Having practiced EM for over 35 years, I respectfully take issue with Professor Ducharme’s reference to marijuana as a “gateway” drug [“A Rational Approach to the Opioid-Seeking Patient,” March ACEP Now, p. 22]. In my experience, that reference is used as a substitute for more scholarly arguments as to why cannabis should remain illegal. The substitution of safer drugs for more harmful ones (heroin, alcohol, tobacco) is a well-established principle in medicine. Why not offer the population a safer alternative? We don’t know how many people use less of these drugs, finding cannabis more safe (except for the legal issues), but I suspect many. It might be found that teens (who shouldn’t be using any mind-altering substances) are using less alcohol and tobacco having cannabis available. The Colorado and Washington experience may answer many of these questions. If any substances should be illegal, they’re alcohol and tobacco (450,000 deaths/year), the true “gateway” drugs. In my many years in the ER, I’ve seen maybe one or two patients with cannabis problems, but many days I’ve seen that many (or more) alcohol/tobacco-related problems. Why not have the “default” position on cannabis be legal and render the really dangerous drugs illegal if throwing people in jail is the best way to drug-educate the population?

David Spilker, MD
Monterey, Calif.