A WHIFF OF 'REEFER MADNESS' IN U.S. DRUG POLICY

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.