Ibogaine Therapy For Addiction: Could The Opioid Crisis Be A Turning Point For Psychedelic Medicine?
A Modern Public Health Crisis Calls For Creative Solutions
For most of history, humans have had a complex relationship with mind altering plants, fungi, and in more recent times, chemicals. Early records suggest intentional cultivation and use of opium poppies as an analgesic dating back to 3400 BC. For just as long, people have been aware of the dark side of opium, suffering the consequences of abuse and addiction to its alkaloids. In the past century, pharmaceutical grade morphine and synthetic opioids have dramatically transformed medicine and provided relief to individuals recovering from surgery or living with chronic pain. But the dark side of opioids continues to haunt society. Between 1999 and 2017, opioid addiction turned into a full blown epidemiological crisis, resulting in an estimated 400,000 overdose deaths, over $1 trillion in financial costs, and human suffering far beyond the bounds of numbers.
Many interventions have been attempted, including tightening regulations on the synthetic opioid fentanyl, and limiting prescription privileges of doctors including to post-operative patients. While deaths have slowed in some areas, they continue unchecked in pockets of the United States, particularly rural and impoverished communities. The crisis has even hit highly educated and financially privileged health care professionals, a demographic not often seen as the face of addiction. It has also resulted in yet more suffering in a far less spoken of side of the crisis, as many individuals dealing with very real pain are being denied adequate relief by physicians.
In the face of such an unprecedented public health emergency, conversations have opened up around some other controversial substances that may hold therapeutic potential in treating addiction and substance abuse disorders.
Although still federally illegal, many states have made attempts to legalize medical or recreational cannabis; in some of these states and counties, rates of opioid-related deaths and medical costs appear to have declined.
Mitragyna speciosa, informally known as kratom, is a Southeast Asian botanical in the coffee family possessing pain relief properties. Aa a partial mu-opioid receptor agonist, it does not appear to hold very high risks of overdose or addiction, but many individuals claim it has helped them quit heroin or pharmaceutical opioids. At the moment, it remains federally legal but unregulated, and an estimated 2–4 million Americans use the plant. Some individual states and counties have banned kratom, and researchers are currently studying its primary alkaloids to evaluate their medical potential.
Perhaps most surprisingly, research has resumed on the therapeutic potential of psychedelics, a class of drugs forgotten since the late 1960s. Studies conducted prior to prohibition suggested that hallucinogens such as LSD and psilocybin held remarkable value in treating alcohol and drug addiction. Despite the positive findings from previous decades, widespread misuse of LSD lead to bad trips and overblown fears of social harm, and all psychedelics were placed into schedule 1 in 1970 under the newly formed Controlled Substances Act. Among the substances prohibited by this blanket ban included Tabernanthe iboga, a West African shrub with some unusual properties and not much notoriety in the US.
While most classic psychedelics alter consciousness by acting as serotonin agonists, ibogaine is unusual in its mode of action. In addition to having some serotonergic properties, it primarily causes powerful dissociative effects by working as a glutamate antagonist like ketamine. It also stands apart from classic hallucinogenic and dissociative drugs by possessing a considerable affinity for kappa opioid receptors. This property may give ibogaine a unique and desperately needed value in regards to treating opioid addiction. Many Americans have traveled to countries where it’s legal or regulated as a pharmaceutical, where ibogaine clinics promise to provide a quick and effective detox. Countless individuals who have received ibogaine insist that it helps alleviate most or all withdrawal symptoms immediately, in addition to producing an intense dreamlike state where the social, spiritual, and mental dimensions of their addiction can be addressed.
In the words of one individual who completed a course of treatment with it, “Ibogaine is a mind healing substance. And it’s partly due to the self conscious state that it puts you in, but it also…rewires neurons and synapses in the brain. And you immediately feel it as it’s happening. It literally cured my 10 year heroin addiction with absolutely zero withdrawals within 12 hours and semi permanently reset my brain to a non depressed state. I felt a sense that I was forgiven for all the bad I have brought to my loved ones.”
Another individual described his success in getting “clean from opiates since December of 2017 after my second dose of Ibogaine. Before treatment I had been on Norcos for around 6–7 years, and topped out at 40–50 a day before treatment. The withdrawal was pretty much mitigated, and I haven’t really been tempted to go back to taking anything. The medicine really did save me, and gave me my life back.”
Despite the glowing testimonials, ibogaine is not without risks and potential consequencs. Despite its legal status, some doctors and legislators are calling for a re-evaluation of its place in medicine in order to finally turn the tide on the opioid crisis.
The Controlled Substances Act and the Basis of US Drug Policy
US drug policy is primarily based on two factors: abuse potential and medicinal value of a substance.
Schedule 1 classifications are relegated to drugs with a high risk of abuse or harm, and no known therapeutic potential; these substances are illegal under all circumstances. Along with ibogaine, other federal schedule 1 substances include LSD, heroin, and cannabis. Schedule 2 drugs are ones holding very high risks of health hazard or abuse potential, but also recognized medicinal uses. These drugs are highly regulated and some are only available within specific medical facilities such as hospitals. Others are available by prescription, but still tightly controlled. Cocaine, adderall and fentanyl are schedule 2 drugs. Schedule 3 substances have acceptable medical uses and low to moderate potential for abuse or dependency. Some are pharmaceuticals such as tylenol with codeine; others are available for use only within clinics or hospitals, such as ketamine.
In determining how to permanently schedule or reschedule a drug, it is investigated in regards to eight factors: direct and relative abuse potential, pharmacology as understood by existing research, breadth of existing research and consensus on its status by the scientific community, history of use and abuse, magnitude and potential consequences of abuse, risk of widespread public health consequences, risk of forming a dependence, and chemical relationship to existing illegal substances.
If undertaken, the DEA’s rescheduling process usually involves the attorney general and Department of Health and Human Services, and can take months to years of evaluation and legislative processes. Clinical trials and exempted use of scheduled substances such as ibogaine can provide important data for this evaluation process. DEA permits for scheduled drugs can be obtained for research purposes in order to facilitate an evaluation, though the process of applying can be grueling and prohibitively expensive.
Despite the constraints, psychedelic research has resumed at institutions such as Johns Hopkins School of Medicine and New York University. In October of 2018, the FDA designated psilocybin as a breakthrough therapy, granting legal use of it in clinical trials as an experimental treatment for depression. In March of 2019, ketamine was also approved by the FDA for use in treating depression. In the latter case, ketamine infusions and nasal sprays are only approved for use in designated clinics and under the supervision of medical professionals, in order to mediate the abuse potential and risks of adverse affects related to its dissociative properties.
Envisioning How Ibogaine Could Be Used as a Pharmaceutical
Given the unprecedented magnitude and speed of which the opioid crisis has unfolded, one could easily imagine a hypothetical policy allowing for the use of ibogaine as a medicine. Within the US, such a policy may be modeled both on clinical use of ibogaine in other countries where it is currently legal under certain circumstances, and on guidelines for the therapeutic use of ketamine which may be considered a similar drug in terms of its risk profile and medical value. In addition to these factors, ibogaine is analogous to ketamine in terms of its pharmacology and mode of action as a glutamate antagonist.
Because the greatest risks of ibogaine are related to possible cardiac toxicity and fatal heart arrhythmia, it’s important that it only be administered in a clinic or medical facility, and under supervision of medical professionals the entire time. The risks of lethal drug interactions and complications are highest in individuals with pre-existing cardiac health problems. As legality of ibogaine varies so much across the world, non-government organizations like ICEERS and The Global Ibogaine Therapy Alliance are attempting to improve safety by offering education, conferences, and multidisciplinary harm reduction standards for clinics and providers. The latter has drafted both a bill of rights for patients, and clinical guidelines for ibogaine-assisted therapy, in cooperation with a team of medical professionals. These detailed guidelines could be used to provide a framework for drug policy reform and clinical use within the US.
Facilities where ibogaine is administered should be held to strict standards in order to prevent fatalities and medical complications from occurring, including full medical and drug history screening of prospective patients, blood or urine tests to rule out the risk of a life threatening drug interaction, and a minimum of one EKG prior to admission, followed by additional EKG during treatment. Any personal or family history or serious heart conditions, particularly arrhythmia, should rule out ibogaine treatment due to the risk. In order to mitigate the consequences of serious drug interactions, all patients should ideally be transferred to a short-acting opiate such as morphine prior to receiving ibogaine.
Another potential risk concerns the psychoactive effects. While many people may be concerned about the abuse potential of hallucinogens, ibogaine does not possess recreational value in comparison to many illegal drugs. Many individuals who have experienced ibogaine would describe its mental effects to be of a difficult or even unpleasant nature. The common effect of ataxia also reduces its abuse potential and further necessitates medical supervision in order to help patients physically move around without injuring themselves. As one individual who has worked with this medicine describes it, “Ibogaine is not something you want to…abuse. It should be done with respect and intention and proper screening…with medical support close by. It is an individual journey.”
While spiritual experiences are commonplace, many also involve a narrative of atoning for the pain that a substance abuse habit has caused to loved ones. Some individuals may become disoriented or afraid during one of these difficult experiences, a risk that could also be calmed by the presence of guides or counselors.
While the experience may be difficult in nature for some, many people who have experienced ibogaine insist that the psychedelic effects are key to its long-term therapeutic value, and analogous to the belief in a higher power within 12 step programs.
At many international clinics, individuals also attend at least one integration session in the aftermath; this provides a valuable opportunity to unpack the experience and learn how to apply it to ones life. In order to reduce the chances of relapse, long term substance abuse counseling is often encouraged following ibogaine therapy.
If the FDA were to temporarily approve ibogaine for clinical use, safety and efficacy as a medicine could easily be evaluated in order to facilitate a long-term rescheduling.
Working Around Potential Downfalls of Ibogaine Therapy
Ibogaine could ultimately save many lives within the US if it were rescheduled or turned into a pharmaceutical. Despite the hope it holds, such policy reform does not come without some disadvantages.
One of the main downfalls is cost, particularly given that opioid abuse disproportionately tends to impact individuals in poor and rural communities. Ibogaine therapy can’t help individuals if they are unable to afford it. In order to reach the individuals who need treatment the most, ibogaine clinics must be built in areas where addiction and overdose rates are particularly high, reducing many of the costs associated with travel and lodging. Clinics may opt to work with various insurance providers in order to make sure costs are at least partially covered for many individuals. Grants and loans from private organizations such as the Global Ibogaine Therapy Alliance are also available under some circumstances in order to help finance the treatment for those who still cannot afford it.
Another concern will be a potential increase in illegal “underground” use of ibogaine that may occur with a rescheduling. Importation, purchase, and informal use of Tabernanthe iboga comes with significant health risks that should not be ignored. As ibogaine has always been a low legal priority even as a schedule 1 substance, this should not be anticipated as a major problem. However, potential use outside of clinics must be considered if ibogaine attracts more attention in the US. Individuals should not be penalized for attempting to purchase live plants or small amounts of dried plant material or alkaloids for personal use. Harm reduction saves lives, and the basis of this is educating people of potential risks and consequences. In the worst case, only vendors of these materials, along with those attempting to facilitate non-clinical ibogaine sessions for other people, should be held accountable for potentially putting individuals at risk. The legal consequences should be no more harsh than current penalties concerning schedule 3 substances, such as suspension of drivers license or fines not exceeding $5000. More severe penalties may be reasonable in the circumstances that an individual actually suffers harm from non-clinical use of ibogaine.
If clinical use of ibogaine proves successful with minimal health risks, it is expected that traditional ceremonial use should be re-evaluated as well. In accordance with the Religious Freedom Restoration Act, the DEA allows exemptions for certain illegal substances with a history of religious use. Ayahuasca and Peyote are two examples of schedule 1 substances that are given legal exemptions as religious sacraments under specific circumstances. Given the long history of ceremonial use in Bwiti initiations, it is highly possible that certain preparations of Tabernanthe iboga could also be approved for legal religious use under the right circumstances within the US.
Finally, legalization and widespread adoption of ibogaine may come with ecological consequences as well. Ibogaine is considered a national treasure in Gabon, where Tabernanthe iboga is a protected plant species under strict regulations for export. While travel to West Africa for the purposes of partaking in ceremonial use has not quite reached the sizable level of ayahuasca tourism in the Amazon, there are already concerns about overharvesting of this unique plant as global interest builds. In order to prevent this from happening and work around import restrictions, synthetic ibogaine HCL should be used exclusively in clinics. This also allows for standardization of dose and reduction in costs, which further improves safety, efficacy, and availability of treatment for patients. While other synthetic analogues of ibogaine may hold therapeutic value in the detox process, some of them lack psychoactive properties and may not have the same efficacy in the long run. Addiction is a complicated disease, and the psychosocial elements of it should not be overlooked by the clinical world.
Looking Towards the Future for Psychedelic Medicine
One major question remains unanswered, and it is one that holds a lot of weight: if ibogaine therapy is successfully integrated, how will this open doors and shape policy for other psychedelics with medical potential?
When LSD was withdrawn from the market in 1966 and outlawed two years later, dozens of medical studies in various stages of progress unexpectedly came to an abrupt halt. Many of them showed considerable promise in using the drug to treat alcoholism and as an adjunct treatment in psychotherapy. Prominent researchers and physicians such as Stanislav Grof were disappointed at what they saw as a legislative overreaction and refusal of the government to acknowledge the beneficial side of psychedelics.
It was decades before psychedelic research resumed within the US, but the studies once more showed promise and positive results. In the last 20 years, multiple studies have suggested that psilocybin may have potential in treating cluster headaches, substance abuse disorders, end of life anxiety, and depression. In 2018, a Johns Hopkins research team called for psilocybin to be rescheduled as a schedule 4 substance based on recent studies and an updated analysis of the abuse potential.
In an unexpected and treacherously narrow vote that will hopefully shape psychedelic policy in the near future, psilocybin was decriminalized in Denver in May. Only weeks later, the city council of Oakland unanimously voted to decriminalize all natural psychedelics, including ibogaine. Time will tell if additional cities and states approve of similar measures, but activists are already organizing similar campaigns across the country.
In addition to FDA approval of ketamine and psilocybin as experimental treatments for depression, MDMA was also approved for a series of double-blinded clinical trials investigating its use in treating PTSD. In 2017, Breakthrough Treatment Designation was granted following successful phase 2 trials; phase 3 trials are currently ongoing in cooperation with the research organization Multidisciplinary Association for Psychedelic Studies.
Given these successes, it seems likely that ibogaine and many other psychedelics may once again prove to have a valuable place in Western medicine. In the words of former LSD researcher Stanislav Grof, “By banning psychedelic research we have not only given up the study of an interesting drug or group of substances, but also abandoned one of the most promising approaches to the understanding of the human mind and consciousness.”
In contrast to existing pharmaceuticals and therapies, psychedelics are particularly effective in treating conditions originating from a complex amalgam of physiological, mental, and social factors. Addiction is one example of a disease fueled by such a mixture of variables; perhaps one reason the opioid crisis blindsided many public health experts was because many of the less obvious risk factors were ignored. Psychedelic medicines may help to fill this unique niche, serving to treat the psychosocial causes of addiction and other illnesses of modern society.