Cannabis as a gateway out of the living hell known as addiction.
One major talking point of our misguided War on Drugs is the widespread notion that when teens use, or even try cannabis, it acts as a ‘gateway’, or as a semiautomatic conveyer belt, from pre-adulthood innocence to an increased risk of addiction to harder drugs such as heroin. This concept has been used for half a century to help fuel a moral panic against cannabis. This panic, in turn, has been exploited as a rationale to continue to criminalize cannabis for all adults and to arrest and incarcerate people for cannabis possession.
Is the ‘gateway theory’ true? Is there any evidence for it? Has there ever been? Does cannabis use “cause” problems with addiction to other substances later on in life? Or are people simply using marijuana to treat their pain, misery, and boredom? Can cannabis actually help with addiction? What is the direction of causality here?
Causality and cannabis
If you look at all of the unfortunate people who eventually go on to later become addicted to opioids - such as yours truly fifteen years ago – there are numerous associations we could come up with. For example, all of them drank milk as children when they were growing up. There is a clear association between milk drinking as a child and later opioid addiction. Yet, no one is decrying, “milk: the gateway to heroin”. We aren’t arresting these preschoolers for nonviolent possession of their milk boxes or charging them as accessories to the deaths from overdoses that will occur years later from fentanyl. Why? Because association is not the same thing as causation. There is no causal link between the milk and the opioids, just a statistical association.
Innumerable other things are associated, without any causal connection. At the beach, in the summer, there is both a witnessed increased in ice cream intake and there are more frequent drownings. No one is claiming that the ice cream is causing the drownings (or that the drownings are causing the increased ice cream consumption). The association is simply due to the fact that more people are at the beach, both eating and attempting to swim during the summer.
Unlike milk, beachgoing, and ice cream consumption, cannabis has generally been assumed guilty until proven innocent. This is due to a drug war mentality imposed upon us by our government over the last half-century, which needed to vilify cannabis in order to support the War on Drugs. The anti-cannabis messages of the DARE program backfired and led to increased teenage drug use, but this is propaganda as a ‘gateway’ not the marijuana itself. The anti-cannabis messages pumped out by our government were reflexively echoed by most members of the medical community, who - as my late dad, a cannabis scholar, noted, were both victims of, and perpetrators of, a wholesale disinformation campaign against cannabis.
While teenage cannabis usage is to be discouraged for other reasons, such as concerns over its potential to harm teen brain development, is there any truth to the idea that early cannabis predisposes users to other, darker addictive behavior?
Lived experience
What do I know about any of this?
I wouldn’t advocate for putting ‘get addicted to opioids, demolish everything in your life, and then get unaddicted, then help others who are addicted’ onto the medical school curriculum. However, if one has the rare experience of surviving these things intact, such as I did, with all the associated collateral damage (felony charges, years on probation, vicious drug withdrawals, divorce, forced trips to medically incompetent rehab facilities, medical license lost, etc. – see my memoir ‘Free Refills’ about this), then one has a leg up in understanding both what goes into becoming addicted and what goes into surmounting an addiction. This is one area where speculation is simply an inadequate substitute for lived experience. It is why many addiction counselors enter into the field from a position of personal recovery (if not necessarily accompanied by a rigorous scientific background).
In addition to lived experience with cannabis and with opioid addiction, I have broad clinical experience with managing opioids, treating patients with medicinal cannabis, and treating all types of addictions. This experience comes not only from having been a primary care doctor at Harvard Medical for a quarter century, with a specialty in cannabis and addiction but also from having served as an Associate Director of the Massachusetts Physician Health Service, where I helped rehabilitate addicted doctors.
Coming from a position of lived and clinical experience with cannabis and opioids, as well as with addiction, it is difficult to understand how the U.S. Government managed to convince so many people, including most doctors, that the ‘gateway’ theory was true.
The ‘gateway theory’
The ‘gateway theory’ centers around the idea that there is a causal relationship between cannabis use in adolescence and illegal drug use in adulthood. Proponents of this theory believe that the use of marijuana somehow kindles or primes the brain to seek out other drugs later on in life.
Once you step off the straight and narrow, you rapidly encounter a slippery slope to perdition. You may become a victim of “voodoo pharmacology”, entirely at the mercy of the drugs, with your personal agency in tatters, even decades later! The only problem is….there has never been any real evidence for this theory. This is not what causes addictions (see below). Instead, it was primarily based on a ‘guilt by association’ type of logic, where spurious associations, such as those discussed above, are forced into a convenient (if you are waging a drug war…) anti-drug theory.
While it is true that teens often start with alcohol or tobacco, and that cannabis commonly follows, this is primarily because weed is a widely used drug, has always been freely available, and teens are both bored and curious. Lots of teens try and use cannabis—this is something that many of us are trying to prevent for reasons of brain health. We suggest, ‘Just say wait’.
Yet, there is no reason to believe, or evidence for, the notion that cannabis somehow ‘causes’ addiction later in life.
What actually causes addiction?
We know, in general, what predisposes people toward addiction. The established causative factors include childhood traumas, abusive relationships, untreated anxiety and depressive disorders, poverty, genetics, and just plain miserable life circumstances. The pain that accompanies all of these can temporarily disappear with the right combination of drugs. It is extremely tempting for people who are suffering to cover it up with a drug. Trust me, I know. Then, slowly, imperceptibly, one finds oneself losing control over one’s usage and sinking into an addiction, which then becomes a separate but superimposed problem.
Generally, in my experience, the cannabis is both a symptom or a marker of someone’s suffering and one cornerstone of self-prescribed efforts to try to alleviate this suffering. Cannabis helps elevate mood, quell anxiety and helps people with sleep, chronic pain and, importantly, with loneliness, mindfulness, and human connection. It is the suffering, and the attempts to alleviate suffering, that connects cannabis with other addictions.
Debunking the ‘gateway theory’
It is an unusual process to debunk a theory that never really had any hard evidence behind it. As early as 1999, the Institute of Medicine of the National Academy of Sciences, part of the U.S. Government (hardly “flower children” as regards cannabis), wrote the following:
Patterns in the progression of drug use from adolescence to adulthood are strikingly regular. Because it is the most widely used illicit drug, marijuana is predictably the first illicit drug most people encounter. 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 the 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. There is no conclusive evidence that the drug effects of marijuana are causally linked to the subsequent abuse of other illicit drugs. (emphasis added)
Or, more recently, as explained in 2021, by the National Bureau of Economic Research:
“This study is the first to use nationally representative data across all 50 states and the District of Columbia to comprehensively explore the broader impacts of RMLs [recreational marijuana laws], providing some of the first evidence on how marijuana legalization is affecting illicit drug use, heavy alcohol use, arrests for drug and non-drug offenses, and objectively-measured adverse drug-related events including drug-related overdose deaths and admissions into substance abuse treatment services. … [W]e find little compelling evidence to suggest that RMLs result in increases in illicit drug use, arrests for part I offenses, drug-involved overdoses, or drug-related treatment admissions for addiction.”
Or, finally, from a 2021 study in the Journal of Experimental Criminology, “Results from this study indicate that marijuana use is not a reliable gateway cause of illicit drug use. As such, prohibition policies are unlikely to reduce illicit drug use.”
The ‘gateway theory’ turned out to be a gateway to millions of needless arrests and social control, with little to do with the drugs themselves.
Cannabis is more accurately viewed as a ‘gateway’ out of addiction
Ironically, in the face of a one-half century of propaganda about the “marijuana gateway theory”, many people have been discovering and openly claiming that cannabis can be a lifeline, or a gateway, that helps them transition themselves out of more dangerous addictions. People are utilizing medicinal cannabis to curtail their usage of drugs that kill, such as opioids or alcohol. There’s even a name for this: many people call themselves ‘Cali Sober’ to denote that they are free of all drugs and alcohol except cannabis (and, possibly psychedelics as well).
In my clinical practices, as well as through my interactions with the recovery community over the decades, I have witnessed thousands of patients use cannabis to help transition themselves away from more dangerous drugs. Why is it not common knowledge that this is happening?
First, many people don’t feel comfortable discussing their cannabis use with their doctors, due to decades of stigma, gaslighting and judgmentalism. Doctors need to do a much better job in creating a climate of trust where patients can speak freely and openly, regardless of the doctor’s personal views on cannabis. Patients often just don’t mention their use to their doctors, particularly their psychiatrists, and go on to adjust their medications on their own. Not particularly safe. We can do much better.
Secondly, our research base is far behind much of the lived experience of cannabis users and will remain so for quite some time. This is due to the biased funding priorities of our government during the war on drugs. During the last half-century, in order to be funded, researchers had to show some form of harm of cannabis, such as dropping I.Q., sperm count, or motivation. Mitigating the usage of dangerous opioids or alcohol did not count as a harm and such studies were not funded. Any demonstration of benefit would undermine the fictions that were necessary to create a widescale Drug War panic.
It is important to note that cannabis is by no means entirely harmless and that the usage of cannabis instead of these other drugs is considered by most to be ‘harm reduction.’ There are many ways to consume and to incorporate cannabis more safely, such as not smoking it, and keeping the dosages within a reasonable limit. I discuss these in detail in my book, ‘Seeing Through the Smoke: A Cannabis Expert Untangles the Truth About Marijuana’,
Generally, if one is using cannabis responsibly and if one is not in one of the categories of people for whom cannabis is more dangerous (e.g., pregnant or breastfeeding women, teenagers, people with a personal history or family history of psychosis), then cannabis is likely significantly, if not vastly, less dangerous than whatever drug you are substituting it for. Given that we lose one hundred thousand people a year to both alcohol and opioids, it is difficult to argue that the transition to cannabis – which is impossible to fatally overdose on, isn’t a net benefit. People are also using cannabis to replace benzodiazepines, gabapentinoids, and non-steroidal pain medications – other deadly categories of drugs.
Cannabis use has also been claimed to worsen addictions to other drugs, which also isn’t true. The only addiction that cannabis use contributes to is addiction to cannabis. Some people can get quite addicted to cannabis – though the rates of addiction to cannabis are significantly lower than to most other commonly-used psychoactive drugs. (Which is why the criticisms of cannabis substitution - that one is simply exchanging ‘one addiction for another’, are nonsense: cannabis is broadly less addictive and less harmful.) The quality of the addiction to cannabis certainly isn’t life-threatening. That said, an addiction to cannabis can be extremely disruptive, is a big deal, and requires treatment with empathy, skill, and compassion, just as does any other addiction.
How does cannabis help?
The use of cannabis can help undercut or alleviate many of the things that predispose one to an addiction in the first place. It can perform whatever role the misused drug did, but in a safer manner. For example, it can help with pain control, anxiety, insomnia as well as with traumatic memories. It also can be quite helpful easing withdrawal symptoms for people transitioning away from opioids – I know this from personal experience, during the dozens of times I weaned myself off of opioids.
If you are trying to recover from an addiction, it is not guaranteed that simply switching to cannabis will do the trick. One increases one’s chances of success by incorporating other components of recovery - such as peer support and comprehensive medical care - to optimize one’s chances of success. One should work with a medical professional in order to have access to the latest medications that help us treat addiction, such as buprenorphine (Suboxone) and methadone for opioid addiction. These medications have been proven to lower overdose deaths.
Given that so many people find cannabis helpful in their recoveries, we need to stop punishing people for cannabis use. In my opinion, rehab centers, pain centers, methadone clinics, and other addiction treatment centers must stop testing for cannabis altogether (unless, perhaps, the person is receiving treatment for cannabis addiction and it is strongly felt that this type of drug testing would be helpful). We fetishize drug testing and it isn’t all that helpful (except to the people that make money from it).
As a final note, all of this harm reduction – people substituting cannabis for more dangerous drugs and pharmaceuticals - is all happening organically, due to changes in laws and increases in public awareness of the potential benefits of cannabis, and largely due to the efforts of patients themselves. Imagine how much progress we’d make if doctors were deprogrammed from all of the drug war nonsense, helpfully educated about how to advise patients about cannabis, on board with the process, and empowering patients to openly and freely communicate. We’d be saving exponentially more lives through the usage of cannabis as a gateway off of addiction.