Opioid Dependence Treatment with Ibogaine

First Posted 12/28/2013
I’ve always assumed that stories about ibogaine curing opioid dependence were fabricated or exaggerated.  But I’ve read more about ibogaine since the drug popped up on an episode of Homeland.  The scene made me wonder how and when the hoopla over ibogaine began, and why it ended.  After all, people treat addiction with all sorts of things that don’t work—so why ban ibogaine?
In the era of the internet, the answers are easy to find.  Ibogaine was used for religious rites in Africa for at least 200 years.  Since the 1930’s the drug, brand-named Lambarène, was used to treat depression and improve energy in France.   The usefulness of ibogaine for treating opioid addiction was described by Howard Lotsof in 1962.  But Lambarene was removed from the market in the 1960s, when the World Health Assembly classified ibogaine as ‘a substance likely to cause dependency or endanger human health.’  A few years later the DEA moved ibogaine to Schedule I—a class of drugs deemed to have ‘no value as medicine.’ Marijuana is schedule I, by the way.
In lack of formal study, several authors have recorded clinical outcomes after ibogaine treatment in non-standard environments.  Carl Waltenburg wrote about treating addicts with ibogaine in a squatters’ village in Denmark in the early 1980’s. Lotsof described a series of patients treated for addiction in a patent awarded for that use of ibogaine in 1985.  In the 1990’s the NIDA funded research of ibogaine treatment of opioid dependence, but that funding was cut in 1995 when a review of early outcome data revealed the death of a young woman treated with ibogaine.  The woman’s death was not clearly attributed to ibogaine, since her belongings were found to include heroin paraphernalia after her death.  But as we all know, attitudes toward medications in the addiction field are subject to emotion and politics, and the death of a young woman during study of a schedule I drug was all it took for NIDA to pull the grant and spend the money elsewhere.
Reports of the efficacy of ibogaine for treating addiction are interesting, and I encourage readers to dig into discussions about the drug with a healthy dose of skepticism.  Remember that scientific truth never comes from one study, or even from a few studies.  Rather, results must be replicated by a number of scientists, preferably with a wide range of bias and perspectives.  In the 1985 patent application for the use of Ibogaine for opioid dependence, Lotsof summarized impressive findings (which are in the public domain and copied below).  Keep in mind, though, that someone applying for a patent is not going to use the application to report their failures!
SUMMARY OF THE INVENTION
It is a principal object of the present invention to provide an improved method for the treatment of opiate addiction.
Another object of the present invention is to provide an improved method for interrupting the physiological and psychological aspects of the heroin addiction syndrome.
Still another object of the present invention is to provide a method of the above nature characterized by its high degree of success, the absence of the great pain and discomfort accompanying earlier treatments, the ease and convenience of application the absence of undesirable or persistent side effects and the persistent effectiveness of the treatment.
The above and other objects of the present invention will become apparent from a reading of the following description which sets forth preferred embodiments thereof.
A feature of the present invention is based on the discovery that an alkaloid of the family Apocynaceae and its therapeutically active derivatives and salts, particularly, ibogaine and its therapeutically active, non-toxic derivatives and salts for example, ibogaine hydrochloride and other non-toxic salts of ibogaine, possess the unexpected unique ability to disrupt the heroin addiction syndrome. Examples of other salts of ibogaine which may be used are ibogaine hydrobromide, and any other non-toxic salt of ibogaine.
For the purpose of definition, the heroin addiction syndrome is meant to consist of all the symptomology demonstrated by addicts in their use of and search for heroin. The interruption of the syndrome was accomplished in five out of seven (71%) of the test subjects who were addicted to heroin. None of the test subjects were seeking to terminate their habits, and all seven were enamored with narcotics.
A single treatment with ibogaine or ibogaine HCl of doses ranging from 6 mg/kg to 19 mg/kg administered orally, disrupted the subject’s use of heroin for about six months.
A treatment lasts about thirty hours during which time ibogaine exerts a stimulant effect. Apparently, an abreactive process is involved during ibogaine therapy but is not noticeable until the patient wakes from natural sleep occurring after primary and secondary effects of ibogaine are diminished. When effective, ibogaine left the addict with no desire to use heroin and no noticeable signs of physical withdrawal. Subjects appeared relaxed, coherent, with a sense of direction and feelings of confidence. 
(Note: abreaction is defined as ‘the release of emotional tension achieved through recalling a repressed traumatic experience.)
Ibogaine was one of five substances we studied. The other four–mescaline, psilocybin, LSD and DMT though different in duration of action and intensity–have similar psychotropic effects that are well documented and will not be discussed here. Ibogaine, unlike the others, is not a euphoriant hallucinogen and did not leave the subjects open to swells of emotion. While under the influence of ibogaine, emotional responses to traumatic repressed thoughts and feelings appeared to be negated.
Another effect of ibogaine administration that was found interesting was that even after twenty-six to thirty hours of wakefulness, subjects slept three to four hours and awoke fully rested. This pattern continued, diminishing slowly, over a three to four month period.
The effects of oral administration of ibogaine are first noticed in fifteen to twenty minutes. Initially, a numbing of the skin is accompanied by an auditory buzzing or oscillating sound. Within twenty-five to thirty-five minutes the auditory transcends across the sensory mechanisms to include the visual: objects appear to vibrate with great intensity. It is at this time that the dream enhancement or hallucinatory effects begin. In many cases an acute stage of nausea follows the hallucinatory phase. The visions end abruptly and the numbness of the skin begins to abate.
This is followed by six to eight hours of a high energy state during which the subjects see “lightening” or flashes of light dance about them. Thoughts which seem to amplify the meaning of the visions seen during the primary phase of ibogaine intoxication continue during this period.
Between twenty-six and thirty-six hours, the level of stimulation diminishes and the test subject falls asleep.
Thus, three stages of ibogaine intoxication have been observed. First, a hallucinatory period lasting for three to four hours during which time the person receiving ibogaine manifests repressed material visually. Second, a high energy period accompanied by flashes of light, the appearance of a vibration to all objects, and the awareness of thoughts appropriate to the visual material seen by the subject. Third, a diminishing energy period free of vibration or light flashes and culminating in sleep.
In the administration of acceptable dosage forms, any one of a variety of preparations may be compounded, for example: capsules, tablets, pills, powders, solutions, etc. In addition to the active agent, there may be present additional substances used in the manufacture of pharmaceutical preparations such as binders, fillers and other inert ingredients.
The entire patent application, including case reports, can be found at the web site of the US Patent Office, or at this site entirely dedicated to ibogaine.
Assignment of a substance to Schedule I creates significant barriers to formal study, at least in the United States.  But US Schedule I status has not prevented the establishment of ibogaine treatment centers in other parts of the world, including Mexico and Canada.  The data pieced together over the years suggests that ibogaine could be a remarkable medication for some people.  But like any medical treatment, there are significant risks to ibogaine treatment.  One particular concern is cerebellar damage in rats treated with doses of ibogaine greater than 100 mg/kg.  Proponents of ibogaine point out that the dose used for treating human opioid dependence is about 50% lower, hardly a reassuring margin of safety.  Best estimates, taken from limited data, suggest an overall fatality rate of 1 in 300 people treated with ibogaine for opioid dependence, with higher death rates in people with certain comorbid conditions.
I’m skeptical of the claims of permanent, positive treatment outcomes from ibogaine.  Addiction to opioids creates a complicated, interconnected collection of physical and psychological dispositions that favor eventual relapse.  I have a hard time believing that one dose of abreactive insight, no matter how profound or intense, can selectively eliminate the desire to use opioids…. while leaving unaffected the desires for all of the normal, good things that humans enjoy.   But then again, opioid dependence is an often-fatal condition.  The significant risks in the risk/reward equation create scenarios where Ibogaine treatment may be appropriate.  I’d be interested in hearing and sharing first-hand accounts from anyone who has been through ibogaine treatment—without need to share your personal identity, of course.

The Ibogaine Cure

First Posted 7/28/2013
Ibogaine, a drug long-rumored to treat opioid withdrawal, has become a hot topic for those taking buprenorphine.  Ibogaine is a complex molecule that comes from a group of plants that are known, in West Central Africa, as Iboga.  In native African culture the drug is used to induce psychedelic states that are part of certain rituals.
A reduction in opioid withdrawal from Ibogaine was first described in 1962.  Since that time, anecdotes have been exchanged about the unique properties of Ibogaine, including claims that the drug does far more than reduce the symptoms of opioid withdrawal.  Some users have described trances that they claim effectively ended their addictions to opioids or other drugs.  On the other hand, some people claim to have had no positive effects from ibogaine, and others claim negative effects or bad experiences.  A list of individual experiences with Ibogaine can be found here.
Ibogaine interacts with a number of neurotransmitter receptors, including at least two classes of opioid receptors (kappa and sigma).  Ibogaine’s effects are partially mediated by NMDA receptors (where glutamate acts as neurotransmitter).  The drug also binds to multiple subtypes of serotonin receptors.
Ibogaine has been associated with a number of deaths, most commonly from arrhythmia or heart failure resulting from sympathetic hyperactivity.  There is no treatment for Ibogaine toxicity. The dangers of Ibogaine have led to classification of the drug as Schedule I by the DEA, blocking research into possible therapeutic benefits.  A recent case report in the American Journal of Addictions (Volume 22, Issue 3) highlights the risk of self-treatment with ibogaine:
A 25yearold gentleman with a past medical history of supraventricular tachycardia and chronic heroin addiction decided to try Ibogaine in an attempt at drug cessation. The patient’s mother directly supervised him and indicated that he ingested 2.5 g of Ibogaine over 3 hours. The patient started experiencing hallucinations, ataxia, muscle spasms, weakness, fever, and urinary retention. Most of those symptoms resolved over that day except for muscle spasms and ataxia. He then developed respiratory difficulty followed by cardiopulmonary arrest. He was successfully resuscitated, and brought to the Emergency Department. Physical exam revealed muffled heart sounds and coarse breath sounds bilaterally. Neurologically, the patient was in a decorticate position. A sample of the ingested substance was analyzed by the Poison Control Center, and toxicology results confirmed that Ibogaine was the ingested substance. Despite aggressive care, the patient expired after 2 days from multiorgan failure.

Because of the heavy interest in the ibogaine, I am adding a section about the drug at SuboxForum, where people can share anecdotes, ask questions, and place links to further information.   I encourage people to approach the discussion with a skeptical mind.  Opioid dependence creates desperation, and desperation makes us eager to chase after anything that is rumored to be a cure.
My opinion?   The whole thing reminds me of laetrile, another wonder drug that the US pharmaceutical industry supposedly withheld from US citizens.   The apricot-pit cancer cure (also known as amygdalin or ‘vitamin B-17’) spawned cancer treatment centers throughout Mexico about 30 years ago.  Steve McQueen was one of the more notable people who died during treatment with laetrile, a drug that the FDA, after decades of study, called ‘a highly toxic product that has not shown any effect on treating cancer’.  Desperate people take desperate measures.
Reducing the severity of opioid withdrawal through actions at multiple neurotransmitters is within the realm of possibility, and could perceivably lead to untold medical benefit if further study was allowed. But the idea that one or two episodes of pleasant psychosis can ‘cure’ opioid dependence sounds, from a neurochemical standpoint, too good to be true.

SuboxDoc Goes Negative!

I received a couple responses to my youtube videos tonight that are worth responding to.  For people who haven’t stumbled across the videos, you will find them if you go to youtube and search under ‘suboxone’ or ‘suboxdoc’.  They are pretty much the same thing as what you read here—a combination of my experiences in treating opiate dependence using Suboxone, education on the actions of buprenorphine, some of my personal ‘theories’ (maybe ‘opinions’ is a better word) on the relationship between sober recovery and buprenorphine maintenance (what I like to call ‘remission treatment’, to distinguish it from methadone maintenance, which works through a different mechanism), and my thoughts on the different treatment options for opiate dependence.

Blogging in general has been an educational experience.  I was initially surprised by the number of people who send out very angry messages to a person who simply tries to share knowledge and advice!  Just today I received a message accusing me of ‘getting my degree from a crackerjacks box’ for my opinion that ‘Suboxone withdrawal is NOT the worst withdrawal ever.’ I didn’t get it there, by the way.    I don’t know how to take the responses posted a few minutes ago that are tonight’s topic;  I am not sure if they are simple questions, respectful disagreements, or sarcastic comments.  You would think a psychiatrist would know one from the other!  Maybe the person will add more angry comments after my post, and then I’ll know for sure.  Or maybe there will be nice comments.  Whatever…

The comments, from someone going by ‘cbarrett34’ on youtube:

Dr. I’m curious, why do you say that there is no cure for opiate addiction? That doesn’t give people a lot of hope, if a Dr. is telling them there is no cure or hope for you. Basically leads to apathy and more using.

(That one was clearly very nice).

And the whole saying, once an addict, always an addict. That’s not a very positive viewpoint either.

(That one is harder to tell, don’t you think?  I might just be paranoid from that crackerjacks comment)

My answer, which as always is just one opiate addict/pain doc/psychiatrist’s opinion:

My first thought is that staying clean from opiates has nothing to do with ‘apathy’.  Maybe smoking pot has something to do with apathy, but people actively using opiates are some of the most non-apathetic people you will ever see!  There is no time for ‘apathy’ for an actively-using opiate addict;  there is that hit that is required every 4-8 hours to avoid being sick, there is that need to scam someone out of money to score the dope that is needed every 4-8 hours to avoid being sick, there is that need to come  up with a good lie to tell the parents/spouse/cops/PO/boss/kids to explain the lousy behavior over the past few months or years…  being an actively using opiate addict is a lot of work!  There is definitely a negative attitude that develops after months or years of using, but it is nothing like ‘apathy’.

Too Negative?
Too Negative?

My next thought is that I wonder what the writer would prefer—‘positive’ lies or ‘negative’ truth?  The idea that heroin or oxycontin addiction is ‘treatable’ is one of the big lies of society;  it makes for good movies and helps keep money rolling in to detox facilities and treatment centers, but if you think I’m wrong, seek out the numbers yourself!  Pick your own criteria for success– one year sobriety, five year sobriety, whatever.  If you look at people in their 20’s who go through residential treatment, the one year rate is way, way, way below 50%, even if you just use the numbers for people who go voluntarily and complete treatment!  Go out to 5 years and the numbers for opiate dependence are ridiculous- sobriety rates of less than 10%!  The writer sees danger in telling the truth about treatment I suppose because the truth will somehow take away ‘motivation’ and cause apathy.  But I see things exactly the opposite.  In my opinion based on how I thought as an actively using opiate addict, a sense of confidence is the ENEMY of sobriety.  As an addict goes from day to day using, and getting deeper into addiction, he/she comforts himself by saying ‘I’m going to get straightened out eventually’.  If the person knew that most people do NOT recover; that he is getting mired deeper in an incurable disease, maybe he will think about seeking help a bit sooner!  And if everyone knew that opiate dependence is a largely untreatable and surely incurable illness, maybe fewer high school kids would pick up in the first place.  I hear addicts say one thing over and over again:  ‘if I only knew that oc would have done this to me I never would have taken it.’  I don’t know if that is true for all of them, but I think that had the truth been known, at least some of them wouldn’t have started.

As far as the comment about ‘once an addict, always an addict,’ that is something that is not even controversial.  Yes–  at least with opiates, once an addict, always an addict.  About 7 years after getting clean ‘the first time’, I assumed that I was cured—after all I had only used opiates for 8 months or so, and it had been 7 years… I had been to hundreds of AA and NA meetings, I had worked the steps all the way through several times, and I never even thought about using!  I would get so annoyed when my old NA and AA buddies would come up to me if they saw me someplace and say ‘we miss you at the meetings, Jeff!’  I would want to tell them to bug off and leave me alone— I’m cured, after all!  I don’t need that crap.  Once an addict, always an addict…. NO WAY!

Had I listened to them I might have saved myself a great deal of trouble.  But probably not, since addicts pretty much need to find things out for themselves.    That is one of the personality traits of ‘us addicts’—we are independent thinkers who don’t think the rules of others should apply to us.  Those words on the Vicodin bottle about dosing and about the danger of dependence?  Those are just ‘suggestions’!

I wasn’t always a fan of the idea of taking a medication to treat opiate dependence.  Even after looking around me and realizing that all of the people who got clean with me had relapsed, I thought that it was better to have one out of ten people in ‘real’ recovery than have people taking medication!  Then I ended up in a position where I actually knew some of the people who were dying.  At NA or AA meetings people talk about the deaths with a ‘tsk tsk’ attitude, as if the person who died should have known better, or almost had it coming, since she stopped going to meetings.  But once I was a person who stopped going to meetings in spite of knowing better, it became harder to blame the dead person.

I have in my mind the images of four smiling people who desperately wanted to be free from opiates.  I knew all four of them pretty well at some point;  none took Suboxone, and all assumed they were going to be fine without it.  After all, they had all gone through at least part and in two cases entire treatment programs.  Three men and one woman, all less than 25 years old, two with children of their own.  Two died from suicides, presumably in part from the shame of failing to get better.  I wonder if they thought, before they died, that they were losers because treatment didn’t work for them?  The other two died from opiate overdoses, one the first time he used after being clean for several months.  I suspect he figured that he ‘beat the disease’;  that is what most of us think as we relapse.  One time won’t hurt, we tell ourselves;  we are different now.  We have been TREATED, after all!  The final person was a woman who had been resuscitated several times in her life, once after an overdose in a drug-treatment halfway house!   Maybe she had a death wish—some addicts seem to use as if they truly want to destroy themselves—or maybe she thought she was blessed by a guardian angel who eventually slept in one day and wasn’t there when she needed him.

To simply answer the writer’s questions without all the stories, I tell people that there is no cure for opiate addiction because my opinion is the same as that of everyone else who treats or studies opiate addiction—   there is no cure for opiate addiction.  As for ‘hopelessness’, sometimes ‘hope’ is just a campaign slogan.  Sometimes ‘hoping’ keeps a person from recognizing the cold hard facts of a situation and taking responsible action.  In medicine and in life, diseases do not always have cures.  Some diseases are simply not curable, and people die.  Want to have ‘hope’ about opiate dependence?  Then DON’T USE OPIATES.

The good news is that while there is no cure, there is a relatively new approach to addiction that is keeping many people alive who would have otherwise died from their addiction.  There are many diseases without ‘cures’—in fact there are probably many more ‘incurable’ diseases than ‘curable’ ones!  But every opiate addict should know the facts:  that he or she will always be vulnerable to relapse, no matter the amount of ‘treatment’.