July 2, 1990
Nitrites and Gateway Drugs
Robert L. DuPont, M.D. President
DuPont Associates
Clinical Professor of Psychiatry
Georgetown University School of Medicine Washington, D.C.
Drugs are chemicals that are used nonmedically to produce feelings that the drug users like. Substances which are drugs, as I use the word in this report, are not necessarily "drugs" as defined in the Federal Food, Drug and Cosmetic Act. Drug use typically begins during the teenage years. The younger drug use begins, in general, the more malignant the course of the drug use. Drug use has a typical pattern beginning with widely used, relatively accepted drugs, and progressing, over time, to less widely used and more dangerous-seeming drugs. Not all users of a particular drug progress to the next drug in the sequence. Those who do progress tend to be the more frequent drug users and the drug users who began drug use at younger ages. The more deviant youth are more likely to progress beyond initial drug use (DuPont, 1989).
Gateway drugs are drugs that are used early in the sequence of drug use. They are widely used in the population and they are considered to be relatively safe. Gateway drugs are thought by drug users not to produce frightening negative effects and their use is thought to be easily controlled. In the United States today the major gateway drugs are alcohol and marijuana. Cocaine showed signs of also becoming a gateway drug in the late 1980s. Tobacco, in the form of cigarettes, while non-intoxicating also qualifies as a gateway drug. These four drugs, with alcohol and marijuana being the prototypes, and cocaine and cigarettes being similar but also different, are the gateway drugs in the United States (DuPont, 1984).
There are many drugs which are commonly used but which are not gateway drugs. The prototypical non-gateway drugs are those that are widely seen as dangerous and therefore used only by the most committed drug abusers. Heroin and PCP are representative of this group. Many psychotropics which have legitimate medical uses are also sometimes abused, but they are not thought of as gateway drugs. Examples include barbiturates, stimulants, analgesics (such as codeine) and the benzodiazepines. LSD and MDMA (or Ecstacy) are also in a special class since they are thought of by some youth to be particularly safe. Nevertheless, they are used by relatively small numbers of youth (compared to alcohol, marijuana, cigarettes, and cocaine). Most youth consider them to be quite dangerous. The volatile solvents are gateway drugs for particular population groups, especially Hispanic youth in the Southwest and in some Native American populations. From time to time even PCP and heroin have been gateway drugs for particular population groups as their use was common for relatively drug-naive youth.
Among the heterogeneous chemicals that are abused by drug abusers the alkyl nitrites (or "poppers") are a special case. There was a time in the early 1970s when their use by youth was relatively common, but their use has declined sharply in the youth population in recent years -- even more sharply than has the use of other drugs, including alcohol and marijuana. Relatively little attention has been devoted to the alkyl nitrites partly because they are seen by drug abuse professionals to pose relatively minor problems. It is rare, if it happens at all, to see a patient in a drug abuse treatment program whose major drug problem is nitrites. When young people do use poppers they generally find the use unrewarding, compared to other drug use, and their nitrite use declines over time.
The Survey Data
The surveys conducted for the National Institute on Drug Abuse (NIDA) in the last two decades document the extent and trends of the use of nitrites and other drugs. The High School Senior survey, the single best data source for information on nitrites, began asking about these substances in 1979 (the survey began in 1975) when 17.3% of high school seniors reported using nitrites at least once in their lives. In that same year 8.9% reported nitrite use in the previous year, and 3.2% reported use in the past month. In 1979 less than 0.1% of high school seniors reported daily use of nitrites (University of Michigan, 1990).
For comparison, the figures for marijuana use rates in that year for high school seniors were: ever used marijuana, 60.4%; past-year use, 50.8%; past-month use, 36.5%; and daily use, 10.3%.
By 1989, the most recent year for which data are available from high school seniors, ever use of nitrates had fallen to 3.3%, past-year use was 1.7%, past-month use was 0.6%, and daily use was 0.3%. Again, for comparison, the figures for marijuana use by high school seniors in 1989 were: ever used, 43.7%; past-year use, 29.6%; past-month use, 16.7%; and daily use, 2.9%.
Focusing on the past-year use figures as the most representative of current general levels of use, nitrate use had fallen by 81% and marijuana use had fallen by 42% over the 10 years from 1979 to 1989. The drop in marijuana use over that decade was the single most dramatic accomplishment of the anti-drug abuse effort in the nation. What is far less widely appreciated is that the fall in nitrite use was the steepest decline in any single abused drug in the United States. Again, for comparison purposes, alcohol, the other commonly used gateway drug, showed a past-year use decline among American high school seniors from 88.1% to 82.7% (a drop of just 6%) from 1979 to 1989.
One of the most striking characteristics of gateway drugs is the tendency for their use to persist once it begins. For example, among high school seniors in 1988 only 7.3% of youth who had ever used alcohol were not still using alcohol in their senior year. Expressed in positive terms that meant that 92.7% of high school seniors who had ever used alcohol were continuing to use it in their senior year of high school. For cigarettes, another gateway drug, only 18.2% of those who had ever used them had stopped by their senior year in high school. For the less widely accepted drugs, those that are not gateway drugs, the rates of stopping were substantially higher. For example, for PCP the rate of stopping was 58.6% and for heroin the rate was 54.5%. For nitrites the stopping rate by the senior year in high school was 46.9% in 1988.
When high school seniors were asked what proportion of their friends were using various drugs, the only two drugs that were used by fewer friends than nitrites were PCP and heroin. In 1988 81.7% of high school seniors said none of their friends was using nitrites. The percentage reporting that none of their friends using marijuana was 24.7% and for heroin it was 87.6%.
In a follow-up of high school seniors it was found that among those ages 19 to 28 the rates of nitrite use in the past year were 2.0% in 1986, 1.3% in 1987, and 1.0% in 1988 (the most recent year for which these data are available) (Johnston, O'Malley, & Bachman, 1989).
Turning to the Household Survey of all Americans 12 years of age and older, there is no category for nitrites, but there is a general category of "inhalants" which has been tracked from 1972 to 1988, the year the most recent survey was conducted. These data show that lifetime inhalant use for Americans aged 12 to 17 had gone from 8.4% in 1972 to 8.8% in 1988. Among Americans 18 to 25 use of inhalants had gone from 9.2% in 1974 (when this question was first asked of this age group) to 12.5% in 1988. Among Americans 26 and older the lifetime inhalant use had gone from 1.2% in 1974 to 3.9% in 1988. Inhalant use in the past 30 days in 1988 for these three age groups was 2.0%, 1.7%, and 0.2%. These data from the household survey are not useful in isolating the use of nitrites, since nitrite use is combined with the use of volatile solvents, a very different drug abuse pattern. Nevertheless, they do establish some boundaries for the use of inhalants as a class (U.S. Department of Health and Human Services, 1989b).
The third major NIDA drug data source is the DAWN (Drug Abuse Warning Network) data on Emergency Room visits and medical Examiner cases (deaths). These data for the end of 1988, the most recent data available, do not list either inhalants or nitrites as special drugs, suggesting that in these contexts, nitrites are a relatively minor problem. In 1986, when DAWN listed the 170 most commonly mentioned drug problems seen in U.S. Emergency Rooms during the year, cocaine was number one followed closely by alcohol and heroin. Aspirin was number 8 and caffeine was number 55. Nitrites were not on the list of 170 drugs (U.S. Department of Health and Human Services, 1987, 1989b).
Conclusions
Nitrites are a relatively minor part of the overall drug abuse problem in the United States. Their use has shown a dramatic decline in the past decade. They do not qualify as gateway drugs either in terms of sequence (e.g., being an initiating drug) or in terms of being widely used.
References
DuPont, R. L. (Ed.) . Stopping Alcohol and Other Drug Use Before It Starts: The Future of Prevention. Rockville, MD: U.S. Department of Health and Human Services, Office for Substance Abuse Prevention. OSAP Prevention Monograph-1, DHHS Publication No. (ADM) 89-1645, 1989.
DuPont, R. L. Gettincr Toucih on Gateway Drugs: A Guide f or the
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Johnston, L.D., O'Malley, P.M., and Bachman, J.G. Drucr Use, Drinking, and Smoking: National Survey Results from High School, College, and Young Adults Populations, 1975-1988. Rockville, MD: U.S. Department of Health and Human Services, National Institute on Drug Abuse, DHHS Publication No. (ADM) 89-1638, 1989.
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Rockville, MD: National Institute on Drug Abuse, Division of Epidemiology and Prevention Research. Statistical Series, Series G, Number 23, DHHS Publication No. (ADM) 89-1620, 1989a.
U.S. Department of Health and Human Services, National Institute on Drug Abuse. Highlights of the 1988 National Household Survey on Drug Abuse, National Institute on Drug Abuse. NIDA Capsules, August 1989b.
University of Michigan, Institute for Social Research (News Release). Drug use continues to decline, according to U-M survey; cocaine down for third straight year. The University of Michigan, News and Information Services, Ann Arbor, MI, February 13, 1990.
