The Fallacy of the Gateway Drug Theory – Pain Medicine News – Dec 2016 – by Lynn R. Webster, MD
In 2012, Vanyukov et al published an article describing two separate views on the role that drugs play in initiating an addiction.
- One is the “gateway theory” and the
- other is the “common liability to addiction concept.”
The gateway theory places the drug as the primary factor in initiating a substance use disorder (SUD).
The belief is that exposure to a licit rewarding drug (e.g., tobacco, prescription opioid) begins a developmental process that progresses like a disease to a more serious stage, culminating in the use of an illicit drug (e.g., marijuana, heroin). Thus, in this theory, exposure to a drug initiates an SUD independent of the biology of the individual.
The gateway theory can be traced to 1975, with a paper by Kandel reporting on the frequency with which adolescent illicit drug users had previously used marijuana.
The difficulty was the failure to demonstrate causality in the relationship.
People who use cocaine or heroin have usually been exposed to marijuana or a licit drug; however, the majority of marijuana users partake of no other illicit drug, and many heroin users skip the “steps” of softer drug use.
Central to the gateway theory is that the locus of control is external, minimizing or eliminating the known biological contributions to the disease.
U.S. Attorney General Loretta Lynch said, “When we talk about heroin addiction, we usually … are talking about individuals that started out with a prescription drug problem, and then because they need more and more, they turn to heroin. In so many cases, it isn’t trafficking rings that introduce a person to opioids; it’s the household medicine cabinet. That’s the source.”
By this logic, drugs other than prescription opioids could also serve as a gateway to heroin use.
addiction is not a stepped disease driving people from softer to harder drugs.
Rather, the more likely theory is that people who develop SUDs have a shared vulnerability to other drugs of abuse based on biological factors, not on the sequence of exposures
Genetics and Environment at Play
In contrast, common addiction liability can explain the clinical spectrum of SUDs not explained by the gateway theory. It does so by accounting for complex genetic and environmental factors that are activated in the disease of addiction
State marijuana ballot initiatives are throwing the discussion of gateway exposure back into public consciousness, as policymakers ponder whether marijuana would help ameliorate or worsen the opioid abuse crisis.
In accordance with the common addiction liability concept, people with an addiction to prescription opioids have a disease that is already expressed, and the person who subsequently seeks heroin is finding the most effective or affordable way to support the disease.
heroin use among people who use prescription opioids for nonmedical reasons is rare, and the transition to heroin use appears to occur at a low rate
Public policymakers seeking to solve the opioid crisis would be advised to acknowledge that the gateway theory of SUDs is unsubstantiated and potentially misleading.
Disorders develop where there is genetic vulnerability and an environment that drives individuals to seek relief from the stresses in their lives.
Solutions to the opioid crisis lie in understanding the biological, social and economic factors that drive demand to escape with illicit use of drugs.
Life in our society has become more performance-oriented, thus stressful and competitive, at the same time as people are becoming more isolated from potential support networks.
This means solutions will not be easy, quick or cheap. Anything less will likely have unintended consequences that could be more harmful than beneficial to society, people with SUDs and people with pain