Among the stated goals of the drug policy reform and harm reduction movements is a concept known as Treatment-on-Demand (TOD). The basic idea of TOD is to make available a variety of treatment options that would be provided to drug users for the asking. At first glance, it appears to be a fairly straightforward concept. However, when we examine the concept more closely, we discover a Pandora's box capable of turning our vision of TOD upside down.

In its broadest sense, TOD has just two main components. They are of course, "treatment" and "demand", but far from being clear and easily defined terms, they are ambiguous, convoluted and subject to broad interpretation by persons of differing views. To begin with, what "treatment" are we speaking of? Upon whose "demand" shall this treatment commence? Examining these questions, I came up with some surprising answers, some of which I shall share with you here.

Is it feasible that the addict will, one day, be permitted to be the final arbiter of whether he or she receives medical treatment on a demand basis, or is it hopeless naiveté to think so? Will addicts be permitted to determine which treatment modality suits their needs, and have ready access to it?

The same reactionary forces in society who vehemently oppose needle exchange programs based upon the erroneous notion that it rewards addicts and sends the wrong message will no doubt be opposed to this version of TOD. They would view it as "affirmative action for addicts", a kind of government subsidy for junkies. Given the current political climate in America, this type of opposition cannot be easily dismissed.

Among the Drug Warriors, there is a different vision of TOD, a vision in which certain individuals of authority, such as police, judges, employers, teachers, or others could "demand" and compel others to undergo "treatment" of one sort or another for specified periods of time. This form of TOD is widely available in America Today. Men and women arrested for simple possession of marijuana frequently are required to enter into some form of "treatment" as part of their sentence or as a condition for probation. In addition, they are often required to pay for this so-called "treatment", which frequently consists of lengthy series of anti-drug lectures given by deputy sheriffs or other law enforcement personnel, coupled with weekly urine tests.

There appears to be no shortage of treatment slots available in this area. Of all treatment options, this is the fastest growing treatment modality being made available in America today. Seen by police and politicians as a panacea to the drug crisis, many respected scientists have jumped on the bandwagon. In July, 1995 the National Institute on Drug Abuse (NIDA) sponsored a two day "National Conference on Marijuana Use" with "treatment" featured as their centerpiece. Among the workshop panels scheduled was "Treatment Strategies for Marijuana Use: Adults and Adolescents". One wonders what Treatment NIDA has in mind for America's 25 million pot smokers.

As for those addicted to heroin and/or cocaine, providing that you are covered by insurance or are independently wealthy, there appears to be no shortage of treatment facilities offering a wide range of therapeutic services for individuals in recovery. But woe to the person whose money or insurance runs out. After that, it's "...hit the road, Jack."

There are, in reality, very few treatment slots available for the majority of addicts who are poor and uninsured. What can be done for the 5-10 million people in the US alone who would be eligible for treatment if TOD were available? These are the people of whom drug policy reformers and harm reductionists must address when they speak of TOD. How could we prevent an already overburdened health care system from collapsing under the sheer numbers of those who would be eligible for and entitled to treatment? What treatment options are available, what is practical, and what works?

Pharmacotherapeutic treatment modalities currently employed in the treatment of narcotic addiction include Methadone, LAAM, Naloxone, and buprenorphine. There is currently no medication approved by the Food and Drug Administration (FDA) for the treatment of cocaine dependency.

Acupuncture is available as a treatment option for both heroin and cocaine dependent persons. Talk therapy is a widely employed treatment technique both in groups like Narcotics Anonymous (NA), as well as individual counseling with psychiatrists, psychotherapists, and psychologists. Sessions run by recovered addicts working in the field abound. Also available are in-patient detoxification programs, out-patient rehabilitation programs, and a wide variety of residential therapeutic communities that keep patients for months and, in some cases, years.

Assessing the efficacy of each of these treatment modalities is a difficult task. They represent different things for different people. It appears that no single treatment method is effective for all, so we must conclude that there should be as many treatment options as possible. But the current diversity of treatment options is clearly insufficient to effectively treat the millions who want and need treatment.

With this in mind, Congress established the Medications Development Division (MDD) and made it part of NIDA. The division became operational in 1990, with a mandate to coordinate and encourage the development of anti-addiction medications.

The criteria defining the ideal properties of a medication developed for the treatment of drug addiction was only recently established. In 1992, the Congress stipulated that the Department of Health and Human Services contract with the National Academy of Sciences to establish a committee in the Institute of Medicine (IOM) to examine and evaluate the progress of NIDA's MDD in their quest for anti-addictive medications¹. Three years later the long awaited IOM report² was released. The report defined, for the first time, the "ideal medication" for the treatment of addiction.

For purposes of clarity, I have enumerated the points. The text, however, remains verbatim.

"A medication developed for the treatment of drug addiction is ideally effective when,

1. administered orally or is able to be implanted,
2. is long lasting,
3. clinically safe,
4. causes few side effects,
5. is acceptable to patients,
6. is designed to reduce both the reinforcing and toxic effects of the addictive drug,
7. has little abuse liability, and
8. is useful for more than one class of abused drugs (because many substance abusers use more than one drug)."

Perhaps the most promising treatment to enter NIDA's medications pipeline was not discovered by government scientists, but by addicts. Addict self-help groups first pioneered the use of Ibogaine on an addict-to-addict basis, and, in 1991, when we were sure that it worked, that is to say that eliminated withdrawal symptoms and permitted the addict a rapid, pain-free detox, we went public with these claims and stormed NIDA, demanding that they conduct research into this area. NIDA agreed to launch and Ibogaine Research Initiative and began pre-clinical trials. Two years later, Dr. Curtis Write of the FDA admitted, "Right now, we don't have any other candidate drug that looks as good as Ibogaine."³

How does Ibogaine match up to the Institute of Medicine's criteria for the "ideal Medication"? Let's address each point.

1. Ibogaine is administered orally.
2. Ibogaine is long lasting - it eliminates the desire to use drugs for an average of six months following a single treatment.
3. Ibogaine is clinically administered. It is provided in a hospital setting, with doctors, nurses, and treatment professionals to assure the comfort and safety of the patient throughout.
4. Side effects: Ibogaine's acute side effects are few and short lived. They include mild ataxia, nausea and dizziness, along with visual and auditory distortions. These side effects last several hours, then abate, and do not recur.
5. Patient acceptability: The tremendous interest from the addict community in Ibogaine indicates it would be acceptable to the majority of patients.
6. Ibogaine initially acts as a rapid detoxificant, reducing the toxic effects of the drug of abuse. Its after-effects reduce the reinforcing quality of drugs by eliminating the craving to seek and use drugs.
7. Abuse potential: Pre-clinical studies indicate that Ibogaine is not a narcotic, nor is it habit forming. As an in-hospital procedure with no take-home doses there appears to be little is any abuse potential.
8. Ibogaine is effective in the treatment of a broad spectrum of abused substances, including heroin, methadone, cocaine and alcohol. It appears that Ibogaine fits the template of the ideal medication. No other medication in development even approaches meeting this criteria.

Although NIDA is proceeding with Ibogaine research, they are doing so at a snail's pace. Ignoring the realities of addiction and AIDS, they have yet to begin community based clinical studies of Ibogaine, despite FDA approval of one study being conducted by the University of Miami in Florida.