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drug that leads to abuse of more harmful illicit drugs, such as cocaine and heroin.

There are strikingly regular patterns in the progression of drug use from adolescence to adulthood. Because it is the most widely used illicit drug, marijuana is predictably the first illicit drug that most people encounter. Not surprisingly, most users of other illicit drugs used marijuana first.81,82 In fact, most drug users do not begin their drug use with marijuana—they begin with alcohol and nicotine, usually when they are too young to do so legally.82,90

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.82 The second 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. The latter interpretation is most often used in the scientific literature, and it is supported, although not proven, by the available data.

The stepping stone hypothesis applies to marijuana only in the broadest sense. People who enjoy the effects of marijuana are, logically, more likely to be willing to try other mood-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. Those factors include physiological reactions to the drug effect, which are consistent with the stepping stone hypothesis, but also psychosocial factors, which are independent of drug-specific effects. There is no evidence that marijuana serves as a stepping stone on the basis of its particular physiological effect. One might argue that marijuana is generally used before other illicit mood-altering drugs, in part, because its effects are milder; in that case, marijuana is a stepping stone only in the same sense as taking a small dose of a particular drug and then increasing that dose over time is a stepping stone to increased drug use.

Whereas the stepping stone hypothesis presumes a predominantly physiological component of 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, the legal status of marijuana makes it a gateway drug.82

Psychiatric disorders are associated with substance dependence and are probably risk factors for progression in drug use. For example, the troubled adolescents studied by Crowley and co-workers31 were dependent on an average of 3.2 substances, and this suggests that their conduct disorders were associated with increased risk of progressing from one drug to another. Abuse of a single substance is probably also a risk factor



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