• Users Online: 108
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2016  |  Volume : 32  |  Issue : 2  |  Page : 171-173

From one substance dependence to another: Are gateway violations common?

Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication25-Apr-2016

Correspondence Address:
Dr. Siddharth Sarkar
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9962.181099

Rights and Permissions

Objectives: This study aimed to assess the progression from one substance dependence to another in a sample of treatment-seeking substance users. Materials and Methods: The present cross-sectional study was based on a consecutive sample of patients with substance use disorder attending a de-addiction service in North India. Information was gathered about the demographic details and substance use pattern from the patient, family members, and previous records using a structured questionnaire. Results: Two hundred seventy-three patients out of 406 consecutive participants were dependent on more than one substance of abuse (67.2% of the sample). Most of the subjects were male, married, employed, and of urban background. In this sample of 273 patients, the substance of first dependence in descending order of frequency was tobacco, opioids, alcohol, and cannabis. Of those patients who had become dependent on opioids, it was the initial substance of dependence among 51.3%. Conclusion: Initial dependence to illicit substances without progressing through “gateway” of alcohol and nicotine dependence can occur due to socio-cultural influences. Knowing the sequence of dependence to substances can help design focused preventive measures.

Keywords: Alcohol, gateway hypothesis, India, nicotine, opiate

How to cite this article:
Sarkar S, Nebhinani N, Gupta S, Parakh P, Basu D. From one substance dependence to another: Are gateway violations common?. Indian J Soc Psychiatry 2016;32:171-3

How to cite this URL:
Sarkar S, Nebhinani N, Gupta S, Parakh P, Basu D. From one substance dependence to another: Are gateway violations common?. Indian J Soc Psychiatry [serial online] 2016 [cited 2022 Aug 16];32:171-3. Available from: https://www.indjsp.org/text.asp?2016/32/2/171/181099

  Introduction Top

Knowledge of the evolution of substance use disorders in the community can be helped by understanding pathways of progression of substance use. This is also potentially helpful in targeting individuals at risk, and to prevent abuse of other substances.[1] The concept of “gateway” drugs proposes that substance users proceed from the use of licit substances such as nicotine and alcohol to other “harder” drugs such as cannabis, cocaine, and amphetamines.[2] Though many studies favor the gateway hypothesis, some recent ones have challenged the universal applicability of gateway theory.[3],[4] The multi-country World Mental Health Survey suggests that alcohol and tobacco use were precursors of illicit substances where the use of alcohol and tobacco was high.[5] Cannabis use preceded the use of other substances in areas where cannabis use was high, refuting the gateway progression. Certain other studies have also found that the use of tobacco or alcohol may not reliably predict progression to other illicit substances.[6]

Treatment seekers comprise a population which experiences severe physical and social adverse consequences of substance use. Understanding the progression of substance use disorder among them can help to discern whether gateway control is likely to be effective. Hence, this study was conducted to understand the progression from one substance dependence to another in a clinic-based population of treatment seekers.

  Materials and Methods Top

The present study was conducted at the Drug De-addiction and Treatment Centre of a Tertiary Care Hospital in India.

The center caters to both referred as well as nonreferred patients with substance use disorders. The patients are usually accompanied by their family members. The center provides both inpatient and outpatient care to substance users. Treatment is provided in the form of pharmacotherapy, psychotherapy, and psychosocial rehabilitation.

The present study was conducted among a consecutive sample of treatment seekers who registered at the center for the first time. Information was gathered in a single setting from the patient, family members, and previous treatment records, if available. The diagnosis of substance use disorder was made in accordance to ICD 10 by trained psychiatrists. In case of discrepancies of reports from the various sources, patient's version was considered to be the most accurate one. The duration of dependence in years was ascertained for each substance and was used in analysis. Two or more substances could have a similar duration of dependence based upon their self-reports. Informed consent was obtained from the participants. Data collection was conducted from September 2011 to December 2011.

The analysis was conducted using SPSS version 17 (IBM Corp). Descriptive statistics was used for demographic data. Progression of substance dependence was assessed for patients who were dependent on two or more substances (treatment seekers who were dependent on only one substance were not included in the analysis). For each substance use pair, the progression of dependence from one substance dependence to another was evaluated.

  Results Top

During the study period, 412 cases were newly registered at the center out of which six did not have a substance use disorder. One hundred thirty-three patients (32.8%) were dependent on only one substance. The remaining 273 (67.2%) were dependent on more than one substance were included in the analysis. Mean age of this sample of 273 patients was 34.6 years (range: 16–65 years), with 272 (99.4%) of them being males, 172 (63.0%) married, 161 (59.0%) employed, 159 (58.2%) educated up to 10th grade, 128 (46.9%) belonged to nuclear family, 93 (34.1%) belonged to Sikh religion, and 156 (57.1%) had urban residence.

[Table 1] shows the numbers and proportion of patients with different substance dependence disorders. Nicotine dependence formed the largest group followed by opioid and alcohol dependence disorders. The greatest proportion of the patients became dependent on nicotine first (87.8%) followed by opioids (51.3%). Among the 79 patients who had become dependent on opioids as the first substance of dependence, 30 (38.0%) were using natural preparations of opioids in the form of opium exudates (“afeem”) and poppy husk (“bhukki”). The progression from one substance use to another is graphically depicted in [Figure 1]. Wherever nicotine was involved, patients progressed from nicotine dependence to other substances of dependence. Greater proportion of patients progressed from opioid dependence to alcohol dependence, rather than the other way round.
Table 1: Substances of dependence among the patients with more than one substance dependence

Click here to view
Figure 1: Progression paths of substance dependence. Note: Arrowhead size shows the direction of the association, arrow thickness shows the size of subgroup for analysis, box size in logarithmic proportion to the number of patients with a substance use disorder, numbers show percentage of patients in the combination progression from the first (distal) to the second (proximal) substance

Click here to view

  Discussion Top

This study suggests that in a population of consecutive treatment seekers, majority of the patients began their substance use careers with nicotine dependence. However, it was interesting to note that a large proportion of opioid users started directly with opioids (without first becoming dependent on alcohol or nicotine). Tobacco dependence progressing on to opioid, alcohol, and cannabis dependence were commonly observed trends, and is otherwise similar to that in published literature.[2]

Many reasons could be possibly ascribed to the “gateway violation” of initial opioid dependence observed in this study. One possibility could be the easy availability of opioids in the region, as India lies between the Golden Triangle and Golden Crescent, the two high opiate producing regions of the world.[7] Another possibility could be the lower initiation rates of tobacco usage due to religious proscription among Sikhs, as well as an effectively implemented anti-tobacco campaign in India.[8] Other unmeasured factors such as internalizing disorders among the substance users might also have led to observed violations in the usual progression of substance dependence.[9]

The results should be interpreted in the light of certain limitations. This study was primarily based upon retrospective recall of patients and family members. Apart from the records that were available with patients, other treatment records could not be accessed (in view of hospital information systems not uniformly being in place in the region). The study attempted to assess dependence and not use per se. Dependence was chosen instead of use as a person might have used a large variety of substances in his lifetime without getting “hooked,” and would have considerable difficulty in recalling such past usage reliably. The study did not attempt to differentiate which substance dependence came first if they had same duration of dependence. Extrapolation of the findings to community should be done with caution as it was a clinic-based study, which attracted persons with more severe substance-related impairment.

The finding of this study that illicit substance use disorder may occur without going through dependence on easily available licit substances suggests that availability and cultural factors might impact on what substances become problematic. This suggests for shift in focus from gateway drugs to a broader targeting of whatever substance is of prevalent in the region. Knowing the pattern of progression can help devise-targeted interventions (educational, therapeutic, or legislative) to reduce the adverse physical and social consequences of substance use disorders.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Botvin GJ, Scheier LM, Griffin KW. Preventing the onset and developmental progression of adolescent drug use: Implications for the Gateway Hypothesis. In: Kandel DB, editor. Stages and Pathways of Drug Involvement: Examining the Gateway Hypothesis. Cambridge, UK: Cambridge University Press; 2002. p. 115-38.  Back to cited text no. 1
Kandel DB, editor. Examining the gateway hypothesis: Stages and pathways of drug involvement. In: Stages and Pathways of Drug Involvement: Examining the Gateway Hypothesis. Cambridge, UK: Cambridge University Press; 2002. p. 3-18.  Back to cited text no. 2
Bretteville-Jensen AL, Melberg HO, Jones AM. Sequential patterns of drug use initiation-Can we believe in the gateway theory? BE J Econ Anal Policy 2008;8;1-29.  Back to cited text no. 3
Melberg HO, Jones AM, Bretteville-Jensen AL. Is cannabis a gateway to hard drugs? Empir Econ 2010;38:583-603.  Back to cited text no. 4
Degenhardt L, Dierker L, Chiu WT, Medina-Mora ME, Neumark Y, Sampson N, et al. Evaluating the drug use “gateway” theory using cross-national data: Consistency and associations of the order of initiation of drug use among participants in the WHO World Mental Health Surveys. Drug Alcohol Depend 2010;108:84-97.  Back to cited text no. 5
van Leeuwen AP, Verhulst FC, Reijneveld SA, Vollebergh WA, Ormel J, Huizink AC. Can the gateway hypothesis, the common liability model and/or, the route of administration model predict initiation of cannabis use during adolescence? A survival analysis – The TRAILS study. J Adolesc Health 2011;48:73-8.  Back to cited text no. 6
Ghosh S. The Traffic in Narcotics and Drug Addiction. New Delhi: Ashish Publishing House; 1987.  Back to cited text no. 7
Kaur J, Kishore J, Kumar M. Effect of Anti-Tobacco Audiovisual Messages on Knowledge and Attitude towards Tobacco Use in North India. Indian J Community Med 2012;37:227-31.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
Degenhardt L, Chiu WT, Conway K, Dierker L, Glantz M, Kalaydjian A, et al. Does the 'gateway' matter? Associations between the order of drug use initiation and the development of drug dependence in the National Comorbidity Study Replication. Psychol Med 2009;39:157-67.  Back to cited text no. 9


  [Figure 1]

  [Table 1]

This article has been cited by
Aryo Galih Saloko,Asfi Manzilati
Jurnal Administrasi Kesehatan Indonesia. 2021; 9(1): 95
[Pubmed] | [DOI]
2 An exploratory study of cannabis use pattern and treatment seeking in patients attending an addiction treatment facility
Siddharth Sarkar,Arpit Parmar,Amit Singh
Indian Journal of Psychiatry. 2020; 62(2): 145
[Pubmed] | [DOI]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded178    
    Comments [Add]    
    Cited by others 2    

Recommend this journal