The Ninth International
Conference on Drug Policy Reform
MEDICAL TRACK MANUAL
October 18 - 21, 1995
Loews Santa Monica Beach Hotel
Treatment on Demand: Realistic Goal or Impossible
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
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.
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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,
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.
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.
What is the ideal medication for the treatment of drug
dependency? How do we define the "magic bullet"? What will it do, how will it do
it, and will we recognize it when it comes along?
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.
developed for the treatment of drug addiction is ideally effective when,
- administered orally or is able to be implanted,
- clinically safe,
- causes few side effects,
acceptable to patients,
- is designed to reduce both the reinforcing and toxic
effects of the addictive drug,
- has little abuse liability, and
- is useful
for more than one class of abused drugs (because many substance abusers use more
than one drug)."
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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
How does Ibogaine
match up to the Institute of Medicine's criteria for the "ideal Medication"?
Let's address each point.
- Ibogaine is administered orally.
- Ibogaine is long lasting - it eliminates the desire to use drugs for an
average of six months following a single treatment.
- 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
- 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
- Patient acceptability: The tremendous interest from the addict
community in Ibogaine indicates it would be acceptable to the majority of
- 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.
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.
- 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
* * * *
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.
Organizations advocating drug policy reform and implementation of harm reduction
strategies should not stand idly by waiting for government to take the lead.
They can and should take the lead to expedite research and development of tools
such as Ibogaine that will undoubtedly play an important role in both
formulating and implementing public policy in the future.
References 1. Alcohol, Drug Abuse and Mental Health
Administration (ADAMHA) Reorganization Act (102-321). return to
2. "The Development of Medications for the Treatment of
Opiate and Cocaine Addictions", IOM Committee to Study Medication Development
and Research at the national Institute on Drug Abuse, National Academy Press,
(1994), p. 56. return to article
3. Blackslee, S.,
"Bizarre Drug Tested in Hope of Helping Addicts", New York Times, 10/27/93. return to article
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