for Disease Control and Prevention's 1995 Youth Risk Behavior Survey of 1l, 000 ninth-through 12th graders, adjusting for other risk factors such as repeated acts of violence and sexual promiscuity.

The correlations are potent:

* Teens who drank and smoked cigarettes at least once in the past month are 30 times more likely to smoke marijuana than those who didn't.

* Teens who drank, smoked cigarettes, and used marijuana at least once in the past month are more than 16 times as likely to use another drug like cocaine, heroin or LSD.

To appreciate the significance of these relationships, consider this: The first Surgeon General's report on smoking and health found a nine to 10 times greater risk of lung cancer among smokers.  The early returns from the monumental Framingham heart study found that individuals with high cholesterol were two to four times as likely to suffer heart disease.

Most people who smoke pot do not move on to other drugs, but then only 5% to 7% of cigarette smokers get lung cancer.  The point for parents and teens is that those youngsters who smoke pot are at vastly greater risk of moving on to harder drugs.  CASA'S studies reveal that the younger and more often a teen smokes pot, the more likely that teen is to use cocaine.  A child who uses marijuana before age 12 is 42 times more likely to use cocaine, heroin or other drugs than one who first smokes pot after age 16.

The IOM report also fails to discuss findings of recent scientific studies that suggest some of the reasons for this high correlation.  Studies in Italy reveal that marijuana affects levels of dopamine (the substance that gives pleasure) in the brain in a manner similar to heroin.  Gaetana DiChiara, the physician who led this work at the University of Cagliari, indicates that marijuana may prime the brain to seek substances that act in a similar way. Studies in the U.S.  have found that nicotine, cocaine and alcohol also affect dopamine levels.

Nor does the IOM report mention studies at the distinguished Scripps Research Institute in California and Cumplutense University in Madrid which found that rats subjected to immediate cannabis withdrawl exhibited changes in behavior similar to those seen after withdrawal of alcohol, cocaine and opiates, Science magazine called this "the first neurological basis for a marijuana withdrawal syndrome, and one with a strong emotional component shared by other drugs." Alan Leshner, director of the National Institute on Drug Abuse, has estimated that at least 100,000 individuals are in treatment because of marijuana use.  Most are believed to be teenagers.

Our concern should be to prevent teen drug use.  We know that someone who gets to age 21 without smoking, using drugs or abusing alcohol is virtually certain never to do so.  We have known for some time, as the IOM report confirms that marijuana harms short-term memory, motor skills and the ability to concentrate, attributes teenagers need when they are learning in school.

Parents, teachers and clergy need to send teens a clear message: Stay away from pot.  The incompleteness of the IOM report and the press's sloppy summaries of it must not be permitted to dilute that message.

In reponse, four letters in the Wall Street Journal, 31 Mar 1999


In his March 26 editorial-page commentary "The Grass Roots of Teen Drug Abuse," Joe Califano says the statistical correlation is so strong that there must be a gateway-type connection between marijuana and hard drug use.  He has been pushing this nonsense for too long. Statistical correlations are the weakest form of proof that exists, and are the easiest numbers to fiddle with.

In the 1950s the feds proved that cancer was caused by emanations from telephone wires.  Eagle-eyed researchers noticed more cancers occurred close to phone wires.  Of course, someone quickly pointed out that since more people live near phone wires, there is bound to be more of everything near them, even cancer.

Using Mr. Califano's false logic, I can prove with statistical precision that eating bread leads directly to a life of crime.  I can prove that working 40 hours a week is self-inflicted suicide since it leads directly to the grave.  I can also prove that people like "Smoking Joe" have caused more damage to this nation's children than all the marijuana that has ever been consumed.

Arthur Sobey
Norfolk, Neb.

* Some ideas are like the fictional Jason, who inspired "Friday the 13" and multiple sequels: they simply cannot be killed.  Clearly, the "gateway" canard, invented by Harry Anslinger and defended by Joe Califano, falls into that category.  Anslinger was nothing if not inventive; the effects of cannabis were so universally unknown in the mid-1930s that he was able to claim (successfully) that it provokes casual users to murderous rage.  Nowadays, thanks to the success of the criminal market he campaigned for, that idea would be hooted off the stage.

Gateway and numerous sons of gateway have proven far more durable than "reefer madness," probably because there is a strong correlation (acknowledged in the IOM report) between use of tobacco, alcohol, cannabis and other drugs.  This is the obverse of Mr. Califano's other nugget: people who haven't used any drugs at all by age 21 are unlikely to do so.  Perhaps the most reasonable interpretation of his tortured "data" is that some people are much more likely to use drugs than others, a tendency usually expressed during their teen years. Unfortunately for Mr. Califano's purposes, that interpretation could hardly justify arresting 700,000 people a year in a futile attempt to shut one gateway while allowing two others to gape invitingly.

Mark Honts
Fort Worth, Texas

* Even Mr. Califano's own organization, the National Center of Addiction and Substance Abuse (CASA), admits in its 1994 report on "gateway drugs" that a biomedical or causal relationship has not been established.  Many unbiased experts believe that the most likely relationship between the use of marijuana and harder drugs is a person's propensity for risk-taking, which may even be exacerbated by the illicit market in marijuana, created by prohibition, which routinely exposes children and adults to harder drugs.

In its landmark March 1999 report of marijuana's health effects, the Institute of Medicine agreed: There is no evidence that marijuana serves as a stepping stone on the basis of its particular drug effect. In 1998, the World Health Organization stated emphatically that the gateway theory between adolescent marijuana use and heroin use is the least likely of all hypotheses.

Chad Thevenot

* Marijuana itself isn't terribly more dangerous than alcohol.  What is dangerous is lying to children, trying to convince them that marijuana is practically like heroin.  When these children realize marijuana isn't so bad after all, that plenty of A-students and star athletes use it with no obvious ill effects, they start to question the association given between marijuana and heroin.  The logical step is, "Well, they told us pot is so bad, and it isn't, so maybe heroin isn't so bad either."

Shaun Breidbart
Pelham, N.Y.

Here is another very interesting viewpoint on Gateway ...

Drug Czar hung by his own report

by Alan Bock
April 02 1999

I have read some criticisms of the Institute of Medicine report on the state of scientific knowledge regarding medical marijuana that have enough validity to be worth considering. Overall, however, the report (available to read or download here) competently summarizes and synthesizes a good deal of what is known and should prove valuable for those who hope that eventually science and reason will triumph over obfuscatory prohibitionism.
     Richard Cowan, former executive director of the National Organization for Reform of Marijuana Laws (NORML), notes an excessive emphasis on the dangers of smoking that is curious in the absence of any confirmed cases of lung cancer caused by marijuana smoking (a fact the report had to acknowledge). He also criticizes the report's writers' fixation on what he calls the "single molecule paradigm,'' the unproven assertion that isolation of single active molecules in the plant would be obviously superior to "licensing'' the whole plant. Many advocates of herbal medicine claim the unique combination of ingredients found in natural plants (not just marijuana) accounts for their therapeutic value. Maybe they're wrong, but shouldn't the viewpoint be mentioned, if only to be refuted?
     Steve Kubby, the former Libertarian Party candidate for governor in California who is a medical marijuana patient (adrenal cancer and high blood pressure) facing criminal trafficking charges for growing his own in his own home, notes that the IOM committee didn't discuss vaporization as an alternative to smoking though it had information about it, and that the study makes no mention of the eight patients who have received 7.1 pounds of marijuana a year from the federal government since the early 1980s, courtesy of the taxpayers. Surely they would have made good subjects for studies on long-term effects.
     All in all, says Mr. Kubby, "the IOM report is badly flawed science with politically poisoned conclusions.'' It may be true that the conclusions have been politically colored, but that may not be such a bad thing. Perhaps including a few politically correct demurrers like undue fear about the effects of smoking per se in an era in which smoking anything has been so demonized is a small price to pay for enhancing the credibility of the nuggets of valuable truth the report contains.
     I suspect the report's authors knew what most legalizers believe -- that, as they conclude after extensive documentation, "the adverse effects of marijuana use are within the range tolerated for other medications,'' that "a distinctive marijuana withdrawal syndrome has been identified but it is mild and short-lived,'' and that strict prohibition is a stupid policy.
     I infer some of this from a single sentence matter-of-factly included in a lengthy discussion of the perception that marijuana is a "gateway'' to the use of other more dangerous illicit drugs. The authors don't bother to tease out the implications but it isn't that difficult.
     The report notes that one of the main reasons many are so adamantly opposed to allowing marijuana to be used medicinally is "the fear that marijuana use might cause, as opposed to merely precede, the use of drugs that are more harmful.'' The authors divide the issue rather intelligently
     "The gateway analogy evokes two ideas that are often confused. The first, more often referred to as the 'stepping stone' hypothesis, is the idea that progression from marijuana to other drugs arises from pharmacological properties of marijuana itself. The second interpretation is that marijuana serves as a gateway to the world of illegal drugs in which youths have greater opportunity and are under greater social pressure to try other illegal drugs. This is the interpretation most often used in the scientific literature, and it is supported by -- although not proven by -- the available data.''
     They then discuss various studies and conclude that "there is no evidence that marijuana serves as a stepping stone on the basis of its particular drug effect," a fact even many prohibitionists will reluctantly concede.
     Then comes the sly kicker
     "Whereas the stepping stone hypothesis presumes a predominantly physiological component to drug progression, the gateway theory is a social theory. The latter does not suggest that the pharmacological qualities of marijuana make it a risk factor for progression to other drug use. Instead it is the legal status of marijuana that makes it a gateway drug.''
     Savor that apparently innocent sentence for a moment"Instead it is the legal status of marijuana that makes it a gateway drug.''
     What implications can be teased from that sentence?
     The main rationale for keeping marijuana illegal is not that it is so dangerous in and of itself, but that it can serve as a gateway to other, more genuinely dangerous drugs. But insofar as there is evidence that marijuana use sometimes leads to the use of harder drugs -- and there is some though it's not conclusive -- the reason is that marijuana possession and use is illegal. A nice piece of logic, eh?
     Take it another step. Those who insist on keeping the plant illegal bear a serious degree of moral responsibility for young marijuana users who do go on to use cocaine, heroin, PCP or other genuinely dangerous or addictive drugs.
     If Barry McCaffery and other drug warriors were really, seriously troubled by the possibility that use of marijuana might lead innocent or psychologically troubled people to harder drugs with much more severe physiological dangers, they would move as quickly as possible to legalize marijuana. The fact that they don't do so makes their plaintive pleas of compassionate concern for those victimized by addiction and drug-induced disorders ring hollow.
     In a word, they refuse to take the action that would be most likely to eliminate (or at least ameliorate) the only "gateway'' properties of marijuana that have a shred of scientific support because their drug war -- with all the money it shovels their way, with the opportunities it presents to seize property, kick in doors and shred the U.S. Constitution -- is far more precious to them than the ruined lives of addicts.
     Give them the benefit of the doubt that they didn't understand about the circularity of the "gateway'' contention before. But with this report -- commissioned by "drug czar'' McCaffery (your tax dollars at work), remember -- they have no excuse left. If they don't take the logical step of legalizing marijuana to reduce harm, how far beneath contempt are they?

Alan Bock is senior editorial writer and columnist at the Orange County Register, Senior Contributing Editor at the National Educator, a contributing editor at Liberty magazine and author of "Ambush at Ruby Ridge."