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However, it does not appear to be a gateway drug to the extent that it is the cause or even that it is the most significant predictor of serious drug abuse; that is, care must be taken not to attribute cause to association. The most consistent predictors of serious drug use appear to be the intensity of marijuana use and co-occurring psychiatric disorders or a family history of psychopathology (including alcoholism).78,83

An important caution is that data on drug use progression pertain to nonmedical drug use. It does not follow from those data that if marijuana were available by prescription for medical use, the pattern of drug use would be the same. Kandel and co-workers also included nonmedical use of prescription psychoactive drugs in their study of drug use progression.82 In contrast with the use of alcohol, nicotine, and illicit drugs, there was not a clear and consistent sequence of drug use involving the abuse of prescription psychoactive drugs. The current data on drug use progression neither support nor refute the suggestion that medical availability would increase drug abuse among medical marijuana users. Whether the medical use of marijuana might encourage drug abuse among the general community—not among medical marijuana users themselves but among others simply because of the fact that marijuana would be used for medical purposes—is another question.

Link Between Medical use and Drug Abuse

Almost everyone who spoke or wrote to the IOM study team about the potential harms posed by the medical use of marijuana felt that it would send the wrong message to children and teenagers. They stated that information about the harms caused by marijuana is undermined by claims that marijuana might have medical value. Yet many of our powerful medicines are also dangerous medicines. These two facets of medicine—effectiveness and risk—are inextricably linked.

The question here is not whether marijuana can be both harmful and helpful but whether the perception of its benefits will increase its abuse. For now any answer to the question remains conjecture. Because marijuana is not an approved medicine, there is little information about the consequences of its medical use in modern society. Reasonable inferences might be drawn from some examples. Opiates, such as morphine and codeine, are an example of a class of drugs that is both abused to great harm and used to great medical benefit, and it would be useful to examine the relationship between their medical use and their abuse. In a "natural experiment" during 1973-1978 some states decriminalized marijuana, and others did not. Finally, one can examine the short-term consequences of the publicity surrounding the 1996 medical marijuana campaign in California and ask whether it had any measurable impact on marijuana con-



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